Bipolar affective disorder

Question 1

About bipolar affective disorder:

Answer 1

• Affects 1 in 100 people.
• Majority of people develop condition between 15-19.
• Characterised by periods of high moods (mania/hypomania), and low moods (depression).
• Serious consequences to episodes.
• Bipolar I – at least one manic episode with or without history of major depressive episodes.
• Bipolar II – one or more major depressive episodes, and at least one hypomanic episode, but no evidence of mania.

Question 2

Mania and hypomania:

Answer 2

Mania: distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week, accompanied by at least 3 additional symptoms (e.g. increased energy/activity, pressure of/incomprehensible speech, flight of ideas, poor concentration, disinhibition, extravagant/impractical plans, delusions or hallucinations), and which:

• is severe enough to cause marked impairment in social/occupational functioning or require hospitalisation, or
• includes psychotic features

Hypomania –
- similar to mania, but symptoms only need to have lasted for 4 days, not severe enough to cause marked impairment/hospitalisation, and no psychotic features.

Question 3

Treating mania and hypomania:

Answer 3

• Consider stopping any antidepressants – they encourage mania
• If patient already on mood stabiliser, maximise dose.
• Use antipsychotics – Haloperidol, Risperidone, Olanzapine, Quetiapine.
• If not tolerated or ineffective, switch to a different antipsychotic.
• If only on antipsychotic, and still insufficient response, consider adding Lithium, or Valproate.
• Do not use Lamotrigine for mania.

Question 4

Bipolar depression treatment:

Answer 4

• Symptoms and diagnosis as for unipolar depression.

- BUT – different treatment approach, as need to consider risk of switching with antidepressants.

Question 5

Treatment for moderate to severe bipolar depression:

Answer 5

• If already on mood stabiliser, maximise dose.
• Fluoxetine and Olanzapine, or Quetiapine.
• Can also consider – Olanzapine on its own, or Lamotrigine.
• If no response to Fluoxetine and Olanzapine, or Quetiapine, use Lamotrigine.

Question 6

Options for maintenance in BPAD?

Answer 6

• Consider drugs used effectively in acute episodes.
• Lithium is most effective.
• Other options if Lithium cannot be used/ineffective:
• Add/switch to Valproate
• Or Olanzapine
• Or Quetiapine if used in acute phase and effective.
  Patient preference

Question 7

Lithium characteristics:

Answer 7

• Brand specific – Priadel, Camcolit. Doses.
• 4 – 7 days to reach steady state.
• Narrow therapeutic range.
• Levels – 12 hours post dose, range 0.4 – 0.8mmol/l (with some exceptions – up to 1mmol/l). Check weekly until stable, then 3 monthly for first year.
• Risk of toxicity.
• Hydration a factor – lithium cleared by the kidneys
• Drug interactions – NSAIDs, diuretics, ACE inhibitors.
• Baseline and regular monitoring of U&Es, eGFR, TFTs, Bone, FBC, ECG, BMI.
• Can cause nephrotoxicity, hypothyroidism, hypercalcaemia.
• Side effects – fine tremor, acneiform eruptions…..
• Signs of toxicity: vomiting and diarrhoea, coarse/severe tremor, CNS disturbances….
• Stopping abruptly can lead to relapse. Reduce gradually.

Question 8

Lithium counselling points:

Answer 8

• Indication, dose, time of dose, frequency
• Brand, MR formulation
• Duration of treatment
• Physical and lithium monitoring
• Why we do monitoring, when we do levels, frequency
• Side effects
• Causes of toxicity – dehydration, changes to salt, other medicines
• Signs of toxicity
• What to do if toxicity occurs
• Drug interactions – only buy OTC medicines from a pharmacy, tell pharmacist that you are taking Lithium.
• Pregnancy

Question 9

Valproate key points:

Answer 9

• Sodium Valproate, and Semisodium Valproate (one you tend to see In bipolar)
• Twice daily dosing
• Baseline and regular BMI, FBC, LFTs – after 6 months, then annually
• Look out for blood and liver problems – medical attention immediately
• Interactions
  Levels only to check adherence, effect, and toxicity
• Reduce dose gradually
• NOT for females of child-bearing potential

Question 10

Valproate - teratogenicity:

Answer 10

• 10.73% of children exposed to Valproate during pregnancy suffer from congenital malformations. Risk greatest at higher doses.
• Dose dependent risk of developmental disorders. Up to 30-40% of children exposed to Valproate in utero experience delays in early development.
• Approximately 3-fold increased risk of autistic spectrum disorder.
• Approximately 5-fold increased risk of childhood autism.
• May be increased risk of ADHD.
• If absolutely must use – pregnancy prevention programme. Annual acknowledgement of risk and review, highly effective contraception, referral if pregnant/planning pregnancy. Patient card at every dispensing, patient guide. Warnings on packaging. If patient unaware of risks, not been reviewed, dispense and refer to GP.

Question 11

Treatment pathway in BPAD:

Answer 11

• Treat acute episodes.
• Review medication once improvement.
• Back to baseline.
• Maintenance treatment.
• Consider patient factors when choosing medication – age, gender, preference, allergies/intolerances, co-morbidities, concurrent medication, previous responses.
• Minimum of medication, lowest dose possible.
• Compliance with medication? Relapse signatures?

Question 12

The role of the pharmacist:

Answer 12

• Medication reconciliation and history
• Medication options
• Counselling and discussion with patient
• Monitoring compliance, levels
• Advice re: interactions, pregnancy, complications of treatment
• Side effect monitoring and advice
• Recognising toxicity
• Reviewing treatment
• Recognising relapse