Bipolar and related disorders Flashcards
What is the 1st line treatment option in bipolar disorders?
Lithium
What is the dose of lithium as a mood stabiliser according to?
Trough level of lithium in the blood
What is a safe lithium starting dose?
500mg po mane
Lithium has a very wide/narrow therapeutic index
Narrow
How often should lithium levels be checked?
4 days after treatment start/change
Every 6 months
What does it mean that lithium blood levels are trough levels?
Blood must be drawn right before the next dose
Give side effects of lithium
Nausea Vomiting Diarrhoea Postural tremor Polyuria w/ polydipsia Hypokalemia Nonspecific interstitial fibrosis (>10y) Hypothyroidism Hyperthyroidism Teratogenesis
Give thyroid side effects of hyperthyroidism
Goiter
Expothalmos
Give cardiac side effects of hypokalemia
T wave flattening/inversion
Sinus dysrythmias
Heart block
Syncope epipsodes
What is the teratogenic result of lithium use?
Ebstein’s anomaly
Give signs of lithium toxicity
Tremor Dysarthria Ataxia N+V Diarrhoea CVS changes Renal dysfunction Myoclonus Muscular fasciculations Seizures Impaired LOC Coma
Which investigations should be performed before a patient begins lithium treatment?
UKE Creatinine clearance FBC TSH Beta-hcg ECG
Why check UKE when starting lithium treatment?
Potassium levels
Kidney dysfunction
Why check creatinine clearance when starting lithium treatment?
Kidney excretion required
Why check FBC when starting lithium treatment?
Lithium causes leucocytosis
Why check TSH when starting lithium treatment?
Lithium interferes with thyroid function
Why check beta-hcg when starting lithium treatment?
Lithium is teratogenic
Why check ECG when starting lithium treatment?
Check for dysrhythmia
Check for heart block
What is the advantage of valproate in 1st line treatment?
Able to titrate dose upwards rapidly
What is the dose of valproate for bipolar disorders?
250-1250mg po bd
Name common side effects of valproate
Sedation Weight gain Thrombocytopenia Hair loss Tremor PCOS Teratogenesis
What is the teratogenic result of valproate?
Neural tube defects
Which investigations should be performed before a patient begins valproate treatment?
LFTs
Beta-hcg
Pelvic sonar
What is the dose of carbamazepine in bipolar disorders?
Start 200mg po bd
Titrate 200mg at a time
Maintenance 600-800mg po bd
Name common side effects of carbamazepine
Exfoliative dermatitis Hyponatermia SIADH GIT S/E Hepatitis Agranulocytosis Teratogenesis Drug metabolism interference
Which investigations should be performed before a patient begins carbamazepine treatment?
LFTs
UKE
FBC
Beta-hcg
What is the teratogenic effect of carbamazepine?
Neural tube defects
Why check LFTs when starting valproate treatment
Liver metabolism of valproate
Why check LFTs when starting carbamazapine treatment
Liver metabolism of carbamazepine
Why check UKE when starting carbamazepine treatment
Hyponatremia
SIADH
Which medication is effective in treating bipolar depression?
Lamotrigine
Lamotrigine is useful in preventing manic episodes and treating manic episodes
True or false?
False
Not effective in treatment of manic episodes
What is the dose of lamotrigine in bipolar disorders?
Start 25mg po nocte
Titrate 25mg every 2 weeks
Maintence 100-200mg po nocte
What risk is there when titrating lamotrigine too rapidly?
Steven-Johnson syndrome
Name common side effects of lamotrigine
Dizziness Ataxia Blurred vision Diplopia Headache Sedation N+V SJS
What do you do in a patient who has started lamotrigine and begun developing a rash?
IMMEDIATELY STOP LAMOTRIGINE
Which atypical antipsychotics can be used in the treatment of bipolar disorder?
Olanzapine 10-20mg po nocte
Quetiapine 300-800mg po nocte
Aripriprazole 10-30mg po nocte
Name a common side effect of atypical antipscyhotics
Metabolic syndrome
Name common side effects of olanzapine
Severe MS Sedation Dizziness Dry mouth Consstipation Dyspepsia Akathisia
Name common side effects of quetiapine
MS
Sever sedation
Dizziness
Postural hypotension
Name common side effects of aripriprazole
Headache Sedation Akathisia Agitation Anxiety Dyspesia Nausea
What is NOT a side effect of aripriprazole that is a side effect of olanzapine and quietapine?
MS
What should be monitored in a patient on an atypical antipsychotic?
Fasting glucose Lipogram BP WC Weight
Name atypical bipolar features
Hypersomnia
Weight gain
Sensitive interpersonal communication
Leaden paralysis
Define rapid cycling
At least 4 distinctive episodes within 1 year
Which drug class can result in mania in bipolar disorder?
Antidepressants
Name specifiers in a current/most recent bipolar disorder episode
Mild, moderate, severe W/ anxious distress W/ mixed features W/ melancholic features W/ atypical features W/ psychotic features (mood congruent/incongruent) W/ catatonia W/ peripartum onset
Name lifetime pattern specifiers in bipolar disorder
W/ rapid cycling
W/ seasonal pattern
In partial remission
In full remission
Give the aetiology of bipolar disorder
Multifactorial
Biological
Genetic
Psychosocial
Which bipolar disorder patients should be hospitalised?
Risk of suicide
Risk of homicide
Relapse w/ grossly impaired ability food/shelter in absence of proper support system
Rapidly progressing symptoms
Which bipolar disorder patients are usually hospitalised?
Manic episodes
Severe depressive episodes
Mixed features
Which bipolar disorder patients usually receive outpatient treatment?
Hypomanic
Mild-moderately severe depressive episodes
Psycotherapy and pharmcotherapy in bipolar disorder are more effective when used alone/in combination
In combination
During which phases and episodes is psychotherapy useful?
Maintenance phase
Hypomania
Mild-moderate depression
During which episodes is psychotherapy unuseful?
Manic
Severe depressive
Psychotic
Mixed features
What is the psychotherapy treatment of choice in bipolar disorder?
Cognitive behavioural therapy
Which drug class is the mainstay of bipolar disorder pharmacotherapy treatment?
Mood stabilisers
Combination mood stabilisers in severe bipolar pathology is unusual
True or false?
False
Name the 4 domains of mood stabiliser
Treat from above
Stabilise from above
Treat from below
Stabilise from below
Which domain of mood stabiliser does manic episode treatment follow?
Treat from above
Which domain of mood stabiliser does manic episode prevention follow?
Stabilise from above
Which domain of mood stabiliser does depressive episode treatment follow?
Treat from below
Which domain of mood stabiliser does depressive episode prevention follow?
Stabilise from below
Why avoid antidepressants in bipolar disorder management?
Hypomania risk
Rapid cycling risk
Name mood stabilisers effective in treating depression in bipolar disorder
Lamotrigine Olanzepine Quetiapine Aripiprazole Lithium Valproate
Which mood stabiliser is best in severe depression requiring urgent treatment and why?
Quetiapine (quicker onset of action)
Why is lamotrigine started slowly?
Side effect profile
SJS
What do you always need to give antidepressants in bipolar disorder?
In combination with at least 1 mood stabiliser
- 1 effective in treating depression
- 1 effective at preventing manic episodes
Discuss management of psychotic depression in bipolar disorder
Add an antipsychotic
Use atypical antipsychotic
Avoid haloperidol
Why avoid haloperidol in psychotic depression of bipolar disorder
Causes dysphoria
Which antipsychotics are best for psychotic depression in bipolar disorder
Olanzapine
Quetiapine
Aripiprazole
Discuss treatment of a manic episode
- Start mood stabiliser for mania
- Add antipsychotic if needed
- Add long acting BZD if needed
- ECT if needed
- Stop antidepressants
- Sedate in emergency if needed
Name mood stabilisers effective in treating mania
Valproate
Lithium
Atypical antipsychotic
Name the advantage of valproate in the manic episode
Can titrate dose upwards rapidly
Name the disadvantage of lithium in the manic episode
Slow titration due to toxicity risk
Which antipsychotics are effective in a manic episode for psychosis?
Haloperidol Atypical antipsychotic (olanzepine)
Which BZD is effective in a manic episode if needed?
Clonazepam 2mg po tds
Give examples of emergency sedation options in treatment of a manic episode
Lorazepam Haloperidol Olanzapine Ziprasidone Clopixol acuphase
Which medication MUST be stopped during a manic episode?
Antidepressant
Discuss treatment of a hypomanic episode
- Start mood stabiliser for mania
- Add antipsychotic if needed
- Add long acting BZD if needed
- Stop antidepressants
Which antipsychotics are effective in a hypomanic episode for psychosis?
Haloperidol
Atypical antipsychotic
UNUSUAL AS IMPLIES MANIC
Which BZD is effective in a hypomanic episode if needed?
Clonazepam 2mg po tds
UNUSUAL AS IMPLIES MANIC
Discuss treatment of mixed features
- Start mood stabiliser
2. Add antipsychotic if needed
Which mood stabilisers are effective in treating mixed features?
Valproate
Lamotrigine
Consider atypical antipsychotic
What is the issue with valproate and lamotrigine combined?
Lamotrigine metabolised by CYP450 in liver -> valproate ihibits the CY450 -> incr serum lamotrigine -> SJS risk increases
What medications are used for the maintenance phase of bipolar disorder?
Lithium
Valproate
Carbamazepine/oxcarbazepine
Lamotrigine
What is lithium most effective in treating and preventing?
Manic episodes
What is valproate most effective in treating and preventing?
Manic episodes
What is valproate the treatment of choice for?
Mixed features
Rapid cycling
Is valproate effective in treatment and prevention of depression?
NO
Why is carbamazepine no longer routinely used?
Same use profile as valproate
Less effective
What is lamotrigine the treatment of choice for?
Preventing depressive episodes
What is lamotrigine effective in treating?
Depressive episodes treatment
Manic episode prevention
Which episodes is lamotrigine not effective in?
Treatment of manic episodes
What are atypical antipsychotics not effective in?
Preventing depressive episodes
Name medications claimed to have efficacy but mostly ineffective as mood stabilisers
Topiramate Gabapentin Levetiracetam Pregabalin Riluzole Memantine Ketamine Amantadine CCBs
What are atypical antipsychotics effective in treating?
Treating manic episodes
Preventing manic episodes
Treating depressive episodes
