Bipolar Disorder

Question 1

Bipolar 1

Answer 1

Manic episode +/- major depressive or hypomanic episodes

Question 2

Bipolar 2

Answer 2

Major depressive episode + hypomanic episode

Question 3

Bipolar Sx/Risk Factors

Answer 3

<25 yo
family hx
increased sleep + appetite
psychomotor retardation
atypical depression
Co-occurring substance abuse

Question 4

4 A’s of Atypical Depression

Answer 4

Anxious
Anger
Agitation
Lack of Attention

Question 5

Rapid cycling

Answer 5

More than 4 episodes per year

Question 6

Dysthymia

Answer 6

persistent depressive disorder (mild but long term depression)

Question 7

Cyclothymia

Answer 7

cycle of ups and downs similar to bipolar disorder but more mild

Question 8

Schizoaffective disorder

Answer 8

mix of schizophrenia with mode episodes of bipolar disorder
treatment:
-mood stabilizers + APS (Paliperidone, Clozapine)

Question 9

Drugs 1st line drugs FDA approved for Acute Mania & Mixed Episodes

Answer 9

Lithium**

AED:
-Valproate**
-Carbamazepine ER + IR

SGA:
-Quetiapine**
-Aripiprazole*
-Asenapine*
-Cariprazine*
-Olanzapine*
-Risperidone*
-Ziprasidone

Question 10

Drugs 1st line drugs FDA approved for Maintenance Therapy

Answer 10

Lithium

AEDs:
-Valproic Acid
-Lamotrigine

SGAs:
-Aripiprazole
-Olanzapine
-Quetiapine
-Risperidone
-Ziprasidone (adjunct to Li/VPA)

Question 11

Drugs 1st line drugs FDA approved for Acute Depression

Answer 11

Lithium

AEDs:
-Lamotrigine (BP II only)
-Cariprazine (Vraylar)

SGAs:
-Lurasidone (Latuda)
-Olanzapine w/ fluoxetine (BP II only)
-Quetiapine (Seroquel)

Antidepressants can be used but not as monotherapy (SNRI better than TCA)

Question 12

Drugs for treatment of Agitation in Bipolar Disorder

Answer 12

Aripiprazole
Lorazepam
Loxapine
Olanzapine

Question 13

Meds NOT recommended in acute mania

Answer 13

gabapentin
topiramate
lamotrigine
verapamil
tiagabine
risperidone + carbamazepine
olanzapine + carbamazepine

Question 14

Meds NOT to use in depressive episodes

Answer 14

gabapentin
aripiprazole
ziprasidone
adjunct levetiracetam (Keppra)

Question 15

Meds NOT to use in maintenance

Answer 15

gabapentin
topiramate
antidepressants
adjunct fluphenthixol

Question 16

Lithium dosing

Answer 16

900mg - 2400mg /day in 2-4 div doses
take with food

Question 17

Target lithium serum concentration

Answer 17

0.6-1.2 mEq/L

Question 18

Toxic lithium serum concentration

Answer 18

> 1.5 mEq/L

Question 19

When is the best time to perform TDM for lithium concentrations

Answer 19

at trough:
8-12 hrs after last dose
5 days after stable dose is achieved
may draw sooner if toxicity or nonadherence concerns

Question 20

Lithium ADE

Answer 20

• nephrotoxicity (Polydipsia and polyuria +/- nephrogenic diabetes insipidus) -> can have irreversible consequences
• AKI, CKD
• GI and CNS (dose related, worst at peak)
• muscle weakness and lethargy
• CV events
• hypothyroidism
• floppy baby syndrome

Question 21

Lithium ADE: Management of GI and CNS effects

Answer 21

lowest effective dose
once daily dosing (XL) at bedtime
take with food
liquid formulation for diarrhea

Question 22

Lithium ADE: Tremor management

Answer 22

long acting preparations
lower dose
add beta blocker (propranolol)

Question 23

Valproate ADE

Answer 23

Dose related:
- GI (transient)
-Tremor (dose decrease / BB)
- Sedation (HS dosing)

Prolonged bleeding
Weight gain
Hyperammonemia
Alopecia (dose dependent)
BBW: pancreatitis and/or hepatotoxicity, urea disorders

Question 24

Lamotrigine ADE

Answer 24

SJS
aseptic meningitis
prodrome chills
sore throat
fever

Question 25

Carbamazepine ADE

Answer 25

Neutropenia
Leukopenia
Hematologic disease
Agranulocytosis
Porphyria
Hyponatremia
decreased ADH release

Warning Asian HLA-B 1502 patients at increased risk of SJS

Question 26

Long acting injections approved for bipolar disorder

Answer 26

Aripiprazole (Abilify Maintena)
Risperidone (Risperdal Consta)

Question 27

Which medication appears to be the most favorable for treating bipolar disorder in pregnant patients

Answer 27

Lamotrigine

Question 28

Aripiprazole ADE

Answer 28

• IMPULSIVITY
  -little weight gain
  -insomnia
  -akathisia
  -restlessness

Question 29

Quetiapine (Seroquel) ADE

Answer 29

-sedation
-metabolic issues
-QTc prolongation
-anticholinergic effects
-cataracts

Question 30

Asenapine (Saphris) ADE

Answer 30

-among the least sedating and anticholinergic of SGAs
-QTc prolongation
-anaphylaxis
-skin irritation with topical patch

Question 31

Cariprazine (Vraylar) ADE

Answer 31

• akathisia

Question 32

Olanzapine (Zyprexa) ADE

Answer 32

• Metabolic Risks
• DRESS
• post injection delirium / sedation syndrome
• QTc prolongation

Question 33

Risperidone (Risperdal) ADE

Answer 33

-EPS
-Prolactin (gynecomastia, abnormal menses etc.)

Question 34

Lurasidone (Latuda) ADE

Answer 34

• less notable weight gain, sedation, and orthostasis compared to other SGAs
• do not use with strong CYP3A4 inhib/inducer