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CDM 4 Exam 2 > Bipolar Disorder > Flashcards

Bipolar Disorder Flashcards

1
Q

Risk factors

A

family history
rapid or early onset of depressive symptoms

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2
Q

Comorbidities

A

Anxiety
SUD

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3
Q

Manic criteria DSM-5

A

Criteria A: At least one week of abnormal, mood that is elevated, expansive, or irritable

Criteria C: Significant social/occupational impairment or requires hospitalization or psychotic features

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4
Q

Hypomanic criteria DSM-5

A

Criteria A: At least four days of abnormal, mood that is elevated, expansive, or irritable

Criteria C: Moderate social/occupational impairment

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5
Q

Secondary causes of mania: drugs

A

alcohol intoxication
antidepressants
drug withdrawal
marijuana
steroids
thyroid medications
methylxanthines (caffeine)

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6
Q

Bipolar 1 Disorder

A

Manic episode
(+/-) Major depressive episode or HYPOmanic episode
(Alternates with normal mood state)

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7
Q

Bipolar 2 disorder

A

HYPOmanic episode AND
Major depressive episode
(NO history of manic episode)

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8
Q

Specifiers

A

Mixed features: full criteria met for manic or depressive episode in addition to 3 features of the other
Rapid cycling: at least 4 separate episodes in last 12 months
Psychotic features: delusions or hallucinations present

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9
Q

Kindling effect

A

acceleration of episode frequency with each episode becoming more difficult to treat

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10
Q

bipolar I disorder onset

A

18 years

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11
Q

Bipolar II disorder onset

A

mid 20s

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12
Q

Acute Mania treatment: Manic Episodes

A

First line: VPA, SGA, Lithium
Severe epsiodes or w/ psychotic symptoms: Lithium or VPA + SGA

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13
Q

Acute Mania treatment: Manic w/ mixed features

A

First line: SGA, VPA, CBZ
Mixed features is a predictor of lithium non-response
Avoid antidepressants

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14
Q

Acute mania treatment considerations

A

Antidepressants: Taper or D/C
BZD: acute control of agitation, anxious features or sleep restoration

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15
Q

Acute Depression: Bipolar I disorder

A

First line: Quetiapine, Lurasidone, Olanzapine/fluoxetine, lithium, lamotrigine

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16
Q

Acute Depression: Bipolar II disorder

A

First line: Quetiapine, Lurasidone, Cariprazine, Olanzapine/fluoxetine

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17
Q

Acute Depression: Considerations

A

Antidepressants: controversial –> always use with mood stabilizer
taper or D/C asap
risk of switch

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18
Q

Maintenance treatment

A

Lithium, LAM, VPA, CBZ, SGA

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19
Q

Lithium drug monitoring: dosing

A

Acute mania: 0.8-1.2mEq/L
Maintenance: 0.6-1 mEq/L

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20
Q

Lithium drug monitoring

A

Draw 12 hour post dose
Steady state after 5 day
Check earlier if toxicity, DDI or serum/electrolyte issues
1st order linear kinetics

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21
Q

Lithium symptoms at 1.5-2mEq/L serum level

A

N/V/D, drowsiness, muscle weakness, coarse tremor

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22
Q

Lithium CI

A

dehydration
sodium depletion
unstable renal or CV disease

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23
Q

Lithium warnings

A

renal: acute and chronic decrease in GFR
renal: decreased renal concentrating ability
pregnancy: risk of fetal malformation

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24
Q

Lithium Boxed warning

A

Lithium toxicity is closely related to serum lithium levels and can occur at doses close to therapeutic levels.

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25
Q

Lithium serious adverse effects

A

Acute kidney injury
Chronic kidney disease (long-term use; controversial)
AV block or conduction issues
Bradyarrhythmia
Brugada syndrome (sudden cardiac death)

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26
Q

Lithium common AE

A

Xerostomia, fatigure, dizziness, wight gain, acne, hairloss, GI upset polydispia, polyuria, leukocytosis, hypercalcemia, hypothyroidism

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27
Q

Lithium major DDI

A

NSAIDs
ACEi/ARB
Diuretics
-all increase Li+ levels

avoid thiazides
mannitol deaceases Li+ levels

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28
Q

Lithium monitoring parameters

A

Renal function (baseline, q 2-3 months)
TSH (baseline, q 6 months)
ECG (baseline and yearly)
Serum drug concentration (weekly until stable dose, quarterly after)

29
Q

Lithium counseling

A

avoid excessive caffeine and abrupt changes in salt intake
avoid dehydration
report lithium toxicity
avoid NSAIDs

30
Q

lithium toxicity

A

N/V/D termor

31
Q

Valproic Acid dosing

A

Target dose is that which controls mania without sig. SE
Dosing forms are NOT interchangeable and may require adjustments in dose

32
Q

Trough serum concentration __ -___days after initial dose or change in dosing for VA

A

3-5 days

33
Q

Valproic Acid CI

A

Hepatic disease/dysfunction
Hyperammonemia
Pregnancy

34
Q

Valproic Acid boxed warning

A

hepatotoxicity

35
Q

Valproic acid serious AE

A

SJS/TENS
Pancreatitis (5%)
Hepatotoxicity (higher risk in pediatrics and within first 6 months; if LFT>3xULN—intervene)
Hyperammonemia
Thrombocytopenia (1-30%; risks increase with older age and higher doses)

36
Q

Valproic Acid toxicity

A

Neurologic manifestations are common (ataxia, tremor, CNS depression)

37
Q

Valproic Acid common AE

A

alopecia, dizziness, sedation, tremor, ataxia, weight gain, N/V/D

38
Q

Valproic Acid DDI

A

Carbapenem antibiotics -> Decreases VPA
Lamotrigine –> Increases lamotrigine
Phenytoin –> unpredictable
Warfarin –> increases warfarin

39
Q

Valproic Acid monitoring

A

CBC (baseline, 2 weeks after initiation)
LFTs (baseline, 2 weeks after initiation)
Serum drug concentration (3-5 days of stable dose)

40
Q

Valproic Acid counseling

A

damage to your liver or pancreas
unusual bleeding or bruising

41
Q

Carbamazepine dosing –> Asian descent

A

HLA-B*1502 allele
Positive result - 10x increased risk of SJS/TEN avoid use of CBZ

42
Q

Carbamazepine dosing consideration

A

induces: 3A4, 1A2, 2B6, 2C9, 2C19, PGP, UGT
Metabolized via 3A4

43
Q

Autoinduction Carbamazepine

A

Autoinduction begins after 3-5 days and is compete 3-5 weeks after stable dose is maintained

Obtain serum concentration 4 weeks after initiation to adjust dose

44
Q

Carbamazepine CI

A

Bone marrow suppression

45
Q

Carbamazepine boxed warning

A

Serious dermatologic reactions including SJS and TEN
Aplastic anemia and agranulocytosis

46
Q

Carbamazepine warnings

A

Fatal hypersensitivity reactions (DRESS, SJS, TEN)—25-30% cross reactivity with oxcarbazepine
Anemia and agranulocytosis

47
Q

Carbamazepine rare adverse effects

A

Rash
Hyponatremia/SIADH
Leukopenia/thromoctyopenia

48
Q

Carbamazepine potentially fatal AE

A

SJS/TEN/DRESS rash
Agranulocytosis
Aplastic anemia
Thrombocytopenia
Hepatic failure

49
Q

Carbamazepine common AE

A

N/V, constipation, dry mouth, ataxia, dizziness, sedation, blurred vision

50
Q

Carbamazepine osteoporosis

A

Autoinduction may increase vitamin D metabolism leading to lower levels
Monitor BMD if patient is on therapy for >5 years

51
Q

Carbamazepine DDI

A

CYP3A4 inhibitors/inducers
CYP3A4 and 1A2 substrates
hormonal contraception
clozapine
grapefruit (increases CBZ levels)

52
Q

CBZ monitoring parameters

A

CBC (baseline, every 2 weeks for 2 months then every 4-6 months)

LFTs (baseline, every 2 weeks for 2 months then every 4-6 months)

Electrolytes (baseline, at 2 weeks then annually)

weight, rash, HLA-B*1502

53
Q

Carbamazepine counseling

A

Grapefruit can increase concentrations
May cause changes in blood cells that affect immune function
Rash, contact healthcare provider
Sedation, nausea, muscle weakness or falls
Birth control may be less effective

54
Q

Lamotrigine Dosing

A

anti-kindling properties
titration based on clinical symptoms and adverse effects
Any break in therapy for >3-5 half-lives warrant re-titration

55
Q

Lamotrigine CI

A

May have prodromal symptoms of chills, malaise, sore throat, fever
Usually occurs within first 2-8 weeks, but can occur at any time

56
Q

Lamotrigine boxed warning

A

Stop at any sign of rash
Life-threatening rashes including SJS and TEN

57
Q

Lamotrigine serious adverse effects rare

A

SJS/TEN rash
Agranulocytosis
Aseptic meningitis

58
Q

Lamotrigine common AE

A

N/V/D, rash, ataxia, dizziness, diplopia, sedation

59
Q

Lamotrigine DDI

A

Estrogen
Carbamazepine
-decrease

VA
clozapine
-increase

60
Q

Lamotrigine monitoring parameters

A

weight, rash

61
Q

Lamotrigine counseling

A

takes time to start working due to need for titration
re-titrate id missed >5 doses/days
serious rashes
oral contraceptives or estrogen may decrease lam con.

62
Q

Antipsychotics 2nd gen

A

improve mania within a few days

63
Q

Clozapine

A

Used for treatment-resistant BD as monotherapy or with mood stabilizers
Patients with affinity for manic polarity respond better to clozapine

64
Q

Pregnancy and antipsychotics

A

Antipsychotics –> Quicker onset, fewer teratogenic risks

65
Q

Pregnancy and Lithium

A

Ebstein’s anomaly
Floppy baby syndrome
AVOID during 1st trimester
TDM during each trimester

66
Q

Pregnancy and VA

A

Neural tube defects (4%), limb defects, cardiac issues, low IQ
AVOID; if using supplement with folic acid 4mg

67
Q

Pregnancy and Carbamazepine

A

Neural tube defects (3%), low IQ, fetal hemorrhage
AVOID; supplement with folic acid 4mg
Vitamin K 10mg during last month

68
Q

Pregnancy and LAM

A

Neural tube defects (2%), midline facial cleft

69
Q

Lactation

A

Lithium - CI
VA-caution (compatible)
Carb- caution (compatible)

CDM 4 Exam 2 (13 decks)

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