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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
Lithium serious adverse effects
Acute kidney injury Chronic kidney disease (long-term use; controversial) AV block or conduction issues Bradyarrhythmia Brugada syndrome (sudden cardiac death)
26
Lithium common AE
Xerostomia, fatigure, dizziness, wight gain, acne, hairloss, GI upset polydispia, polyuria, leukocytosis, hypercalcemia, hypothyroidism
27
Lithium major DDI
NSAIDs ACEi/ARB Diuretics -all increase Li+ levels avoid thiazides mannitol deaceases Li+ levels
28
Lithium monitoring parameters
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
Lithium counseling
avoid excessive caffeine and abrupt changes in salt intake avoid dehydration report lithium toxicity avoid NSAIDs
30
lithium toxicity
N/V/D termor
31
Valproic Acid dosing
Target dose is that which controls mania without sig. SE Dosing forms are NOT interchangeable and may require adjustments in dose
32
Trough serum concentration __ -___days after initial dose or change in dosing for VA
3-5 days
33
Valproic Acid CI
Hepatic disease/dysfunction Hyperammonemia Pregnancy
34
Valproic Acid boxed warning
hepatotoxicity
35
Valproic acid serious AE
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
Valproic Acid toxicity
Neurologic manifestations are common (ataxia, tremor, CNS depression)
37
Valproic Acid common AE
alopecia, dizziness, sedation, tremor, ataxia, weight gain, N/V/D
38
Valproic Acid DDI
Carbapenem antibiotics -> Decreases VPA Lamotrigine --> Increases lamotrigine Phenytoin --> unpredictable Warfarin --> increases warfarin
39
Valproic Acid monitoring
CBC (baseline, 2 weeks after initiation) LFTs (baseline, 2 weeks after initiation) Serum drug concentration (3-5 days of stable dose)
40
Valproic Acid counseling
damage to your liver or pancreas unusual bleeding or bruising
41
Carbamazepine dosing --> Asian descent
HLA-B*1502 allele Positive result - 10x increased risk of SJS/TEN avoid use of CBZ
42
Carbamazepine dosing consideration
induces: 3A4, 1A2, 2B6, 2C9, 2C19, PGP, UGT Metabolized via 3A4
43
Autoinduction Carbamazepine
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
Carbamazepine CI
Bone marrow suppression
45
Carbamazepine boxed warning
Serious dermatologic reactions including SJS and TEN Aplastic anemia and agranulocytosis
46
Carbamazepine warnings
Fatal hypersensitivity reactions (DRESS, SJS, TEN)—25-30% cross reactivity with oxcarbazepine Anemia and agranulocytosis
47
Carbamazepine rare adverse effects
Rash Hyponatremia/SIADH Leukopenia/thromoctyopenia
48
Carbamazepine potentially fatal AE
SJS/TEN/DRESS rash Agranulocytosis Aplastic anemia Thrombocytopenia Hepatic failure
49
Carbamazepine common AE
N/V, constipation, dry mouth, ataxia, dizziness, sedation, blurred vision
50
Carbamazepine osteoporosis
Autoinduction may increase vitamin D metabolism leading to lower levels Monitor BMD if patient is on therapy for >5 years
51
Carbamazepine DDI
CYP3A4 inhibitors/inducers CYP3A4 and 1A2 substrates hormonal contraception clozapine grapefruit (increases CBZ levels)
52
CBZ monitoring parameters
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
Carbamazepine counseling
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
Lamotrigine Dosing
anti-kindling properties titration based on clinical symptoms and adverse effects Any break in therapy for >3-5 half-lives warrant re-titration
55
Lamotrigine CI
May have prodromal symptoms of chills, malaise, sore throat, fever Usually occurs within first 2-8 weeks, but can occur at any time
56
Lamotrigine boxed warning
Stop at any sign of rash Life-threatening rashes including SJS and TEN
57
Lamotrigine serious adverse effects rare
SJS/TEN rash Agranulocytosis Aseptic meningitis
58
Lamotrigine common AE
N/V/D, rash, ataxia, dizziness, diplopia, sedation
59
Lamotrigine DDI
Estrogen Carbamazepine -decrease VA clozapine -increase
60
Lamotrigine monitoring parameters
weight, rash
61
Lamotrigine counseling
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
Antipsychotics 2nd gen
improve mania within a few days
63
Clozapine
Used for treatment-resistant BD as monotherapy or with mood stabilizers Patients with affinity for manic polarity respond better to clozapine
64
Pregnancy and antipsychotics
Antipsychotics --> Quicker onset, fewer teratogenic risks
65
Pregnancy and Lithium
Ebstein’s anomaly Floppy baby syndrome AVOID during 1st trimester TDM during each trimester
66
Pregnancy and VA
Neural tube defects (4%), limb defects, cardiac issues, low IQ AVOID; if using supplement with folic acid 4mg
67
Pregnancy and Carbamazepine
Neural tube defects (3%), low IQ, fetal hemorrhage AVOID; supplement with folic acid 4mg Vitamin K 10mg during last month
68
Pregnancy and LAM
Neural tube defects (2%), midline facial cleft
69
Lactation
Lithium - CI VA-caution (compatible) Carb- caution (compatible)

CDM 4 Exam 2 (13 decks)

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