Bipolar disorder

Question 1

What are the types of Bipolar

Answer 1

Bipolar 1 - more severe
Bipolar 1- early age of onset
mixed affective - depression with mania
rapid cycling disorder - repeatedly swing from high to low without a normal period

Question 2

Why aren’t antidepressants used?

Answer 2

they can increase mania or mood instability

Question 3

what needs measuring before or when starting antipsychotics?

Answer 3

• weight or BMI
• pulse & BP
• fasting blood glucose or HbA1c
• blood lipid profile
• Offer (ECG) if:
  o it is specified for drug’s
  o CV risk / family history or risk factors such as cardiac arrhythmia
  o inpatients

Question 4

What is the treatment guideline?

Answer 4

Lithium or
valproate or olazapine or quetiapine

Question 5

What is the treatment for moderate to severe Bipolar and they’re taking lithium or valproate already?

Answer 5

check lithium levels and increase dose
increase dose of valproate
if already max dose then add either fluoxetine+olanzapine, quetiapine
if no response stop the add ons and add lamotrigine

Question 6

What is the treatment for moderate to severe bipolar if not taking anything?

Answer 6

fluoxetine+olanzapine or quetiapine
olanzapine on own or lamotrigine
if no response from fluoxetine+olnazapine then add on lamotrigine

Question 7

what is the treatment for mania if not taking lithium/ valproate already?

Answer 7

slowly taper off antidepressant if taking
offer antipsychotic whether antidepressant has been stopped or not
(haloperidol, olanzapine, quetiapine or risperidone)
try alternative antipsychotic if the first one didnt help depending on pt prefrence, co-morbidities and SE

Question 8

What is the treatment for mania if pts taking lithium or sodium valproate?

Answer 8

for lithium - monitor lithium levels and increase dose
sodium valproate - use max dose in BNF

Question 9

What needs measuring before lithium?

Answer 9

weight / BMI
test for urea, electrolytes, calcium, eGFR, thyroid, FBC
ECG for CV pts

Question 10

When should lithium levels be measured?

Answer 10

1 week after starting and weekly until stable and after every dose change

Question 11

what is the initial lithium level target?

Answer 11

0.6 - 0.8mmol/L

Question 12

What should levels be for acute period of mania?

Answer 12

0.8-1mmol/l

Question 13

How long after administration should lithium levels be taken?

Answer 13

12hrs post dose and serum level should be 0.4 - 1mmol/l

Question 14

What is the recommendation on NSAIDS and lithium?

Answer 14

recommend pts dont buy OTC as it ^ lithium levels
only take if prescribed and as prescribed not PRN
and lithium levels are monitored whilst on NSAIDs until stable

Question 15

What advice should be given to pts regarding lithium?

Answer 15

seek medical help if they become acutely unwell
stay hydrated
speak to GP if pregnant or planning
NO OTC NSAIDS

Question 16

How often is lithium monitored?

Answer 16

1st year - every 3 mnths
2nd year onwards - every 6 mnths
measure weight/BMI etc every 6 mnths

Question 17

How long does it take to stop lithium?

Answer 17

over 4 weeks to 3 months with monitoring during and afterw

Question 18

What are the SE of lithium?

Answer 18

nausea
diarrhoea
drymouth/ metallic tatse
mild tremor
weight gain

Question 19

what are the symptoms of lithium toxicity?

Answer 19

mild to moderate toxicity-
muscle weakness, GI discomfort, nausea, tremors, diarrhoea, vomiting
severe - (levels of 2.0 or more) - seizures, agitation, kidney failure, tachycardia, hyperthermia, arrhythmias

Question 20

What are the common interaction for lithium?

Answer 20

NSAIDS= ^ lithium
ACEi/ARBs/CCB/ celecoxib/ indomethacin/ acetominophen / metronadiazole / diuretics = ^lithium

all SSRIS - ^ serotonin syndrome
and QT prolongation with (cital+esc)

Question 21

What are the CI for lithium?

Answer 21

cardiac rhythm disorders
addisons
untreated hypothyroidism
dehydration
low sodium

Question 22

What are the 3 main types of lithium toxicity?

Answer 22

acute = overdose
acute on chronic= long term use with one over dose
chronic = accumulation over time

Question 23

What is the treatment for lithium toxicity?

Answer 23

mild - hydration
moderate to severe - stomach pump, IV, anticonvulsants

Question 24

What foods/ drinks interact with lithium?

Answer 24

salt ^ = low lithium
caffeine ^= low lithium
alcohol = hepatic toxicity

Question 25

What are the first generation antipsychotics?

Answer 25

Haloperidol
chlorpromazine
promazine
prochlorperazine
flupentixol

Question 26

If pt stops smoking does antipsychotic dose need adjusting?

Answer 26

dose needs decreasing smoking decrease levels

Question 27

What are the interaction with first haloperidol?

Answer 27

antiepileptics = decrease conc of halo
interacts with drugs which ^ QT interval
^ risk of hypotension with antihypertensive meds
ritonavir - ^ conc of halo
rifamipicin - decreases levels

Question 28

What are the SE for all antipsychotics?

Answer 28

Agitation; amenorrhoea; arrhythmias; constipation; dizziness; drowsiness; dry mouth; erectile dysfunction; fatigue; galactorrhoea; gynaecomastia; hyperglycaemia;

Question 29

What are the SE for haloperidol?

Answer 29

Depression; eye disorders; headache; hypersalivation; nausea; neuromuscular dysfunction; psychotic disorder; vision disorders; weight decreased