Bipolar Disorder

Question 1

T/F Monotherapy is standard for BPD

Answer 1

FALSE, monotherapy is not appropriate

Question 2

Which LAIs are approved for BPD?

Answer 2

Aripiprazole
- Maintena
- Asimtufii

Risperidone
- Consta
- Rykindo

Question 3

What is aripiprazole approved for?

Answer 3

Mania BPD, Maintenance BPD, MDD augmentation

Question 4

What is asenapine approved for?

Answer 4

Mania BPD, Maintenance BPD

Question 5

What is cariprazine approved for?

Answer 5

Mixed BPD, Depression BPD, Mania BPD

Question 6

What is lumateperone approved for?

Answer 6

Mixed BPD, Depression BPD

Question 7

What is lurasidone approved for?

Answer 7

Mixed BPD, Depression BPD

Question 8

What is olanzapine approved for?

Answer 8

Mixed BPD, Depression BPD (w/ fluoxetine), Mania BPD, Maintenance BPD, MDD augmentation (w/ fluoxetine)

Question 9

What is Lybalvi approved for?

Answer 9

Mania BPD, Maintenance BPD

Question 10

What is quetiapine approved for?

Answer 10

Mixed BPD, Depression BPD, Mania BPD, Maintenance BPD, MDD augmentation

Question 11

What is risperidone used for?

Answer 11

Mania BPD, Maintenance BPD

Question 12

What is ziprasidone used for?

Answer 12

Mixed BPD, Mania BPD, Maintenance BPD

Question 13

Which SGA can be used for maintenance BPD?

Answer 13

• Aripiprazole
• Asenapine
• Olanzapine
• Lybalvi
• Quetiapine
• Risperidone
• Ziprasidone

AAOLQRZ

Question 14

Which SGA can be used for mania in BPD?

Answer 14

• Aripiprazole
• Asenapine
• Cariprazine
• Olanzapine
• Lybalvi
• Quetiapine
• Risperidone
• Ziprasidone

AACOLQRZ

Question 15

Which SGA can be used for depression in BPD?

Answer 15

• Cariprazine
• Lumateperone
• Lurasidone
• Olanzapine
• Quetiapine

CLLOQ

Question 16

Which SGA can be used for mixed BPD?

Answer 16

• Asenapine
• Cariprazine
• Lumateperone
• Lurasidone
• Olanzapine
• Quetiapine
• Ziprasidone

ACLLOQZ

Question 17

Which AEDs/mood stabilizers can be used in BPD mania?

Answer 17

• Carbamazepine
• Lithium
• Valproate

Question 18

Which AEDs/mood stabilizers can be used in BPD maintenance?

Answer 18

• Lamotrigine
• Lithium

Question 19

T/F Lithium should not be used in suicide risk

Answer 19

FALSE: Lithium has anti-suicidal properties

Question 20

T/F It’s not a good sign if a patient feels great after 2 weeks of therapy

Answer 20

TRUE: It is a sign of a manic switch

Question 21

What is IGALMI?

Answer 21

Dexmedetomidine
- SL film for acute agitation in BPD or schizo
- Alpha 2 agonist
- SL is a limitation (difficult to administer)

Question 22

What is Lybalvi?

Answer 22

Olanzapine + samidorphan
- Samidorphan reduces metabolic effects of olanzapine
- DO NOT use with opioids -> withdrawal

Question 23

Lithium

Answer 23

• Not good for rapid cyclers and mixed states
• No hepatic anything
• CI in severe renal or cardiac disease
• Nephrogenic diabetes up to 50% of patients, AKI common, CKD reported
• Thyroid must also be monitored
• GI/CNS ADE dose related
• Muscle weakness/lethargy/tremor common
• Best for euphoric mania
• Significant dermatologic effects

Question 24

Lithium in pregnancy/lactation

Answer 24

Not recommended in pregnancy - floppy baby syndrome

Contraindicated in nursing

Question 25

How long does lithium take to work?

Answer 25

6-10 days for mania, full effect in 3 weeks 6-8 weeks for antidepression Best for less complicated patients (fewer episodes, not mixed)

Question 26

Which drugs can increase lithium levels?

Answer 26

- ACE/ARBs - NSAIDs - Diuretics

Question 27

Which drugs can decrease lithium levels

Answer 27

Methylxanythines (caffeine, theophylline)

Question 28

Valproic acid

Answer 28

- Early dose forms GI irritating - ER form has lower bioavailability - Tremor, sedation - Prolonged bleeding - Weight gain!! - Alopecia

Question 29

What are the BBW for valproic acid?

Answer 29

Hepatotoxicity Fetal risk Pancreatitis

Question 30

What can be used to treat tremor in most cases?

Answer 30

Beta blockers

Question 31

Carbamazepine

Answer 31

- Bone marrow suppression, leukopenia -> probably not a good idea - Asian HLA-B 1502 increases SJS/TEN risk 10x - Hyponatremia, confusion

Question 32

Does lamotrigine require serum concentration monitoring?

Answer 32

No

Question 33

T/F: Antidepressants should not be used unopposed in BPD

Answer 33

TRUE: Can cause manic switch, especially TCAs

Question 34

Benzodiazepine place in BPD

Answer 34

High potency (clonazepam, lorazepam) can be used short-term as adjunct for anxiety/panic/agitation during acute mania - Lorazepam IM for hepatic dysfunction - Avoid in substance abuse

Question 35

T/F augmentation agents should be continued in BPD once proven efficacious

Answer 35

FALSE: taper and discontinue if possible when the acute mood episode is in remission

Question 36

Which BZDs have no hepatic burden?

Answer 36

OTL - over the liver Oxazepam Temazepam Lorazepam***