BIPOLAR DISORDER Flashcards
What is bipolar disorder?
Alternating depression and mania can last for several weeks or months
o depression - feeling very low and lethargic
o mania - feeling very high and overactive
What are the different mood states of BPD?
- Low or depressive
- High or manic
- Hypomanic
- Mixed
What is TYPE 1 BPD?
- 1 high/manic ep = longer than a week
- May only experience mania
- Some experience deep depression after 1 ep of mania
- Manic ep may last 3-6 months
What is TYPE 2 BPD?
- 1 or more ep of severe depression
- 1 or more hypomania = at least 4 days
- No mania
1st Generation antipsychotics (typical)
Haloperidol
Chlorpromazine
Flupentixol
2nd Gen antipsychotics (atypical)
Quetiapine
Olanzapine
Risperidone
Clozapine
Atypical antipsychotics - MoA
Block post-synaptic dopamine (D2) receptors.
Also have activity at other receptors (5-HT2A)
Atypical antipsychotics - General side effects
Metabolic disturbances
- Weight gain
- Diabetes
- Lipid changes
Prolong QT interval
- Arrhythmias
Typical vs atypical
Compared to typical antipsychotics:
- Greater activity at other receptors (antagonism of 5-HT2A)
- Looser binding to D2 receptors.
- Lower risk of extrapyramidal symptoms.
- More efficacious in treatment resistant schizophrenia.
Risperidone: SFx
Increased prolactin
Breast symptoms (men and women)
Sexual dysfunction
Clozapine - RARE SFx
Agranulocytosis (severe deficiency of neutrophils) = severe infections
Myocarditis
How long should treatment be for bipolar
- For at least 2 yrs since the last manic episode
- Or up to 5 yrs if pt has risk factors for relapse
Which drugs are used in BPD
- AP
- HORQ - Carbamazepine
- Valproate
- LITHIUM
ACUTE treatment for mania/hypomania
- Review meds
* Stop antidepressant immediately, don’t taper down - FIRST LINE: Haloperidol, olanzapine, quetiapine and risperidone
- Continue for at least 4 weeks after symptoms have subsided to maintain stability.
- If response is inadequate, then lithium (off label) or valproate may be added.
* If already on lithium – check levels and add antipsychotic
* If on valproate – increase dose and add antipsychotic if no improvement
What is the main use of antipsychotics in bipolar?
To treat **acute episodes ** of mania and hypomania
What do you do in the ACUTE treatment of BPD if antipsychotic response are inadequate
Lithium (off label) or valproate may be added.
PROPHYLAXIS/LONGTERM TREATMENT of BPD
- Psychological intervention
- Drug history
1. FIRST LINE: Lithium
o Most effective long term treatment
o Consider likelihood of recurrence in the individual patient
- SECOND LINE: Valproate
o If lithium is not tolerated or contraindicated
o Can be used as monotherapy or in combination of lithium if lithium alone is ineffective - Olanzapine or quetiapine as alternatives
- Benzodiazepines
- Carbamazepine
What antipsychotics can be used for the PROPHYLAXIS/ LONGTERM treatment
Olanzapine
Quetiapine
Asenapine
Asenapine
- Second generation antipsychotic drug
- moderate to severe manic episodes
Olanzapine
- long-term management
- licensed for the prevention of recurrence in patients whose manic episode has responded to olanzapine therapy
Discontinuing antipsychotic drugs
If the patient is taking an antipsychotic and another antimanic drug, then withdraw antipsychotics GRADUALLY over 4 weeks
If the patient is taking an antipsychotic as monotherapy, then reduce the antipsychotic GRADUALLY over 3 months
Benzodiazepines for PROPHYLAXIS/LONGTERM TREATMENT
e.g lorazepam
o used in initial stages of treatment for behavioural disturbance or agitation
o Should not be used for long periods due to dependence
Carbamazepine for PROPHYLAXIS/LONGTERM TREATMENT
- specialist
- prophylaxis of manic-depressive disorder in pt unresponsive to** combination of other prophylactic drugs **
Which valproate is used for bipolar?
- valproid acid (as semisodium salt)
- sodium valproate
Use of valproate in bipolar
- Prophylaxis of bipolar
- Treating acute eps of mania
Use of lithium in bipolar
- Prophylaxis of mania
- Treat acute eps of mania
Bipolar depression
- Psychological intervention: CBT
- If not on any treatment:
Fluoxetine + olanzapine (mood stabilising ability)
Quetiapine
* requires frequent ECG monitoring due to QT interval prolongation
* does increase = do ECG
Olanzapine only
Lamotrigine if no response to the above
* Monitor skin rash
* Note titration schedule
* 25mg od for 2 weeks, increase to 50mg od for another 2 weeks, 100mg for a week
* Titrate slowly (risk of sfx)
Quetiapine in bipolar depression
- requires frequent ECG monitoring due to QT interval prolongation
- does increase = do ECG
Lamotrigine in bipolar depression
If no response to previous treatment
* Monitor skin rash
* Note titration schedule
* 25mg od for 2 weeks, increase to 50mg od for another 2 weeks, 100mg for a week
* Titrate slowly (risk of sfx)
What is the therapeutic range of lithium?
0.4 - 1mmol/L
What is the therapeutic range of lithium in acute episode?
0.8-1mmol/L
Measuring lithium levels
Measure levels 12 hours after dose
Then weekly until stable
Then 3 monthly for 1 year. Then 6 monthly after that
Lithium SFx
Long term use has been associated with:
* Thyroid disorder (amiodarone also has this as a SFX)
* Mild cognitive and memory impariemnt
* Rhabdomyolysis
* Benign intercranial hypertension (look out for headaches)
* 1st trimester = teratogenic
* Lower seizure threshold
Lithium interactions
- Hyponatraemia – increases risk of toxicity – diuretics
- Salt imbalance
- Serotonin syndrome
- Extrapyramidal SFx
o haloperidol + metoclopramide - QT prolongation
- Renally cleared drugs (increase risk of toxicity)
- Reduced seizure threshold
- Hypokalaemia
What levels is lithium toxic at?
2 mmol/L
Lithium toxicity
- Renal impairment – incontinence
- Extrapyramidal Sfx – tremors
- Visual disturbances – blurred vision
- Nervous system disorder – confusion and restlessness
- GI disorder – diarrhoea and vomiting
Lithium toxicity vs other
lithium: SICK + TREMOR
theophylline: SICK + FAST
digoxin: SICK + SLOW
Lithium: patient and carer advice
- Report signs and symptoms of lithium toxicity,
- hypothyroidism, renal dysfunction, and benign intracranial hypertension (persistent headache and visual disturbances)
- Maintain adequate fluid intake and avoid dietary changes which reduce or increase sodium intake
- May cause drowsiness, avoid alcohol.
- Always carry lithium alert card
Lithium: monitoring
- Renal, cardiac and thyroid function
- ECG in patient with cardiovascular disease
- Body-weight or BMI
- Serum electrolytes (hyponatraemia = toxicity)
- Full blood count
Lithium Extrapyramidal symptoms
Fine treatment increasing to course tremor
Ataxia
Dysarthria
Myoclonus
Nystagmus
Muscle weakness
Lithium - Prescribing
Prescribe by brand.
Lithium salts and different preparations vary in bioavailability.
Lithium - pregnancy
Teratogenic
Effective contraception in women of child-bearing age.
Toxicity can occur in breastfed infants
Interactions - increases risk of seizures w Lithium
Quinolones (ciprofloxacin)
SSRIs
Epilepsy (lowers seizure threshold)
