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PR - CNS > BIPOLAR DISORDER > Flashcards

BIPOLAR DISORDER Flashcards

1
Q

What is bipolar disorder?

A

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

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2
Q

What are the different mood states of BPD?

A
  1. Low or depressive
  2. High or manic
  3. Hypomanic
  4. Mixed
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3
Q

What is TYPE 1 BPD?

A
  • 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
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4
Q

What is TYPE 2 BPD?

A
  • 1 or more ep of severe depression
  • 1 or more hypomania = at least 4 days
  • No mania
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5
Q

1st Generation antipsychotics (typical)

A

Haloperidol
Chlorpromazine
Flupentixol

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6
Q

2nd Gen antipsychotics (atypical)

A

Quetiapine
Olanzapine
Risperidone
Clozapine

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7
Q

Atypical antipsychotics - MoA

A

Block post-synaptic dopamine (D2) receptors.
Also have activity at other receptors (5-HT2A)

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8
Q

Atypical antipsychotics - General side effects

A

Metabolic disturbances
- Weight gain
- Diabetes
- Lipid changes

Prolong QT interval
- Arrhythmias

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9
Q

Typical vs atypical

A

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.

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10
Q

Risperidone: SFx

A

Increased prolactin
Breast symptoms (men and women)
Sexual dysfunction

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11
Q

Clozapine - RARE SFx

A

Agranulocytosis (severe deficiency of neutrophils) = severe infections
Myocarditis

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12
Q

How long should treatment be for bipolar

A
  • For at least 2 yrs since the last manic episode
  • Or up to 5 yrs if pt has risk factors for relapse
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13
Q

Which drugs are used in BPD

A
  1. AP
    - HORQ
  2. Carbamazepine
  3. Valproate
  4. LITHIUM
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14
Q

ACUTE treatment for mania/hypomania

A
  1. Review meds
    * Stop antidepressant immediately, don’t taper down
  2. FIRST LINE: Haloperidol, olanzapine, quetiapine and risperidone
  3. Continue for at least 4 weeks after symptoms have subsided to maintain stability.
  4. 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
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15
Q

What is the main use of antipsychotics in bipolar?

A

To treat **acute episodes ** of mania and hypomania

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16
Q

What do you do in the ACUTE treatment of BPD if antipsychotic response are inadequate

A

Lithium (off label) or valproate may be added.

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17
Q

PROPHYLAXIS/LONGTERM TREATMENT of BPD

A
  • Psychological intervention
  • Drug history
    1. FIRST LINE: Lithium
    o Most effective long term treatment
    o Consider likelihood of recurrence in the individual patient
  1. 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
  2. Olanzapine or quetiapine as alternatives
  3. Benzodiazepines
  4. Carbamazepine
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18
Q

What antipsychotics can be used for the PROPHYLAXIS/ LONGTERM treatment

A

Olanzapine
Quetiapine
Asenapine

19
Q

Asenapine

A
  • Second generation antipsychotic drug
  • moderate to severe manic episodes
20
Q

Olanzapine

A
  • long-term management
  • licensed for the prevention of recurrence in patients whose manic episode has responded to olanzapine therapy
21
Q

Discontinuing antipsychotic drugs

A

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

22
Q

Benzodiazepines for PROPHYLAXIS/LONGTERM TREATMENT

A

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

23
Q

Carbamazepine for PROPHYLAXIS/LONGTERM TREATMENT

A
  • specialist
  • prophylaxis of manic-depressive disorder in pt unresponsive to** combination of other prophylactic drugs **
24
Q

Which valproate is used for bipolar?

A
  • valproid acid (as semisodium salt)
  • sodium valproate
25
Q

Use of valproate in bipolar

A
  1. Prophylaxis of bipolar
  2. Treating acute eps of mania
26
Q

Use of lithium in bipolar

A
  1. Prophylaxis of mania
  2. Treat acute eps of mania
27
Q

Bipolar depression

A
  1. Psychological intervention: CBT
  2. 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)
28
Q

Quetiapine in bipolar depression

A
  • requires frequent ECG monitoring due to QT interval prolongation
  • does increase = do ECG
29
Q

Lamotrigine in bipolar depression

A

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)

30
Q

What is the therapeutic range of lithium?

A

0.4 - 1mmol/L

31
Q

What is the therapeutic range of lithium in acute episode?

A

0.8-1mmol/L

32
Q

Measuring lithium levels

A

Measure levels 12 hours after dose
Then weekly until stable
Then 3 monthly for 1 year. Then 6 monthly after that

33
Q

Lithium SFx

A

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

34
Q

Lithium interactions

A
  • 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
35
Q

What levels is lithium toxic at?

A

2 mmol/L

36
Q

Lithium toxicity

A
  • Renal impairment – incontinence
  • Extrapyramidal Sfx – tremors
  • Visual disturbances – blurred vision
  • Nervous system disorder – confusion and restlessness
  • GI disorder – diarrhoea and vomiting
37
Q

Lithium toxicity vs other

A

lithium: SICK + TREMOR
theophylline: SICK + FAST
digoxin: SICK + SLOW

38
Q

Lithium: patient and carer advice

A
  • 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
39
Q

Lithium: monitoring

A
  • Renal, cardiac and thyroid function
  • ECG in patient with cardiovascular disease
  • Body-weight or BMI
  • Serum electrolytes (hyponatraemia = toxicity)
  • Full blood count
40
Q

Lithium Extrapyramidal symptoms

A

Fine treatment increasing to course tremor
Ataxia
Dysarthria
Myoclonus
Nystagmus
Muscle weakness

41
Q

Lithium - Prescribing

A

Prescribe by brand.
Lithium salts and different preparations vary in bioavailability.

42
Q

Lithium - pregnancy

A

Teratogenic
Effective contraception in women of child-bearing age.
Toxicity can occur in breastfed infants

43
Q

Interactions - increases risk of seizures w Lithium

A

Quinolones (ciprofloxacin)
SSRIs
Epilepsy (lowers seizure threshold)

PR - CNS (61 decks)

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