Bipolar disorder

Question 1

Lithium

Answer 1

• Only med to reduce suicide rate
• Effective in longterm prophylaxis of both mania and depression in 70% BAD 1 patients
• Positive response predictors:
  
  • Family member with response
  • Class pure mania, followed by depression

Question 2

Bipolar disorder

Answer 2

• 10% completed suicide rate

- Firearms > jumping > hanging

Question 3

Lithium SE

Answer 3

• GI most common, early in tx and resolves; thyroid, leukocytosis, ADH antagonism, interstitial renal fibrosis, hair loss, acne, seizures, cognitive slowing (alt lamotrigine), tremor
• 1.5-2: GI, dizzy, slurred speech, nystagmus
• 2-2.5: GI, blurry vision, clonus, convulsions, delirium, syncope
• 2.5-3: convulsions, renal failure (bad with ACE-I)

Question 4

Valproate (Depakote)

Answer 4

• As good as lithium to prevent mania, but not depression. Better tolerated.
• Positive response predictors:
  
  • Rapid cycling and mixed patients
  • Substance use (decreases it)
  • Anxiety disorder

Question 5

Lithium monitoring

Answer 5

• Baseline CBC, Cr, TSH, pregnancy test, q6m
• 5 days, 12 hr ss level, then q 3 mo
• Goal 0.6-1.2

Question 6

Valproate monitoring

Answer 6

• Baseline CBC, LFTs, pregnancy (neural tube)
• Start folic acid in women
• 5 days, 12, hr ss level; repeat CBC, LFTs
• Goal 50-125

Question 7

Valproate side effects

Answer 7

• Thrombocytopenia, PLT dysfunction
• GI: N/V, wt gain
• Transaminitis
• Sedation, tremor
• Neural tube defect
• Hair loss

Question 8

Carbamazepine (Tegretol)

Answer 8

• First line for acute mania and mania prophylaxis, but not used as much due to many SE
• Good for rapid cyclers and mixed patients

Question 9

Cabamazepine monitoring

Answer 9

• Baselien CBCs, LFTs, ECG
• 5 days 12hr ss level, repeat CBC, LFTs
• Goal 4-12 mcg/ml
• CHECK AND ADJUST at 1 month because induces own metabolism

Question 10

Carbamazepine side effects

Answer 10

• Rash most common
• AV conduction delays
• Drug-Drug interactions
• GI: N/V/D, transaminitis
• Sedation, dizzy, confusion
• Aplastic anemia, agranulocytosis in water retention and hyponatremia

Question 11

Lamotrigine (Lamictal)

Answer 11

• Good for less cognitive, and for neuropathic/chronic pain

Question 12

Lamotrigine monitoring

Answer 12

• Baseline LFTs
• Slow titration!! 25 by 2 weeks. Otherwise SERIOUS RASH
• If pt stops for 5 days must start over!
• NEED 100 for any benefit, which takes a month! Need a bridge e.g. lithium.

Question 13

Lamotrigine side effects

Answer 13

• SJS. If ANY rash develops, DC immediately
• VPA doubles lamotrigine level, so use slowe dose titration. Sertraline also increases lamotrigine.
• Less sedation, dizziness, ataxia, confusion

Question 14

33W hospitalized with first episode of mania. No previous depression. No drug or alcohol. No medical issues. What med?

Answer 14

• Lithium! Check Cr, TSH, pregnany. Discuss BC (IUD - not condom, pill, or depot - affects mood).
• Tegretol

Question 15

27M admitted with manic episode. Has had at least 4 manic or depressive episodes this past year. Struggled with EtOH. What med?

Answer 15

• Valproate.
• LFTs increase: Drinking versus transaminitis (watch over time - as long as they do not more than triple, no change in therapy indicated)