bipolar disorder Flashcards
what is bipolar disorder?
lifelong, cyclical mood disorder
recurrent fluctuations in mood, energy & behaviour
mania & depressive
what can induce bipolar disorder?
treatment with antidepressants: few days to 2 weeks, increase NE/DA transmission
medical conditions inducing mania?
CNS disorders (brain tumor, stroked, head injuries)
CNS injfections (encephalitis, sepsis)
electrolyte/metabolic abnormalities
endocrine/hormonal dysregulation (hypothyroidism, hyperthyroidism)
vitamins & nutritional deficiencies
what medications can induce mania?
theophylline, caffeine
pseudoephedrine
st john’s wort
drug abuse: alcohol
drug withdrawal
antidepressants
DA augmenting agents
NE augmenting agents
thyroid hormone (levothyroxine)
steorids
what are the clinical presentation?
DIG FAST
distractability
irresponsible
grandious
flight of ideas
activities increased
sleep decreased
talkaltives
what is important to identify during hx taking?
hx of mania/hypomania
sucidal/homicidal ideations & risks
what lab test do you need to do before treatment?
FBC
TFT
renal panel
liver panel
ECG
FBG, lipids
pregnancy
HLA-B*1502 before starting carbamezepine
what is the goal of treatment?
reduce frequency, duration and severity of mood episodes
prevent suicide
maximise adherence with therapy
minimise side effects
what are the non-pharmacological approach for bipolar?
recognise early signs & symptoms
psychotherapy
stress reduction therapies
sleep hygiene
how is benzodiazepine use?
short term, PRN
onset within hours
taper off when condition improved & mood stabilizer optimized
which mood stablizier have the strongest evidence for suicide reduction?
lithium
what mood stabiliser can be use for mania?
antipsychotic: aripiprazole, olanzapine, quetapine, risperidone, haloperidol
lithium: 1st line for maintenance & relapse/suicide prevention
valproate (least prefered)
which mood stabiliser to be used for depression?
lithium: 1st line for maintenance & relapse/suicide prevention
quetapine, olanzapine + fluoxetine, lurasidone, cariprazone
lamotrigine
what is the MOA for lithium?
decrease 5HT & DA reuptake
what should be monitored when on lithium?
TFT, eletrolyte, calcium & renal function, urinalysis, FBC, ECG, pregnancy
serum lithium level: target steady dose in 5 days
acute mania: 0.8-1.0 mEg/L
maintenance: 0.6-1.0 mEg/L
what are the side effects for lithium?
fine coarse tremors
hypothyroidism
polyuria
ECG changes
weight gain, nausea, cognitive impairment, DM insipidius
what is the MOA for sodium valproate?
increase GABA levels
what should be monitored for sodium valproate?
LFTs, pregnancy
serum valproate: target 50-125mcg/mL
adverse effects for sodium valproate
hepatotoxicity in child
rash, SJS/TEN
decrease PLT, pancreatitis
increase weight
what to take note for sodium valproate?
cannot give to pregnant women
cannot give together with lamotrigine –> increase risk of SJS/TEN
side effects of carbamazepine?
decrease Na, WBC
rash, SJS, TEN
what to take note for carbamezepine?
should not give together with clozapine, increase risk of agranulocytosis
what increases the risk of lithium toxicity?
STAND UP
sodium depletion
thiazide
ACEi/ARB
NSAIDs
dehydration
clearance of lithium?
100% renal, not affected by liver
which mood stabilizer should be administered without food?
lithium & valproate
food slow down absorption
when is blood sample taken for lithium TDM?
sample 12hrs after prev dose
take 5-7 days after, q2w till stabilize, q3 months for 1 yr, q3-6mths
when should blood sample be taken for valproate?
trough sample
not routinely taken, unless signs of toxicity/non-adherence
when should carbamazepine blood sample be taken?
after 4wks, 3-5days later, q6month for 1 yr thn annually
how long should mood stabilizer be given?
2-4 weeks
if no response, augment or switch to SGA
what to take note for ECT?
lithium, anticonvulsants & benzodiazepeines need to be stop 12hrs before
what should be monitored for when on carbamezepine?
FBC, LFT
serum lvl, target 4-12 mcg/mL
which is a CYP inducer?
carbamezepine
how to manage bpd in pregnancy?
avoid valproate
ECT is severe
which mood stabilizer for renal impairment?
valproate
which mood stabilizer for liver impairment?
lithium
