Bipolar Disorder Flashcards
- What are some key characteristics about Bipolar 1 ?
- What else can characterize Bipolar 1? - Key characteristics about Bipolar 2?
- MANIA (>=1 week) +/- Major depression . Any sort of hospitalization
- Major depression + HYPOMANIA (>=4 days)
DSM-5TR Criteria -Mania
1. Distinct period of abnormally and persistently elevated, expansive , or irritable mood and abnormally
-AND persistently increased ___ or ___
-Lasting at least ????
- 3 or more of the following sx’s (4 if mood is only irritable)
(Explain DIGFAST)
- Activity, energy
- 1 week, and present MOST of the day, nearly everyday OR any period of hospitalization - Distractibility,
Indiscretions (excessive involvement in activities that have high potential for painful consequences)
Grandiosity or inflated self esteem
Flight of ideas (racing thoughts)
Activity (incr goal directed activity or psychomotor agitation)
Sleep (decreased need)
Talkativeness
DSM5 TR Criteria - Depression
1. 5 or more of the following sx’s have been present during the same 2 week period
(Explain DSIGECAPS)
- At least one of these following sx’s must be present for diagnosis
- Depressed mood, most of day, nearly everyday
-Sleep can be up or down
-Interests markedly diminished (Anhedonia)
-Guilt or feelings of worthlessness
-Energy is DOWN
-Concentration is DOWN
-Appetite is up or down
-Psychomotor agitation or retardation
-Suicidal ideation - Depressed mood or Anhedonia
See Chart on Agents and Indications
See chart and memorizie
Lithium (Lithobid or Eskalith) :
1. FDA labeled indications?
2. Off label ?
3. Formulations such as IR and ER?
-Liquid version ?
4. Starting dose?
5. Maintenance dose?
-Max daily dose?
6. ADjust dosing in which population ?
7. Why would single daily dosing be considered?
8. Conversion between lithium citrate and carbonate?
- Bipolar disorder : acute mania and Maintenance
- Bipolar depression, antidepressant augmentation, prevention of suicide
- IR and ER : Carbonate
-Liquid = citrate - 300mg BID
- 900-1800 mg in 2-3 divided doses
2400 mg/day - Elderly
- Decr polyuria, decr renal AE’s
- 8mEQ lith citrate = 300mg lith carb
Lithium AE’s :
1. Acute presentation (7)
- Long term Impacts : L,H,W,P,A,C,N,H,Reduced ____
- Acute toxicity : V/D, Course ___, A, M,Lack of ___, B____, Large volumes of ____, S, C
- GI upset (N/V/D)
- Polyuria, polydipsia
- acne
- FINE hand tremor
- cognitive dulling, sedation
- impaired memory
- weight gain !!!
- Leukocytosis (benign)
- Hypothyroidism
- Weight gain (~4-6kg over 2 yrs)
- Psoriasis
- Alopecia
- Cardiac ECG changes
- Nephrogenic diabetes insipidus
- Hypercalcemia
- Reduced kidney function
- Vomiting /diarrhea
- Course tremor
- Ataxia
- Muscle weakness
- Lack of coordination
- Blurred vision
- Large volumes of dilute urine
- Seizure
- Coma
Lithium : Monitoring
1. 5 things
2. Pregnancy test bc u must avoid use in ? –> can cause?
- Why must it be monitored? *BBW
- Target blood concentrations for acute tx vs maintenance?
- When should u check serum levels? When should these levels be drawn?
Severity levels/Serum Levels and Signs/sx’s + treatment :
A. Mild
B. Mod
C. Severe
- Renal (Scr. BUN)
- Thyroid function (TSH, T4)
- Electrolytes (serum Na+, CA2+)
- CBC w/differential
- EKG for >40
- 1st trimester, increased congenital cardiac malformations (ebstein’s anomaly)
- Narrow thera index
- Acute : 0.8-1.2 mEq/L (up to 1.5)
Maintenance : 0.6-1.0 mEq/L - 3-5 days after initiation or change in dose
-Levels should be drawn 12 hrs post dose
A. >1.5
-Diarrhea, vom, drowsy, muscle weakness, decr coordination
-hold lithium x 1 day then re-eval
B. > 2
-Ataxia, blurred vision, tinnitus, ECG changes
-Correct fluid and electrolyte imbalance
C. > 2.5
-Neuological changes, coma
-Hemodialysis
- What drugs decrease lithium levels? (5)
- What drugs increase Lithium levels? (5)
- Theophylline, Caffeine, acetazolamide , loop diuretics , Incr Na intake
- Nsaids, Thiazide diuretics, ACEI/ARBS, Decr Na intake
Patient Education : Lithium
1. When should u take lithium
2. How to avoid upset stomach?
3. What to do with ER products?
4. How to cater diet ?
5. Report any ?
6. Maintain adequate __ and avoid ___ but report excessive ___ and or presence of ___
7. Avoid ____
8. Make sure who knows you’re prescribed lithium?
9. Contact provider if?
10. Report any worsening of ___,___ or __
- Same time every as prescribed
- Take with food
- DO NOT CRUSH, CHEW OR SPLIT
- Avoid excessive caffeine, let ur provider know if u change ur sodium intake. Low salt diet = incr lithium concentrations
- Changes or worsening of N/V/D/Tremor
- Hydration, dehydration , thirst, signif urination
- OTC anti inflamm agents
- providers
- You are breast feeding, become preg or plan to become preg
- Sleep, depressive, or manic sx’s
Valproic Acid/Divalproex
1. FDA indications?
2. Off label indications?
3. General starting dose?
4. FOr each formulation how often are they dosed?
5. Loading strategy ?
6. How do u quickly calculate a patients daily dosing needs?
7. How do you convert between formulations?
- Focal/gen onset seizure
-migraine prophylaxis
-Acute manic or mixed episodes (Superior to Li+ for mixed episodes) - Bipolar maintenance+ depression, migraine , status epilepticus
- 750 mg daily in divided doses
- ER = daily , DR = BID, IR = TID
- 20mg/kg/day (25mg/kg for ER)
- add a zero to the pt’s weight in pounds to get a general estimation
- IR to DR –> Same dose, can decr frequency of dosing once at steady state
DR–> ER: increase ER dose by 8-20%, dosed ONCE DAILY
AE’s : Valproic ACid
1. Contraindicated in ? (4)
- Dose related ?
- BBW ? (3)
- Other non dose related ae’s?
- Hepatic disease/signif hepatic dysfunction
-Hypersensitivity
-urea cycle disorders
-mitochondrial disorders caused by mutations in POLG or children <2yrs supsected of having POLG related disorder - N/V/D
-Tremor
-Sedation
-Dizzy or ataxia
-Alopecia
-WEIGHT GAIN
-Thrombocytopenia
-Hyperammonemia (treat w l carnitine or lactulose)
-Mildy incr LFTS - Pancreatitis, Teratogenicity, Hepatoxicity
- Agranulocytosis, Enceph, PCOS, Metab syndrome, rash, SJS/TEN/DRESS, incr suicidality
VPA Monitoring :
- Drug monitoring : Level range?
-Typically used to assess?
-Target ? - DDI’s : VPA levels decrease due to which 2 drugs?
- DDI’s : VPA levels INCR with which drugs?
- VPA will DECR LEVELS OF? but INCR levels of?
- This drug has additive effects from use with ?
- Inr risk of bleeding when administered with ?
- Can cause __ w/hepatotoxic agents
- 50-125 mcg/mL (maintenance)
80-125 (Acute mania)
-Toxicity
->80-90 mcg/mL - Carbapenem abx, and phenytoin
- Lamotrigine and ritonavir
- Total phenytoin
- Lamictal (2 fold) - Other sedating agents
- ASA and warfarin
- hepatitis
VPA : Patient Education
1. When should u take it ?
2. Which formulation can you sprinkle over food?
3. Check with PCP before taking any other meds including ?
4. Medicine can cause damage to liver/pancreas, report signs such as?
5. How will this concentration of drug be checked?
6. Don’t become __ while on med.
7. Side effects are common and include?
8. Report any unusual ___ to provider
9. Report any worsening of __,__ or __
- Take at same time everyday as prescribed, ideally w/food
- DR capsules, but dont chew the contents. (ER and DR tabs must be taken whole)
- OTC meds and herbal/vitamin products
- abdom pain, nausea, vomiting, flu like sx’s or malaise. Dark urine, tiredness, decr appetite or yellowing of skin/eyes
- Blood draws
- pregnant
- Hand or arm tremors/shakiness, feeling sleepy, hair loss, dizzy, weight gain, weakness or unsteadiness, and menstrual changes in women
8/. bruising
- sleep, mood sx’s or suicidal thoughts
Carbamazepine (Tegretol):
1. FDA labeled indications? (3)
2. Off label ?
3. Potent ___ with ___. This begins how many days after therapy initiation ? When does it stop?
- Acute manic or mixed bipolar 1 episodes
(Less efficacy in maintenance or BP depression)
-Epilepsy
-Trigeminal Neuralgia - Bipolar maintenance and depression
- CYP3A4 inducer w/autoinduction
- Starts 3-5 days after therapy initiation w/complete autoinduction 3-5 weeks at stable dose
Carbamazepine AE’s :
- Common ae’s include?
- Distinguishing AE’s:
-Name 2 BBW’s
-Ae’s in case of overdose (2)
-H, H, O
- N/V, constipation
* Dry mouth
* Sedation
* Dizziness/ orthostasis
* Confusion/ataxia
* Anticholinergic side effects
* Diplopia
* Increased LFTs (transient)
* Rash - Fatal hypersensitivity rxns (SJS, TEN, DRESS with HLAB1502)
-Hematologic effects (Aplastic anemia and agranulocytosis)
-Cardiac abnorms, seizure
-Hyponatremia (SIADH)
-Hepatotoxic
-Osteoporosis/Osteomalacia
Monitoring for Carbamazepine : dont have to know
1. Serum electrolytes particularly ?
2. C__
3. Liver?
4. Heart?
5. Women who can become with child?
6. Kidney?
7. Weight
8. Bones?
9. HLA… which 2?
- Therapeutic drug monitoring : Doesnt correlate well to ___ in bipolar disorder
-Whats the epilepsy therapeutic range?
-Draw levels when ?
-Due to autoinduction, what happens to levels?
–> COnsider serum concentrations after 4 weeks
- Na+
- CBC with differential
- LFTS
- EKG
- Preg test, category D
- Renal function
- weight
- bone mineral density
- HLAB1502 if asian
HLAA3101 genetic testing - efficacy
-4-12 mcg/mL
-2-5 days after initiation or dose change
-Levels may not be stable until 3-5 weeks at stable dose
DDI’s Carbamazepine :
1. CBZ will decrease levels of which drugs? (6)
2. CBZ levels INCREASE WITH ? (2)
3. CBZ levels DECREASE with ? (1)
- Anticonvulsants (CBZ itself bc of auto induction), lamictal, VPA
- CCB’s
-Protease inhibs
-3a4 substrates (alpraz, Birth control, abilify, citalopram, lurasidone)
- 1A2 substrates (CLozapine, olanz, asenapine)
-Apixaban, Dabigatran, Rivaroxaban, Warfarin - 3A4 inhibs (Azole antifungals, cimedtidine, fluoxetine, grapefruit juice)
-ccb’s - 3a4 inducers (rifampin, phenytoin, phenobarb)
CBZ : PATIENT EDUCATION
1. TAKE AT WHAT TIME EVERDAY?
2. IR TABS OR SUSPENSION NEEDS TO BE TAKEN WITH ?
3. ER FORMS NEED TO BE TAKEN ?
4. ER CAPSULES CAN BE ?
5. WHAT CAN INCR SERUM CONCENTRATION AND SHOULD BE AVOIDED?
6. CHECK WITH __ BEFORE OTHER MEDS
7. Med can cause change in blood cells affecting immune function, report what sx’s?
8. If you develop __ consult with PCP immed
9. What will be drawn to monitor for blood or electrolyte problems
10. Report any _____
11. use during __ not advised. dont become __ while taking med!
12. your BC may become ____ on CBZ. May need ____
13. Report any worsening of ? (3)
- same time everyday as prescribed
- food
- whole, not crushed or chewed or split
- opened and contents sprinkled on food
- grapefruit
- pcp
- mouth sores or flu like sx’, or if u have history of blood problems
- rash
- blood
- incr of sedation , naueua, muscle weakness , or falls
- pregnancy. pregnant
- less effective . higher dose, and or alt birth control
- sleep, mood sx’s or suicidal thoughts
Lamotrigine (Lamictal) :
1. Indicated for ? (3)
2. Off label for?
3. How is the drug metabolized?
4. Metab will be increased for meds that do what? What meds are we referring to ? (4)
5. Titration of lamictal must be restarted if?
- Maintenance tx of bipolar 1 disorder
-Partial and primary gen tonic clonic seizures - Bipolar Depression
- Glucoronidation
- Meds that induce/inhibit UGT. Phenytoin, phenobarb, carbam, primidone
- Doses are missed for >= 3 days
Lamictal AE’s :
1. Whats the BBW?
2. What increases the risk for this?
3. More common ae’s such as B, N,V, D, A,CNS (name a few sx’s) , increased ___, abnorm ___, DRESS, A__
LAMICTAL MONITORING :
- DDI’s? (2)
- SJS/TEN
- Rapid titration of drug
-delayed reaction can occur typically in 2-8 weeks - Benign rash, nausea, vom, diarrhea, agranulocytosis
-Ataxia, dizzy, sedation , diplopia, HA, dream abnorms
-Suicidality
-ecg findings
-aspetic meningitis
- estrogen containing products will decr lamotrigine and VPA will INCR lamo by 2fold
LAMICTAL PATIENT ED:
1. Food with med?
2. What to do if med makes u tired?
3. Does it begin working right away?
4. Warn patient what to do with rash
5. Avoid trying?
6. Report use of other meds such as?
7. Which drugs decrease lamo concentration?
8. Report a planned or unplanned ___ ,and report if you plan on ___ to doctor. However, this is to adjust drug values… shouldnt be harmful to baby.
- With or without food, depending on how it makes u feel
- take in morning OR evening
- No, takes time to work bc of titration
- Rash appears, stop taking med, call healthcare provider. rash can come in 1st few weeks or several months
- new body products (soap, meds, foods) to avoid occurrence of unknown rashes
- VPA, CBZ
- Oral contraceptives or estrogens.
- Pregnancy , breast feeding
ANTIPSYCHOTICS :
1. Which are effective for acute mania?
2. Which ones are preferred?
3. Which can worsen depression?
4. Name 7 antipsychotics FDA INDICATED for Mania?
5. Name 1 that’s off label indicated for mania and maintenance ?
6. Name 4 that are fda labeled for MAINTENANCE?
7. Name 5 that are FDA LABELED for Bipolar DEPRESSION
- FGA’s and SGA’s
- SGA’s , due to tolerability
- FGA’s
- Abilify, Asenapine, Cariprazine, Olanzapine, quetiapine, risperidone, ziprasidone
- Clozapine
- abilify, olanzapine, quetiapine, ziprasidone (as an adjunct!)
- Cariprazine, lumateperone , lurasidone, olanzapine/fluoxetine combo strictly, quetiapine
Non pharm :
1. Adequate ___
2. S
3. E
4. __ reduction
5. P
6. E
7. B
8. R
- Nutrition (mediterranenan diet can improve depressive sx’s )
- Sleep!
- Exercise (can help w/depressive sx’s)
- Stress
- Psycho educational programs (adjunct)
- Electroconvulsive therapy
- Bright light therapy
- Repetitive transcranial magnetic stimulation
Kim , see CANMAT guidelines
Special POP Pregnancy!
See chart
