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Therapeutics 3 > Bipolar Disorder > Flashcards

Bipolar Disorder Flashcards

1
Q

What is bipolar disorder?

A

a serious brain disorder characterized by extreme alterations in mood, energy level, and thought processes, with a reduced capacity to function “normally” in daily life; associated with HIGH RATES OF MEDICATION NON-ADHERENCE

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2
Q

What medications may produce manic-like symptoms?

A

-antidepressants= TCAs, MAOIs, SSRIs
-anxiolytics= buspirone, benzodiazepines
-stimulants= cocaine, MPH, AMP, ephedrine, pseudoephedrine
-endocrine= corticosteroids, thyroid supplements, androgens
-others: levodopa, EtOH, bronchodilators

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3
Q

Describe Bipolar I Disorder

A

at least 1 manic episode- if a patient has a manic episode (even if the have hypomanic/depression episodes) it is considered B1D

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4
Q

Describe Bipolar II Disorder

A

at least 1 hypomanic/depressive episode, but if pt has a manic episode then they would be categorized as B1D

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5
Q

What are the goals of treatment of Bipolar Disorder?

A

-eliminate mood episode/remission of symptoms
-mood stabilization; recurrence/relapse prevention
-return to baseline psychosocial functioning
-maximize adherence
-educate patient, family, caregivers
-treat comorbid substance use and use disorders
-avoid stressors or substances that precipitate an acute episode

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6
Q

What are the potential pharmacological treatment options for Bipolar Disorder?

A

-lithium
-valproic acid
-carbamazepine
-lamotrigine
-antipsychotics

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7
Q

MOA: Lithium (Li)

A

increases 5HT (serotonin) function, reduces dopamine function, and enhances GABA and normalizes levels

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8
Q

What are the benefits of using Lithium in Bipolar Disorder?

A

BAP GUIDELINES: the most effective treatment preventing relapse and hospital admissions in Bipolar I Disorder
alleviates mania and provides prophylaxis against both manic and depressive episodes. anti-suicidal effects also seen and benefits for impulsivity

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9
Q

What is the Black Box Warning of Lithium?

A

lithium toxicity is closely related to serum lithium concentrations and can occur at doses close to therapeutic concentrations

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10
Q

What is the dosing of Lithium?

A

600-1800mg/day in 1-3 divided doses
AVOID IN SEVERE RENAL IMPAIRMENT

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11
Q

What are the baseline monitoring parameters before treatment with Lithium?

A

-ECG (especially if age >50 or if history of CV disease)
-blood pressure
-thyroid function
-parathyroid hormone/calcium
-CBC
-BMP
-pregnancy status

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12
Q

What is the reasoning for monitoring ECG while on lithium?

A

sick sinus syndrome, BRADYCARDIA, unmask Brugada syndrome, AV block

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13
Q

What is the reasoning of monitoring thyroid function while on lithium?

A

lithium can precipitate hypothyroidism

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14
Q

What is the reasoning for monitoring CBC while on lithium?

A

risk of leukocytosis (75-100% may have it to some degree)

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15
Q

What is the reasoning for monitoring BMP while on lithium?

A

Na+ (hyponatremia) and kidney function (risk of nephrogenic diabetes insipidus)

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16
Q

When would serum lithium levels be monitored in bipolar patients?

A

4-5 days after initiation at ~12 hours post dose

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17
Q

What is the treatment of lithium toxicity?

A

*a medical emergency; rapid, aggressive treatment is needed to reduce risk of suffering permanent neurologic damage *
if mild= hold dose, if severe (any Li level >6 or chronic use Li level >4)= hemodialysis

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18
Q

What are the risk factors for lithium toxicity?

A

-sodium restriction
-dehydration
-vomiting
-diarrhea
-fever
-heavy exercise
-large quantities of caffeine or alcohol
-pregnancy & delivery

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19
Q

What are the adverse effects of lithium?

A

-tremor (high incidence): can be reduced with slow titration
-cognitive problems: agitation/confusion/mental dullness
-nausea/vomiting/diarrhea
-dermatologic: rashes
-weight gain
-polyuria/excessive thirst

20
Q

What are the drug interactions of lithium?

A

-diuretics
-NSAIDs
-renin angiotensin system antagonists (ACEI or ARBs)

21
Q

What is the reasoning for discouraging the use of lithium during pregnancy?

A

lithium can cause epsteins anomaly when used in the first trimester and causes neonatal toxicity

22
Q

What is the indication of Valproic Acid in Bipolar Disorder?

A

acute mania & maintenance

23
Q

With what condition may valproic acid be specifically useful with?

A

comorbid substance use disorder

24
Q

What are the black box warnings of Valproic Acid?

A

-hepatoxicity, hepatic failure
-pancreatitis
-contraindicated in mitochondrial disorders/urea cycle disorders
-fetal risk

25
Q

What are the monitoring parameters for Valproic Acid?

A

-CBC
-LFTs
-pregnancy test
-drug levels (50-125 mccg/mL) which are obtained at steady state

26
Q

What are the adverse effects of Valproic Acid?

A

-sedation, N/V/D, dizziness
-tremor
-PCOS (10% risk)
-increased AST/ALT
-hyperammonemia and/or hyperammonemic encephalopathy

27
Q

What are the drug interactions of Valproic Acid?

A

topiramate due to increased risk of hyperammonemic encephalopathy

28
Q

Why is Valproic Acid contraindicated in women in child-bearing age?

A

teratogenic (BBW)= malformations, developmental delays, autism

29
Q

What is the indication of Carbamazepine?

A

acute mania and mixed episodes NOT A FIRST LINE OPTION- COMBO THERAPY

30
Q

Which drug induce auto-induction metabolism?

A

carbamazepine

31
Q

What are the black box warnings of Carbamazepine?

A

-SJS/TEN: genetic testing for HLA-B*15:02
-aplastic anemia and agraulocytosis

32
Q

What are the special dosing recommendations for Carbamazepine?

A

-slow titration to minimize neurological adverse effects
-close monitoring around dosing adjustments or dosage conversions

33
Q

What is the target drug plasma level of Carbamazepine?

A

4-12 mcg/mL

34
Q

What are the adverse effects of Carbamazepine?

A

-dizziness, diplopia, ataxia, drowsiness, confusion
-cardiac conduction abnormalities= tachycardia, bradyarrhythmia, AV block
-SIADH/hyponatremia

35
Q

What are the drug interactions of Carbamazapine?

A

-hormonal contraceptives= decreased efficacy
-lamotrigine= enhances the adverse/toxic effects of LTG

36
Q

What are the recommendations for pregnant patients while on Carbamazepine?

A

folic acid supplementation

37
Q

What is the indication of Lamotrigine?

A

maintenance therapy of BPD or bipolar depression (off label)
NOT EFFECTIVE FOR MANIA

38
Q

What are the black box warnings of Lamotrigine?

A

SJS/TEN do not exceed recommended dose titrations

39
Q

What drugs titration must be restarted if >5 half lives of dosing have been missed?

A

Lamotrigine

40
Q

What are the adverse effects of lamotrigine?

A

-headache
-diplopia
-ataxia, somnolence
-blurred vision
-N/V/D
-considered a class 1B antiarrhythmic at therapeutically relevant drug concentrations
-benign rash

41
Q

What are the drug interactions of Lamotrigine?

A

-valproic acid (decreases clearance of LTG)
-carbamazepine, phenytoin, primidone, phenobarbital (increase clearance of LTG)
-oral contraceptives (increased clearance of LTG)

42
Q

What drug is cautioned to be used in children <16 yo due to serious rash?

A

Lamotrigine

43
Q

What is the place of second generation antipsychotics in the treatment of bipolar disorder?

A

first line as monotherapy or in combination in acute mania

44
Q

What is the first line treatment for mania?

A

mood stabilizers or atypical antipsychotics

45
Q

What drugs may be used for depressive episodes in BPD?

A

-mood stabilizers: lithium, lamotrigine
-atypical antipsychotics: quetiapine, lurasidone (recommended in children), olanzapine, cariprazine

46
Q

What is the recommendation of antidepressant use in BPD?

A

avoid use due to precipitation of mania, especially avoid TCA due to high risk of switch rates

47
Q

What drugs are recommended maintenance treatment?

A

lithium, valproic acid, lamotrigine, quetiapine

Therapeutics 3 (14 decks)

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