Bipolar Disorder

Question 1

What is the first line treatment for bipolar disorder?

Answer 1

Lithium

-treats mania and depression of bipolar and maintenance

Question 2

What drug reduces the risk of suicide in patients?

Answer 2

Lithium

Question 3

How long does it for lithium to take full therapeutic effect?

Answer 3

2-3 weeks

Question 4

How does lithium effect neurotransmitters?

Answer 4

1. increases effects of 5-HT
2. decreases turnover of NE and DA
3. Increases synthesis of acetylcholine

Question 5

Does lithium have an effect on electrolytes and ion transport? why?

Answer 5

yes due to similarity to Na

Question 6

Does lithium have a narrow or wide therapeutic window?

Answer 6

narrow

.6-1.2 >1.2 is toxic effects

Question 7

How is lithium excreted?

Answer 7

renally

Question 8

What kidney drugs lead a decrease in lithium level?

Answer 8

drugs that affect the proximal tubule

1. acetazolamide
2. mannitol

-also aminophylline, theophylline, caffeine, and pregnancy

Question 9

What kidney drugs do not change the level of Li?

Answer 9

Loop diuretics

1. furosemide
   - also amiloride, acetaminophen, aspirin, sulindac

Question 10

What kidney drugs increase the level of Li?

Answer 10

proximal tubule and collecting duct

1. thiazides
2. K+ sparing diuretics
3. ACE inhibitors
4. Angiotensin 2

also: NSIADS, COX2 inhibitors, dehydration, Na depletion, renal impairment and advanced age

Question 11

What are lithium side effects?

Answer 11

Derm: acne, psoriasis, rashes, alopecia
Endocrine: Hypothyroid**, hyperparathyroid
GI: Nausea, Diarrhea
Heme: increase WBC
Neuro: fine tremor, decreased concentration, sedation
Other: weight gain, edema

More serious: NDI, mild renal insufficiency, end stage renal disease

Question 12

Lithium Toxicity Mild toxicity ?

Answer 12

nausea, vomiting, diarrhea
lethargy, drowsiness
muscle weakness, coarse hand tremor

Question 13

Lithium Toxicity Moderate toxicity?

Answer 13

confusion, myoclonic twitches, dysarthria, ataxia, nystagmus
ECG changes

Question 14

Lithium toxicity severe toxicity?

Answer 14

Grossly Impaired consciousness; coma
Increase DTR’s Seizures
Syncope

Question 15

What do you test before starting someone on lithium?

Answer 15

1. TSH
2. Renal function
3. ECG-if pt > 50
4. BMI
5. Pregnancy test (ebstein anomaly)

Question 16

After starting lithium what level do you need to check?

Answer 16

Lithium level

Question 17

After being stable on the drug what do you need to check every 6-12 months?

Answer 17

1. TSH
2. Renal function
3. BMI
4. Lithium level

Question 18

What is the difference between depakene and depakote?

What is depakote used for?

Answer 18

depakote-enteric kote that decreases nausea and diarrhea

Type 1 mania/non-severe mania & Type2
Type 1&2 depression

Question 19

How highly is depakote protein bound?

Answer 19

90% protein bound 100% absorbed

• can displace other protein bound drugs like: phenytoin-increases potential toxicity
• can be displaced itself by caffeine aspirin

Question 20

How is depakote metabolized? How does depakote affect drugs that have hepatic metabolism?

Answer 20

Metabolized by hepatic glucuronide conjugation
inhibits hepatic metabolism
-inhibits metabolism of other anticonvulsants-increases risk of toxicity

Question 21

What are side effects of depakote?

Answer 21

Derm: alopecia
GI: nausea, vomiting, diarrhea, mild increase LFTs
Heme: decrease platelets
Neuro:ataxia, headache, dizziness, tremor, sedation
Other:increase in ammonia level, weight gain, polycystic ovarian syndrome, increase in suicide risk

Toxicity: mild increase in LFTS, hepatotoxicity, hyperammonemia

Question 22

What do you test the patient for before starting them on depakote?

Answer 22

1. LFT’s
2. Platelet count
3. BMI
4. Pregnancy test

Question 23

What do you check after starting depakote?

Answer 23

depakote levels

Question 24

What do you check once the patient is stable on depakote every 6-12 months?

Answer 24

1. LFT’s
2. platelet count
3. BMI
4. Depakote levels

Question 25

How does carbamazepine (tegretol) affect the metabolism of other drugs? WHat is tegretol used for?

Answer 25

via CYP 450 1. induces multiple CYP450 enzymes 2. Induces UDP glucuronosyltransferase 3. auto-induces its own metabolism Type 1 Non severe & Type 2

Question 26

What are the side effects of carbamazepine(tegretol)?

Answer 26

Derm: Stevens Johnson Syndrome GI: Nausea, vomiting, mild increase LFTs, hepatotoxicity Heme: decrease in WBC, aplastic anemia, agranulocytosis Neuro: ataxia, diplopia, dizziness, tremor, sedation Other: decrease Na, weight gain, increased suicide risk teratogenic -increased risk of neural tube defects

Question 27

How is lamotrigine (lamictal) metabolized? WHat is lamictal used for?

Answer 27

low protein binding 55% -metabolized by glucuronidation DDI 1. Depakote+lam - lam doubles 2. oral contraceptives+ lam - lam halves 3. carbamazepine+ lam - lam halves Type 1&2 depression

Question 28

What are side effects of lamotrigine(lamictal) ?

Answer 28

``` derm: rash(benign and Steven Johnson)** GI: nausea, vomiting Heme: decreased WBC, blood dyscrasias Neuro: ataxia, headache, dizziness, double vision, blurred vision, fatigue Other: insomnia ```

Question 29

Are anti-psychotics used for treating biopolar disorder?

Answer 29

yes -many approved for mania, and maintenance -just 3 approved for bipolar depression For severe bipolar mania-psychosis, suicidal/dangerous behavior start: 1. Li + SGA 2. Depakote +SGA Used for Type 1 Manic/Non severe& type 2 Sometimes for Type 1&Type 2 depression (FGA-not used in type1&type 2 depression)

Question 30

What has the greatest risk of serious birth defects of all psychotropic meds?

Answer 30

depakote | -12-16X gen population rate of neural tube defects

Question 31

Do you treat Type 1 manic/non severe& type 2 with antidepressants?

Answer 31

no

Question 32

WHat are benzos used as in bipolar manic/non severe& type 2 and for type1&2 depression?

Answer 32

adjunct