bipolar disorder

Question 1

symptoms

Answer 1

mania, hypomania, depression, mixed mania and depression

Question 2

mania

Answer 2

euphoria/elation, irritability/anger, impulsive high risk behavior, aggressive, grandiose ideas, decreased sleep and appetite, difficulty concentrating, delusions, flight of ideas, hallucinations

Question 3

treatment

Answer 3

hospitalization, psychotherapy,

pharmacotherapy: mood stabilizers (lithium), atypical anticonvulsants (valproate), CCBs, combination

Question 4

anticonvulsants used in bipolar

Answer 4

valproate, carbamazepine, oxcarbazepine, lamotrigine, topiramate

Question 5

lithium

Answer 5

Decreases number and severity of episodes in bipolar disorder
*Noted to decrease suicidal thinking
Immediate release dosage forms preferred due to increased bioavailability and improved GI tolerability
Narrow therapeutic window
Toxicities: GI, ataxia, hand tremor, altered mental status, seizure, lethargy, confusion, agitation
Laboratory Monitoring: Baseline: Seru Cr/BUN, Urine specific gravity, sodium, potassium, EKG, TSH/T4, CBC with differential, Weight, Pregnancy Test, *Increasing lithium levels: ARBs, ACE inhibitors, NSAIDs, Decreased lithium levels: caffeine, osmotic diuretics, sodium bicarbonate, increased sodium (excreting faster)

Question 6

valproic acid

Answer 6

Common first line monotherapy
Adverse Effects: GI, tremor/sedation/ataxia, alopecia, *teratogenic (neural tube defects, recent evidence of negative effects on IQ of offspring – Category D), elevated LFTs, increased appetite, rash, *PCOS: polycystic ovarian syndrome; common causative factor in women
Monitoring: Baseline: pregnancy, LFTs, Routine: LFTs, CBC with differential and platelets, serum concentration, Increased lamotrigine concentration leading to SJS

Question 7

carbamazepine/oxcarbazepine

Answer 7

Usually 2nd/3rd line
Carbamazepine: Pregnancy Category D
Oxcarbazepine: used as adjunctive treatment

Question 8

lamotrigine and topiramate

Answer 8

Lamotrigine: firstline treatment for depressive episodes; slow dose titration
*Topiramate: clinically used as adjunctive treatment; slow dose titration, may cause weight loss

Question 9

antipsychotic use

Answer 9

Atypicals are FDA-approved for acute and/or maintenance treatment of bipolar disorder
Quetapine: FDA approved for bipolar depression
Aripiprazole: FDA approved for adjunctive treatment in depression
Lurasidone: FDA approved for bipolar depression

Question 10

pregnancy

Answer 10

Category D: Lithium, valproic acid, carbamazepine and topiramate
Atypicals antipsychotics are often used in pregnancy because they are Category C
Lurasidone is Category B

Question 11

antidepressants in bipolar

Answer 11

• *Depression is the mood pole that is experienced most often in bipolar disorder
• *Use of antidepressants is linked with a switch to mania = questionable effect
• *Need to have maintenance mood stabilizer therapy in combination with antidepressant