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Bipolar Disorder Flashcards

1
Q

Types of bipolar disorder?

A

Bipolar I

Bipolar II

Cyclothymic disorder (where the criteria for depression or mania are not fully met)

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2
Q

Which type is the most severe version of bipolar?

A

Bipolar I disorder

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3
Q

What’s mania xterized by?

A

Elevated mood where pts have a lot of energy

Sx of mania in bipolar I can be so severe that they may req psychiatric hospitalization, impair social or occupational functioning or have features of psychosis such as hearing voices or delusions (false beliefs)

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4
Q

Difference btw bipolar I and II?

A

Bipolar II has the same sx as bipolar I, however sx are described as “hypomania” bcuz they are less severe than in pure mania

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5
Q

What’s hypomania?

A

Will not affect social or occupational fxning and pts with bipolar II will not require hospitalization for hypomania or have psychotics features

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6
Q

What’s the first like for treating mania and maintaining a stable mood?

A

Mood stabilizers (lithium, valproate, lamitrigine)

AND

2nd gen anti-psychotics (SGAs)

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7
Q

What’s a mood stabilizer?

A

By definition, a mood stabilizer is a med that can treat either mania or depression without inducing either.

T/4 antidepressants are not considered mood stabilizers

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8
Q

Which of the SGAs have NO indications for bipolar mania?

A

CLIP

Clozapine

Lurasidone

Iloperidone

Paliperidone

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9
Q

Which SGAs have an indication for bipolar DEPRESSION?

A

Lurasidone

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10
Q

Why are first gen antipsychotics no longer used for mania?

A

Pts with bipolar are more susceptible to EPS and FGAs have an increased risk of causing EPS

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11
Q

What does the most current guidelines recommend?

A

Either a mood stabilizer, SGAs or a combo of mood stabilizer + SGAs

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12
Q

If psychotic features are present, what’s reasonable to start with?

A

SGAs

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13
Q

What meds have a role as adjunctive therapy in depression and can also be used for mania and maintenance?

A

Aripiprazole

Quetiapine ext-release

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14
Q

Uses of Lamotrigine?

A

Used in bipolar DEPRESSION and maintenance, however is not beneficial in mania dut to SLOW TITRATION

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15
Q

Uses of lithium?

A

Mania, depression and maintenance

More commonly used in combo with SGAs in severe cases

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16
Q

Whats valproate and carbamazepine approved for?

A

Bipolar MANIA

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17
Q

When is antidepressant used in bipolar?

A

When the pt is already on mood stabilizer

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18
Q

What class of meds used in bipolar req medguides?

A

Antidepressants, anticonvulsants, antipsychotics

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19
Q

Whats the preferred mood stabilizer during pregnancy?

A

Lamotrigine (Cat. C)

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20
Q

Should mood stabilizers (even Lamotrigine that’s preferred) be avoided during 1st trimester?

A

Yes, if possible

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21
Q

The SGAs are approved for pregnancy (Category C), which SGAs is cat B?

A

Lurasidone

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22
Q

Effect of lithium in pregnancy?

A

Ass with increase in congenital cardiac malformations

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23
Q

Effects of valproate in pregnancy?

A

Increased risk of fetal anomalies, including neural tube defects, fetal valproate syndrome and long-term adverse cognitive effects

It should be avoided in preg, esp 1st trimester

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24
Q

Effects of CBC in pregnancy?

A

Fetal CBZ syndrome

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25
Q

Which antidepressant should NOT be used, if an antidepressant is needed in pregnancy?

A

Paroxetine (due to risk of cardiac defects)

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26
Q

How do u rule out illicit drug use from bipolar mania?

A

Toxicology screen should be taken prior to start of tx and as needed, to rule out mania due to illicit drug use

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27
Q

MOA of Valproic acid/Valproate

A

T-type Ca channel blocker and fast Na channel blocker that increases gamma-aminobutyric activity (GABA), an inhibitory neurotransmitter

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28
Q

What’s the brand name of Valproic acid/Valproate?

A

Depakene

Stavzor (delayed-release)

Depacon

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29
Q

What’s the brand name of Divalproex?

A

Depakote

Depakote ER

Depakote Sprinkle (also used for migraine prophylaxis)

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30
Q

Whats the range of acceptable serum levels to maintain while on Valproic acid/valproate/ Divalproex?

A

50-125 mcg/mL

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31
Q

Can Depakote ER be substituted for Depakote (delayed release)?

A

Can’t substitute Depakote ER for delayed release Depakote

Need to increase Depakote ER by 8-20%

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32
Q

What do you do if albumin is low? (<3.5)

A

Adjust using phenytoin formula (bcuz true valproate level will be higher than it appears)

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33
Q

What’s the blackbox warning of Valproic acid/valproate/ Divalproex?

A

PTH

Pancreatitis

Teratogenicity

Hepatic failure

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34
Q

What may be used as supplementation when using Valproic acid/valproate/ Divalproex?

A

Calcium and Vit. D

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35
Q

What may reduce stomach upset associated with Valproic acid?

A

Switch to delayed release Divalproex (Depakote) may reduce stomach upset

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36
Q

Because valproate is a weak inhibitor of 2C9, what drug level may be increased if co-admin?

A

Carbamazepine

Lamotrigine

Phenobarbital

Warfarin

Zidovudine

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37
Q

What may occur if valproate + Lamotrigine are used today?

A

Risk of serious rash

38
Q

Effects of using Salicylates with Valproic acid?

A

Salicylates may displace Valproic acid from protein-binding site, leading to toxicity

39
Q

Effects of using valproate with phenytoin?

A

Valproate can displace phenytoin from albumin, resulting in phenytoin toxicity

40
Q

Effects of using valproate with warfarin?

A

Warfarin is highly protein-bound; valproate can displace warfarin and can cause an increase in INR

41
Q

Effects of using Carbapenems with Valproate?

A

Carbapenems can reduce valproate levels leading to seizures

42
Q

What are the sx of pancreatitis that may develop from Valproic acid use?

A

Nausea

Vomiting

Severe abdominal pain

Loss of appetite

43
Q

Should you use a regular eating spoon to measure Valproic acid?

A

No!

Use a special dose-measuring spoon or cup

44
Q

How should Valproic acid be taken?

A

Take each dose with a full glass of water

Take with food to avoid stomach upset

45
Q

What tests do u need when on Valproic acid?

A

Blood test and liver function test

46
Q

MOA of Lamotrigine?

A

Inhibits release of glutamate and aspartate (excitatory amino acids), fast Na channel blocker and t-type Ca channel blocker stabilizing neuronal membranes

47
Q

What’s the brand name of Lamotrigine?

A

Lamictal

Lamictal ODT

Lamictal CD (chewable)

Lamictal XR

48
Q

How’s Lamotrigine (Lamictal) dosed in children?

A

By body weight.

Divide bid (unless using XR)

49
Q

What changes do you make to Lamotrigine when using Valproic acid, CBZ, phenytoin, or phenobarbital?

A

Reduce Lamotrigine dose - Valproic acid/valproate/Divalproex
(increase Lamotrigine levels)
(Higher titration schedules are req here)

Increase Lamotrigine dose - CBZ, phenytoin, phenobarbital (they
decrease Lamotrigine)
(Higher titration schedules are req here)

50
Q

Is Lamotrigine used in mania?

A

No! Not used in mania

51
Q

When a higher titration schedule of Lamotrigine is req (due to co-admin with strong inducers e.g. CBZ, phenytoin, phenobarbital)?

A

Lamotrigine is started at 50mg daily

52
Q

When a LOWER titration schedule of Lamotrigine is req (due to co-admin with Valproate/Divalproex, which are inhibitors and increase Lamotrigine levels leading to a significant increase in the risk of rash)?

A

Lamotrigine 25mg Q other day

53
Q

What grp of people have a higher chance of developing rash while on Lamotrigine?

A

Children 2-16 yrs

54
Q

What other factors may increase the risk of developing a rash?

A

Using Lamotrigine + Valproate (Valproic acid, or Depakene, Stavzor, or Depacon) or Divalproex (Depakote)

Using a higher starting dose than prescribed

Increase dose faster than prescribed

55
Q

What condition does Lamotrigine rarely causes, but it’s very severe if it causes it?

A

Ascetic meningitis

56
Q

What’s the brand name of Lithium?

A

Lithobid

57
Q

What’s the trough therapeutic range of lithium?

A

0.6-1.2 mEq/L (trough)

Acute mania may need up to 1.5 mEq/L

58
Q

Can lithium be used in renal impairment?

A

No!

Lithium (Lithobid) is 100% renally cleared

59
Q

SE of lithium (Lithobid)?

A

GI upset (take with food or change to ER forms)

Cognitive effects, Cogwheel rigidity, Fine hand tremor, Weight gain

Polyuria/polydipsia, hypothyroidism - must monitor

Serotegenic (avoid co-admin with other serotonergic agents)

60
Q

What’s the result of lithium (Lithobid) toxicity levels > 1.5 mEq/L?

A

V CCAP

Vomiting

Confusion

Coarse hand tremor

Ataxia

Persistent diarrhea

61
Q

What’s the result of lithium (Lithobid) toxicity levels > 3 mEq/L?

A

CNS depression

Arrhythmia

Seizures

Irreversible brain damage

Coma

62
Q

What may increase lithium levels?

A

Reduced salt intake

NSAIDs

ACE-I, ARBs

Diuretics

63
Q

What are safer options of NSAIDs when pt is on lithium?

A

Aspirin

Sulindac

64
Q

What may decrease lithium levels?

A

Increased salt intake

Caffeine

Theophylline

65
Q

What may increase risk of 5HT-syndrome if given with lithium?

A

SSRIs

SNRIs

Triptans

Linezolid

And other serotonergic drugs

66
Q

What may increase neurotoxicity risk (Ataxia, Tremors, Nausea) if used with lithium (Lithobid)?

A

Verapamil, Diltiazem

Phenytoin

CBZ

67
Q

How much water should be drank daily while on lithium (Lithobid), not including any caffeinated sodas, coffee or tea?

A

8 to 12 glasses of water

68
Q

What’s the relationship btw lithium and salt consumption?

A

Don’t change the amt of salt consumed

69
Q

List SGAs in bipolar disorder

A

Aripiprazole (Abilify, Abilify Discmelt)

Olanzapine/Fluoxetine (Symbyax)

Olanzapine (Zyprexa, Zydis ODT, Relprevv inj)

Quetiapine extended release (Seroquel, Seroquel XR)

Risperidone (Risperdal)

Ziprasidone (Geodon)

Asenapine (Saphris)

Lurasidone (Latuda)

70
Q

What’s the brand name of Aripiprazole? (SGAs)

A

Abilify

Abilify Discmelt

71
Q

What’s the brand name of Quetiapine extended release? (SGAs)

A

Seroquel

Seroquel XR

72
Q

What’s the brand name of Risperidone? (SGAs)

A

Risperdal

73
Q

What’s the brand name of Ziprasidone? (SGAs)

A

Geodon

74
Q

What’s the brand name of Lurasidone? (SGAs)

A

Latuda

75
Q

Can SGAs cause metabolic issues?

A

Yes

Dyslipidemia

Weight gain

Diabetes

76
Q

What other SE can be seen from SGAs use?

A

Risk of Neuroleptic Malignant Syndrome

Risk of Tardive Dyskinesia

Risk of leukopenia, neutropenia, agranulocytosis

Orthostasis/dizziness

77
Q

What common SE is associated with Aripiprazole (Abilify, Abilify Discmelt)?

A

Akathisia (esp in younger pts)

Restlessness

Insomnia

Constipation

Fatigue

Blurred vision

78
Q

What common SE is associated with Olanzapine?

A

Cognitive dysfunction

Dry mouth

Fatigue

Sedation

Increased appetite/weight

Peripheral edema

Tremor

Blurred vision

Reduced CVD risk than other listed APs

79
Q

What common SE is associated with Quetiapine (Seroquel, Seroquel XR)?

A

QT risk

Sedation

Dry mouth

Constipation

Dizziness

Increased appetite/weight

80
Q

What common SE is associated with Risperidone (Risperdal)?

A

Sedation

Increased appetite

Fatigue

Insomnia

Parkinsonism

Akathiasia

Nausea

Some QT risk

Nausea

81
Q

What common SE is associated with Ziprasidone (Geodon)?

A

QT risk (greatest)

Sedation

EPS

Dizziness

Akathisia

Abnormal vision

Asthenia

Nausea

82
Q

What common SE is associated with Asenapine?

A

Numbs mouth

Sedation (avoid driving when initiating or titrating therapy)

Dizziness

Weight gain (less than Risperidone and Olanzapine)

Some QT risk

83
Q

Which SGAs carry the greatest QT risk?

A

Ziprasidone

84
Q

Which SGAs have EPS as a SE?

A

Ziprasidone

85
Q

What’s ADA screening recommendations for pt on SGAs?

A

B4 starting pt on antipsychotics, pt should be screened for
Overweight and obesity

Dyslipidemia

Hyperglycemia

HTN

Personal and FH of risk

86
Q

What’s ADA monitoring recommendations for pt on SGAs?

A

While being treated pt should be monitored for tx-emergent changes in weight

Waist circumference

Plasma lipids

Glucose levels

Acute sx of diabetes e.g. Polyuria, polydipsia

87
Q

Effect of Lisinopril in lithium levels?

A

Lisinopril can increase lithium levels

88
Q

List antipsychotics that have QT prolongation?

A

Quetiapine

Risperidone

Ziprasidone

Thioridazine

Haloperidol

89
Q

What’s one of the benefit of using Quetiapine extended-release?

A

Little risk of movement disorders

90
Q

What’s bipolar disorder?

A

Mood disorder where moods can fluctuate from depression to elevated moods referred to as “mania”

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