Bipolar Disorder Flashcards
Types of bipolar disorder?
Bipolar I
Bipolar II
Cyclothymic disorder (where the criteria for depression or mania are not fully met)
Which type is the most severe version of bipolar?
Bipolar I disorder
What’s mania xterized by?
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)
Difference btw bipolar I and II?
Bipolar II has the same sx as bipolar I, however sx are described as “hypomania” bcuz they are less severe than in pure mania
What’s hypomania?
Will not affect social or occupational fxning and pts with bipolar II will not require hospitalization for hypomania or have psychotics features
What’s the first like for treating mania and maintaining a stable mood?
Mood stabilizers (lithium, valproate, lamitrigine)
AND
2nd gen anti-psychotics (SGAs)
What’s a mood stabilizer?
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
Which of the SGAs have NO indications for bipolar mania?
CLIP
Clozapine
Lurasidone
Iloperidone
Paliperidone
Which SGAs have an indication for bipolar DEPRESSION?
Lurasidone
Why are first gen antipsychotics no longer used for mania?
Pts with bipolar are more susceptible to EPS and FGAs have an increased risk of causing EPS
What does the most current guidelines recommend?
Either a mood stabilizer, SGAs or a combo of mood stabilizer + SGAs
If psychotic features are present, what’s reasonable to start with?
SGAs
What meds have a role as adjunctive therapy in depression and can also be used for mania and maintenance?
Aripiprazole
Quetiapine ext-release
Uses of Lamotrigine?
Used in bipolar DEPRESSION and maintenance, however is not beneficial in mania dut to SLOW TITRATION
Uses of lithium?
Mania, depression and maintenance
More commonly used in combo with SGAs in severe cases
Whats valproate and carbamazepine approved for?
Bipolar MANIA
When is antidepressant used in bipolar?
When the pt is already on mood stabilizer
What class of meds used in bipolar req medguides?
Antidepressants, anticonvulsants, antipsychotics
Whats the preferred mood stabilizer during pregnancy?
Lamotrigine (Cat. C)
Should mood stabilizers (even Lamotrigine that’s preferred) be avoided during 1st trimester?
Yes, if possible
The SGAs are approved for pregnancy (Category C), which SGAs is cat B?
Lurasidone
Effect of lithium in pregnancy?
Ass with increase in congenital cardiac malformations
Effects of valproate in pregnancy?
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
Effects of CBC in pregnancy?
Fetal CBZ syndrome
Which antidepressant should NOT be used, if an antidepressant is needed in pregnancy?
Paroxetine (due to risk of cardiac defects)
How do u rule out illicit drug use from bipolar mania?
Toxicology screen should be taken prior to start of tx and as needed, to rule out mania due to illicit drug use
MOA of Valproic acid/Valproate
T-type Ca channel blocker and fast Na channel blocker that increases gamma-aminobutyric activity (GABA), an inhibitory neurotransmitter
What’s the brand name of Valproic acid/Valproate?
Depakene
Stavzor (delayed-release)
Depacon
What’s the brand name of Divalproex?
Depakote
Depakote ER
Depakote Sprinkle (also used for migraine prophylaxis)
Whats the range of acceptable serum levels to maintain while on Valproic acid/valproate/ Divalproex?
50-125 mcg/mL
Can Depakote ER be substituted for Depakote (delayed release)?
Can’t substitute Depakote ER for delayed release Depakote
Need to increase Depakote ER by 8-20%
What do you do if albumin is low? (<3.5)
Adjust using phenytoin formula (bcuz true valproate level will be higher than it appears)
What’s the blackbox warning of Valproic acid/valproate/ Divalproex?
PTH
Pancreatitis
Teratogenicity
Hepatic failure
What may be used as supplementation when using Valproic acid/valproate/ Divalproex?
Calcium and Vit. D
What may reduce stomach upset associated with Valproic acid?
Switch to delayed release Divalproex (Depakote) may reduce stomach upset
Because valproate is a weak inhibitor of 2C9, what drug level may be increased if co-admin?
Carbamazepine
Lamotrigine
Phenobarbital
Warfarin
Zidovudine
What may occur if valproate + Lamotrigine are used today?
Risk of serious rash
Effects of using Salicylates with Valproic acid?
Salicylates may displace Valproic acid from protein-binding site, leading to toxicity
Effects of using valproate with phenytoin?
Valproate can displace phenytoin from albumin, resulting in phenytoin toxicity
Effects of using valproate with warfarin?
Warfarin is highly protein-bound; valproate can displace warfarin and can cause an increase in INR
Effects of using Carbapenems with Valproate?
Carbapenems can reduce valproate levels leading to seizures
What are the sx of pancreatitis that may develop from Valproic acid use?
Nausea
Vomiting
Severe abdominal pain
Loss of appetite
Should you use a regular eating spoon to measure Valproic acid?
No!
Use a special dose-measuring spoon or cup
How should Valproic acid be taken?
Take each dose with a full glass of water
Take with food to avoid stomach upset
What tests do u need when on Valproic acid?
Blood test and liver function test
MOA of Lamotrigine?
Inhibits release of glutamate and aspartate (excitatory amino acids), fast Na channel blocker and t-type Ca channel blocker stabilizing neuronal membranes
What’s the brand name of Lamotrigine?
Lamictal
Lamictal ODT
Lamictal CD (chewable)
Lamictal XR
How’s Lamotrigine (Lamictal) dosed in children?
By body weight.
Divide bid (unless using XR)
What changes do you make to Lamotrigine when using Valproic acid, CBZ, phenytoin, or phenobarbital?
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)
Is Lamotrigine used in mania?
No! Not used in mania
When a higher titration schedule of Lamotrigine is req (due to co-admin with strong inducers e.g. CBZ, phenytoin, phenobarbital)?
Lamotrigine is started at 50mg daily
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)?
Lamotrigine 25mg Q other day
What grp of people have a higher chance of developing rash while on Lamotrigine?
Children 2-16 yrs
What other factors may increase the risk of developing a rash?
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
What condition does Lamotrigine rarely causes, but it’s very severe if it causes it?
Ascetic meningitis
What’s the brand name of Lithium?
Lithobid
What’s the trough therapeutic range of lithium?
0.6-1.2 mEq/L (trough)
Acute mania may need up to 1.5 mEq/L
Can lithium be used in renal impairment?
No!
Lithium (Lithobid) is 100% renally cleared
SE of lithium (Lithobid)?
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)
What’s the result of lithium (Lithobid) toxicity levels > 1.5 mEq/L?
V CCAP
Vomiting
Confusion
Coarse hand tremor
Ataxia
Persistent diarrhea
What’s the result of lithium (Lithobid) toxicity levels > 3 mEq/L?
CNS depression
Arrhythmia
Seizures
Irreversible brain damage
Coma
What may increase lithium levels?
Reduced salt intake
NSAIDs
ACE-I, ARBs
Diuretics
What are safer options of NSAIDs when pt is on lithium?
Aspirin
Sulindac
What may decrease lithium levels?
Increased salt intake
Caffeine
Theophylline
What may increase risk of 5HT-syndrome if given with lithium?
SSRIs
SNRIs
Triptans
Linezolid
And other serotonergic drugs
What may increase neurotoxicity risk (Ataxia, Tremors, Nausea) if used with lithium (Lithobid)?
Verapamil, Diltiazem
Phenytoin
CBZ
How much water should be drank daily while on lithium (Lithobid), not including any caffeinated sodas, coffee or tea?
8 to 12 glasses of water
What’s the relationship btw lithium and salt consumption?
Don’t change the amt of salt consumed
List SGAs in bipolar disorder
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)
What’s the brand name of Aripiprazole? (SGAs)
Abilify
Abilify Discmelt
What’s the brand name of Quetiapine extended release? (SGAs)
Seroquel
Seroquel XR
What’s the brand name of Risperidone? (SGAs)
Risperdal
What’s the brand name of Ziprasidone? (SGAs)
Geodon
What’s the brand name of Lurasidone? (SGAs)
Latuda
Can SGAs cause metabolic issues?
Yes
Dyslipidemia
Weight gain
Diabetes
What other SE can be seen from SGAs use?
Risk of Neuroleptic Malignant Syndrome
Risk of Tardive Dyskinesia
Risk of leukopenia, neutropenia, agranulocytosis
Orthostasis/dizziness
What common SE is associated with Aripiprazole (Abilify, Abilify Discmelt)?
Akathisia (esp in younger pts)
Restlessness
Insomnia
Constipation
Fatigue
Blurred vision
What common SE is associated with Olanzapine?
Cognitive dysfunction
Dry mouth
Fatigue
Sedation
Increased appetite/weight
Peripheral edema
Tremor
Blurred vision
Reduced CVD risk than other listed APs
What common SE is associated with Quetiapine (Seroquel, Seroquel XR)?
QT risk
Sedation
Dry mouth
Constipation
Dizziness
Increased appetite/weight
What common SE is associated with Risperidone (Risperdal)?
Sedation
Increased appetite
Fatigue
Insomnia
Parkinsonism
Akathiasia
Nausea
Some QT risk
Nausea
What common SE is associated with Ziprasidone (Geodon)?
QT risk (greatest)
Sedation
EPS
Dizziness
Akathisia
Abnormal vision
Asthenia
Nausea
What common SE is associated with Asenapine?
Numbs mouth
Sedation (avoid driving when initiating or titrating therapy)
Dizziness
Weight gain (less than Risperidone and Olanzapine)
Some QT risk
Which SGAs carry the greatest QT risk?
Ziprasidone
Which SGAs have EPS as a SE?
Ziprasidone
What’s ADA screening recommendations for pt on SGAs?
B4 starting pt on antipsychotics, pt should be screened for
Overweight and obesity
Dyslipidemia
Hyperglycemia
HTN
Personal and FH of risk
What’s ADA monitoring recommendations for pt on SGAs?
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
Effect of Lisinopril in lithium levels?
Lisinopril can increase lithium levels
List antipsychotics that have QT prolongation?
Quetiapine
Risperidone
Ziprasidone
Thioridazine
Haloperidol
What’s one of the benefit of using Quetiapine extended-release?
Little risk of movement disorders
What’s bipolar disorder?
Mood disorder where moods can fluctuate from depression to elevated moods referred to as “mania”
