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PHAR 557 > Bipolar Disorder > Flashcards

Bipolar Disorder Flashcards

1
Q

Two main types of bipolar disorder?

A
  1. BDI

2. BDII

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2
Q

Define BDI:

A

Mood disorder with at least 1 wk of:

  1. elevated or irritable mood
  2. increased activity or E
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3
Q

Define BDII

A

Mood disorder w/ both of

  1. current/past HYPOMANIC episode, and
  2. current/past depressive episode
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4
Q

A person who has an episode of mania is automatically diagnosed as having…

A

BDI

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5
Q

T or F: Bipolar disorder is curable

A

F (it can only be managed and maintained, but not cured)

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6
Q

Which gender has more manic episodes, and which has more depressive episodes?

A

Males = manic

Women = depressive

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7
Q

In bipolar pts, what can antidepressants do to them?

A

It can cause them to suffer from mania

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8
Q

NE: excitatory or inhibitory NT?

A

excitatory

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9
Q

Serotonin: excitatory or inhibitory NT?

A

inhibitory

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10
Q

DA: excitatory or inhibitory NT?

A

excitatory

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11
Q

Besides serotonin, what other NT(s) are inhibitory?

A

GABA

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12
Q

glutamate: excitatory or inhibitory NT?

A

excitatory

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13
Q

T or F: Relapses in mood episodes make it easier to tx the pt.

A

F

It actually makes it harder since the brain becomes more and more sensitized and labile

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14
Q

One of the leading causes of death in BD

A

suicide

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15
Q

Main diff b/w mania and hypomania?

A

Hypomania symptoms last a shorter amt of time (~4 days), and are less severe

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16
Q

T or F: Patient is diagnosed w/ BDI if he/she has experienced only hypomanic episodes.

A

F

need a full manic episode for BDI dx

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17
Q

How long does a manic episode need to last to be dx’ed w/ BDI?

A

1 week at least

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18
Q

T or F: A manic episode is automatically dx’ed as BDII.

A

F

BDII is characterized by only hypomania and MDD

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19
Q

Differentiate b/w BDI and BDII

A

They BOTH have MDD, but only BDI has full manic episodes, whereas BDII has hypomania (and no mania)

As soon as mania is seen, it becomes BDI

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20
Q

What is unipolar illness?

A

MDD (just another term to distinguish it from bipolar disorder)

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21
Q

What is cyclothymia?

A

Mood disorder that cycles between manic and depressive states without ever fully meeting diagnostic criteria for hypomania, mania, or MDD

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22
Q

T or F: BDI dx can never be made without a full manic episode

A

T

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23
Q

What are the three main categories of mood stabilizers used for BD tx?

A
  1. Li
  2. anticonvulsants
  3. atypical antipsychotics
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24
Q

What’re the most commonly used drugs used as mood stabilizers?

A
  1. Li

2. valproic acid/divalproex

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25
Q

Li time to peak (liquid)

A

0.5-1h

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26
Q

Li time to peak (reg. release cap)

A

1-3 h

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27
Q

Li time to peak (XR)

A

4-12 h

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28
Q

Li t1/2 w/ normal renal fn:

A

12-27h

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29
Q

How does Li’s Vd in the elderly differ from that of normal adults?

A

It decreases due to less body water and lean body mass in elderly ppl

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30
Q

T or F: Li concs in elderly decrease due to reduced body water and lean body mass

A

F

[Li] INCREASES since it dissolves in less total body water (less dilution = higher conc)

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31
Q

Main elimination organ of Li?

A

Kidneys

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32
Q

Which plasma protein does Li bind to?

A

None

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33
Q

How is Li reabsorbed by the kidneys?

A

With Na

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34
Q

What kind of diet should pts taking Li avoid?

A

Na-free diets (will lead to the body holding on to/reabsorbing Na > the body will also hang on to/reabsorb Li)

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35
Q

How does dehydration affect Li levels and why?

A

It leads to reabsorption of Na > water AND Li follow > Li tox

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36
Q

How does pregnancy affect Li levels and why?

A

Preggos have more fluid > higher Vd > less plasma conc

37
Q

How do sodium supplements affect Li levels and why?

A

Increased Na > increased excretion of Na by kidneys > increased Li excretion (bc Li follows Na)

38
Q

Therapeutic Li range for acute mania tx:

A

1-1.2 mmol/L

39
Q

Therapeutic Li range for maintenance bipolar disorder tx:

A

0.6-1 mmol/L

40
Q

Therapeutic Li range for bipolar disorder tx in ELDERLY pop:

A

0.6-0.8 mmol/L

41
Q

T or F: Li is very safe, hence monitoring is not req’d

A

F

It’s a narrow therapeutic range drug

42
Q

When do we draw blood samples for TDM of Li?

A

12h post dose

43
Q

Initial dosing of Li for acute mania?

A

600-900mg/day (in 1-2 divided doses)

44
Q

After giving the initial 600-900mg/day Li dose for acute mania, what should we do?

A

Take 12h post dose levels (goal: 0.8-1.2mmol/L)

45
Q

Common AEs of Li?

A

GI, esp. nausea

46
Q

Normal starting Li doses for elderly pop for acute mania tx?

A

150mg-300mg

47
Q

Normal Li maintenance doses for BD?

A

900mg (600-1800mg/day)

48
Q

T or F: Li doses do not have to be adjusted in renal impairment.

A

F

They are 95% eliminated in kidneys, so definitely need adjustments

49
Q

How do loop diuretics affect Li levels?

A

Increases excretion of fluid > body holds on to Na > body holds on to Li > INCREASED Li levels

50
Q

How do NSAIDs affect Li levels?

A

Nsaids reduce renal perfusion > increased Li levels

51
Q

Li: Acute intoxication AEs

A

CNS, GI sys, kidneys

52
Q

Li: Chronic toxicity AEs

A

CNS (slurred speech, blurred vision, confusion, lethargy) > drunk-like, essentially

53
Q

What does Li having a linear PK profile mean for dosing?

A

Makes it easy > changes in doses are directly proportional to changes in plasma levels

54
Q

What do we need to know before changing Li doses for a pt?

55
Q

What is divalproex sodium?

A

A valproic acid prodrug

56
Q

What is valproic acid used for?

A
  1. seizures (broad spectrum anti-epileptic agent)

2. mood stabilizer for BD

57
Q

Which plasma protein is valproic acid mostly bound to?

A

Albumin (85-90%)

58
Q

Above what plasma levels of valproic acid does unbound fraction increase disproportionally to the dose?

A

above 500 micromol/L

59
Q

Major route of valproic acid elimination

A

> 95% metabolized by liver

60
Q

Valproic acid t1/2

61
Q

General valproic acid therapeutic range

A

350-700 micromol/L

62
Q

T or F: It’s v. important that we get valproic acid within the target range.

A

F > it’s highly individualized

63
Q

When do we take trough levels of valproic acid?

A

when it’s reached steady state (2-4 days after initial tx)

64
Q

CI of valproic acid

A

Hepatic dz > reduced plasma proteins and clearance

65
Q

DIs of valproic acid

A
  1. val. acid = enzyme inhibitor (CYP2C9, and others)

2. drugs that have stronger albumin binding > displace valproic acid

66
Q

How do we adjust lamotrigine levels when on valproic acid?

A

Cut the dose in half since lamotrigine levels are increased by 50%

67
Q

Main side effects of valproic acid

A

GI (N/V, anorexia), CNS (remor, sedation, ataxia), thrombocytopenia

68
Q

MOA of lamotrigine:

A
  1. reduces release of glutamate (excitatory NT)

2. 5HT3 receptor inhibitor (weak)

69
Q

What’s a very important aspect of lamotrigine dosing?

A

It must be titrated VERY SLOWLY to avoid rash

70
Q

Titration of lamotrigine must be restarted if doses are missed for THIS long.

A

5 days of missed doses

71
Q

When will we half a lamotrigine dose?

A

When pt is on valproic acid too

72
Q

Carbamazepine MOA

A
  1. reduces repetitive APs in depolarized neurons via voltage-dependent sodium channels
  2. increases ADH release > increases reabsorption of H2O
73
Q

Carbamazepine: main route of elimination

A

Hepatic via CYP

74
Q

What’s special about carbamazepine?

A

It induces CYP3A4 and is metabolized by it too > it AUTOINDUCES its own metabolism

75
Q

Half life of carbamazepine:

A

VARIABLE due to autoinduction

76
Q

When does autoinduction reach its max?

A

after 3-4 wks of a stable dosing regimen

77
Q

Common AEs of carbamazepine

A

GI (N/V, anorexia)

CNS (lethargy, dizziness, drowsiness, h/a, incoordination, ataxia, blurred vision, double vision, sedation)

78
Q

Important idiosyncratic carbamazepine AE

A

SIADH > hyponatremia

79
Q

How often should carbamazepine sampling take place during autoinduction phase?

A

q1-2 wks during auto-induction 1 h prior to her next dose

80
Q

What are the three anticonvulsants used in BD?

A

valproic acid/divalproex, lamotrigine, and carbamazepine

81
Q

Main type of antipsychotics used in BD?

A

Atypical (2nd gen)

82
Q

General MOA of all antipsychotics?

A

DA blockade

83
Q

T or F: Doses of antipsychotics are higher for bipolar disorder compared to doses for psychosis

A

F

Doses are LOWER compared to those used for psychosis

84
Q

1st gen vs 2nd gen antipsychotics: which one has lower risk of extrapyramidal sx’s?

A

2nd gen (atypicals)

85
Q

What’s the risk of using antidepressants in BD pts?

A

They can cause the pt to switch to mania, and can worsen manic episodes

86
Q

When would antidepressants be appropriate in bipolar pts?

A

If pt is suffering from severe depression and has a hx of mild mania

87
Q

Preferred antidepressants in bipolar pts:

A
  1. SSRIs (except paroxetine - it has neg evidence)

2. bupropion

88
Q

Which antideps are assoc w/ higher risk of switching to mania?

A

SNRIs and TCAs

89
Q

Main SSRIs used in BD pts

A
  1. citalopram
  2. escitalopram
  3. fluoxetine
  4. sertraline

PHAR 557 (36 decks)

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