Bipolar Disorder

Question 1

Which four drugs are the traditional mood stabilizers used in bipolar drug therapy?

Answer 1

lithium, valproic acid, lamotrigine, and carbamazepine

Question 2

Patients with bipolar disorder are more likely to experience what side effect associated with antipsychotics?

Answer 2

EPS

Question 3

What is one key diagnosis that must be ruled out before initiating treatment for bipolar disorder?

Answer 3

depression (really you would likely be ruling out bipolar disorder in the diagnosis of depression, but for the sake of consistency in this section….)

Question 4

two first-line treatment options for manic state

Answer 4

valproic acid or lithium + antipsychotic

Question 5

For bipolar depression, _______ and _______ are the two first-line treatment options, but _______ is FDA approved as well.

Answer 5

lithium, lamotrigine, olanzapine/fluoxetine (symbyax)

Question 6

Why is lamotrigine an option for maintenance mood stabilization, but not acute treatment of mania?

Answer 6

Due to risk of severe skin rash, lamotrigine has a very slow titration schedule.

Question 7

Which mood stabilizer is preferred in pregnant patients due to its relative safety compared to others and lack of evidence of major fetal abnormalities (though most data is in epileptic patients)?

Answer 7

lamotrigine - per ACOG recommendations, is a category C drug while other 3 mainstays of bipolar therapy are category D

Question 8

This medication has the best safety profile in pregnancy, but is not a mainstay of mood stabilization therapy and is only indicated for bipolar depression.

Answer 8

lurasidone (category B)

Question 9

The brand name formulation of carbamazepine approved for bipolar disorder treatment is _______.

Answer 9

Equetro

Question 10

3 formulations of lithium

Answer 10

tablet, capsule, suspension

Question 11

starting and max doses of lithium for bipolar disorder

Answer 11

150-900 mg/day divided TID up to 900-1800 mg/day divided TID or QID

Question 12

Lithium levels should be monitored, with goal levels being ______ as a _______ (peak/trough).

Answer 12

0.6-1.2 mEq/L as a trough

Question 13

Toxicity of lithium can occur above levels of ______ resulting in what symptoms? Above the major toxicity threshold of ______, what other symptoms may be observed?

Answer 13

1. 5 mEq/L - persistent vomiting and diarrhea, coarse hand tremor, confusion, ataxia
2. 5 mEq/L - CNS depression, coma, irreversible brain damage, arrhythmia, seizures

Question 14

What are the side effects of lithium?

Answer 14

GI upset (careful titration), cogwheel rigidity, FINE hand tremor, hypothyroidism, weight gain, polyuria/dypsia

Question 15

Why is renal function monitored in lithium therapy?

Answer 15

it is 100% renally cleared - changes in function can affect levels of a narrow therapeutic index drug

Question 16

Lithium should be avoided with agents that increase this neurotransmitter.

Answer 16

serotonin

Question 17

Lithium levels and salt consumption have a ______ (direct/inverse) relationship.

Answer 17

inverse - increasing salt consumption decreases lithium levels

Question 18

What two substances, other than sodium, can decrease lithium levels?

Answer 18

caffeine and theophylline

Question 19

What is the significance of hydration status and lithium therapy?

Answer 19

Dehydration can lead to adverse effects with lithium therapy. Patients should be counseled to drink 8-12 glasses of water a day.

Question 20

8 mEq of lithium in solution is equal to how many milligrams of lithium in caps/tabs?

Answer 20

300 mg

Question 21

How can patients be counseled to mitigate the side effects and difficulties associated with lithium titration?

Answer 21

take with food - helps with nausea
stay hydrated
with divided doses, take more of dose in evening