Bipolar disorder and mania

Question 1

What are the two types of bipolar disorder episodes ?

Answer 1

Mania- feeling very high and overactive. Less severe mania is called hypomania
Depression- feeling very low and lethargic

Question 2

Which antipsychotics are useful in acute episodes of mania and hypomania?

Answer 2

Second generation antipsychotics: quetiapine, olanzapine, ripseridone

Question 3

What other drugs can be added to antipsychotics in bipolar disorder if response is inadequate ?

Answer 3

Lithium or varlpoic acid

Question 4

What drug can be given in moderate-severe manic episodes ?

Answer 4

asenapine ( second generation antipsychotic drug )

Question 5

What drugs are used in prophylaxis of bipolar disorder?

Answer 5

Lithium salts, olanzapine ( if response in manic episode )

valproate, carbamazepine ( rapid-cycling bipolar disorder unresponsive to other drugs )

Question 6

What are the contraindications in bipolar disorder ?

Answer 6

Do not give antidepressants if rapid cycling bipolar disorder, recent history of hypomania, manic episode, rapid mood fluctuations

Question 7

What are the Lithium uses ?

Answer 7

prophylaxis and treatment of mania, hypomania, and depression in bipolar disorder, resistant depression and aggressive or self-harming behaviour

Question 8

Whats is Lithium therapeutic range ?

Answer 8

• 0.4 mmol/L to 1 mmol/L ( lower end for prophylactic treatment/ elderly )
• 0.8 mmol/l to 1 mmol/l for acute manic episodes, patients who have previously relapsed or have subsyndromal symptoms

Question 9

When should lithium blood samples must be taken ?

Answer 9

12 hours post dose

Question 10

How often lithium levels should be monitored ?

Answer 10

every three months

Question 11

When would additional monitoring for lithium would be indicated ?

Answer 11

significant intercurrent illness or significant changes to diet or water intake

Question 12

Why should abrupt withdrawal of lithium should be avoided ?

Answer 12

higher risk of relapse

Question 13

What are the signs and symptoms of Lithium toxicity ?

Answer 13

• Renal disturbances : polyuria, incontinence, hypernatraemia
• Extrapyramidal symptoms : fine tremor increasing to course tremor, ataxia, dysarthria, myoclonus, nystagmus and muscle weakness
• Visual disturbance: blurred vision
• Nervous system disturbances: confusion and drowsiness increasing to incoordination, restlessness and stupor
• GI effects: diarrhoea and vomiting

Question 14

What symptoms occur when Lithium levels are above 2 mmol/l ?

Answer 14

renal failure, arrhythmias, bradycardia, seizures, BP changes, circulatory failure, coma and sudden death

Question 15

What side effects occurs due to long term use of lithium ?

Answer 15

mild cognitive/ memory impairment, thyroid disorders

Question 16

Lithium side effects ?

Answer 16

Hypo/hyperthyroidism 
Renal impairment 
Benign intracranial hypertension 
QT prolongation 
Lowers seizure treshold

Question 17

What are the lithium monitoring requirements ?

Answer 17

thyroid function tests, renal function tests, cardiac function

Question 18

Which electrolyte disturbances predispose to lithium toxicity ?

Answer 18

hyponatraemia

Question 19

How should patients on Lithium be counselled ?

Answer 19

Maintain constant, adequate salt and water intake ( prevent dehydration ).
Lithium can cause drowsiness.
Avoid alcohol
Avoid ibuprofen, soluble analgesics, antacids

Question 20

Is lithium safe in pregnant or breastfeeding women ?

Answer 20

Teratogenic: effective contraception must be in place

Toxicity can occur in breast fed infants

Question 21

Lithium lowers seizure threshold, therefore when given with certain drugs may result in increased risk of seizures ? What are these certain drugs ?

Answer 21

Quinolones, SSRIs, epilepsy

Question 22

Lithium causes QT prolongation, which other drugs cause QT prolongation ?

Answer 22

quinolones, SSRIs, clarithromycin, amiodarone, antipsychotics, imipramine,

Question 23

Hypokalaemia can result in QT prolongation and therefore drugs that cause hypokalaemia should be avoided with lithium ?

Answer 23

theophylline, corticosteroids, B2 agonists, loop/thiazide diuretics

Question 24

Which drugs reduce renal excretion and therefore increases the risk of lithium toxicity ?

Answer 24

ACE inhibitors/ARBs, NSAIDs ( nephrotoxic drugs )

Question 25

Hyponatraemia predisposes to lithium toxicity, which drugs cause hyponatraemia ?

Answer 25

Loops, thiazide diuretics, K+ sparing diuretics, aldosterone antagonists, antidepressants ( SSRIs, TCAs )

Question 26

There is a risk of extrapyramidal symptoms if Lithium is given with which drugs ?

Answer 26

Haloperidol, phenothiazines, clozapine. Also in people who suffer from Parkinson’s disease , metoclopramide

Question 27

What OTC drugs should patients on Lithium avoid and why ?

Answer 27

Antacids that contain high amount of sodium, such as Gaviscon. Soluble and effervescent tablets. Ibuprofen due to nephrotoxicity

Question 28

There is increased risk of neurotoxicity if lithium is given with which drugs ?

Answer 28

phenytoin, carbamazepine, antipsychotics, amitriptyline

Question 29

There is an increased risk of serotonin syndrome if lithium is given with which drugs ?

Answer 29

sumatriptan, citalopram, granisetron, MAOIs, amfetamines, ST johns wort, tramadol