Bipolar disorder and mania Flashcards
What are the two types of bipolar disorder episodes ?
Mania- feeling very high and overactive. Less severe mania is called hypomania
Depression- feeling very low and lethargic
Which antipsychotics are useful in acute episodes of mania and hypomania?
Second generation antipsychotics: quetiapine, olanzapine, ripseridone
What other drugs can be added to antipsychotics in bipolar disorder if response is inadequate ?
Lithium or varlpoic acid
What drug can be given in moderate-severe manic episodes ?
asenapine ( second generation antipsychotic drug )
What drugs are used in prophylaxis of bipolar disorder?
Lithium salts, olanzapine ( if response in manic episode )
valproate, carbamazepine ( rapid-cycling bipolar disorder unresponsive to other drugs )
What are the contraindications in bipolar disorder ?
Do not give antidepressants if rapid cycling bipolar disorder, recent history of hypomania, manic episode, rapid mood fluctuations
What are the Lithium uses ?
prophylaxis and treatment of mania, hypomania, and depression in bipolar disorder, resistant depression and aggressive or self-harming behaviour
Whats is Lithium therapeutic range ?
- 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
When should lithium blood samples must be taken ?
12 hours post dose
How often lithium levels should be monitored ?
every three months
When would additional monitoring for lithium would be indicated ?
significant intercurrent illness or significant changes to diet or water intake
Why should abrupt withdrawal of lithium should be avoided ?
higher risk of relapse
What are the signs and symptoms of Lithium toxicity ?
- 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
What symptoms occur when Lithium levels are above 2 mmol/l ?
renal failure, arrhythmias, bradycardia, seizures, BP changes, circulatory failure, coma and sudden death
What side effects occurs due to long term use of lithium ?
mild cognitive/ memory impairment, thyroid disorders
Lithium side effects ?
Hypo/hyperthyroidism Renal impairment Benign intracranial hypertension QT prolongation Lowers seizure treshold
What are the lithium monitoring requirements ?
thyroid function tests, renal function tests, cardiac function
Which electrolyte disturbances predispose to lithium toxicity ?
hyponatraemia
How should patients on Lithium be counselled ?
Maintain constant, adequate salt and water intake ( prevent dehydration ).
Lithium can cause drowsiness.
Avoid alcohol
Avoid ibuprofen, soluble analgesics, antacids
Is lithium safe in pregnant or breastfeeding women ?
Teratogenic: effective contraception must be in place
Toxicity can occur in breast fed infants
Lithium lowers seizure threshold, therefore when given with certain drugs may result in increased risk of seizures ? What are these certain drugs ?
Quinolones, SSRIs, epilepsy
Lithium causes QT prolongation, which other drugs cause QT prolongation ?
quinolones, SSRIs, clarithromycin, amiodarone, antipsychotics, imipramine,
Hypokalaemia can result in QT prolongation and therefore drugs that cause hypokalaemia should be avoided with lithium ?
theophylline, corticosteroids, B2 agonists, loop/thiazide diuretics
Which drugs reduce renal excretion and therefore increases the risk of lithium toxicity ?
ACE inhibitors/ARBs, NSAIDs ( nephrotoxic drugs )
Hyponatraemia predisposes to lithium toxicity, which drugs cause hyponatraemia ?
Loops, thiazide diuretics, K+ sparing diuretics, aldosterone antagonists, antidepressants ( SSRIs, TCAs )
There is a risk of extrapyramidal symptoms if Lithium is given with which drugs ?
Haloperidol, phenothiazines, clozapine. Also in people who suffer from Parkinson’s disease , metoclopramide
What OTC drugs should patients on Lithium avoid and why ?
Antacids that contain high amount of sodium, such as Gaviscon. Soluble and effervescent tablets. Ibuprofen due to nephrotoxicity
There is increased risk of neurotoxicity if lithium is given with which drugs ?
phenytoin, carbamazepine, antipsychotics, amitriptyline
There is an increased risk of serotonin syndrome if lithium is given with which drugs ?
sumatriptan, citalopram, granisetron, MAOIs, amfetamines, ST johns wort, tramadol
