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PHA333 > bipolar disorder in practice > Flashcards

bipolar disorder in practice Flashcards

1
Q

What is bipolar disorder?

A

a chronic relapsing and remitting disorder

abnormally elevated mood/irritability alternates with depresssed mood

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2
Q

What is bipolar affective disorder associated with?

A

poor physical health

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3
Q

physical health check for BP

A

annually

weight/BMI
diet
nutritional status
level of physical activity
CV status (pulse, BP)
metabolic status (fasting blood glucose, HbA1c, prolactin, blood lipid profile, liver fxn)
if Rx Li - renal fxn, TFTs, Ca levels
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4
Q

suspected BPAD (bipolar affetive disorder)

A

referred to specialist mental health services

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5
Q

choice of drug depends on what factors

A 
age
s/e
interactions and cautions
child bearing potential
previous Hx
medical comorbidities
individial prefernences
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6
Q

treatment for acute mania/hypomania

A

withdraw any antidepressants/stimulants

if not Rx any antipsychotics/mood stabilisers start

  • haloperidol, olanzapine, quetiapine, risperidone
  • poorly tol/inieffective alternative
  • not sufficient add lithium or valporate (Li not suitable)

taking Li

  • check plasma levels
  • consider adding antipsychotic

severe agitation
- ST BDZs

psychotherapy

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7
Q

When to discuss LT Tx after acute tx for mania?

A

within 4 weeks of resolution of symptoms

can continue tx for 3-6mths then review

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8
Q

drugs NOT recommended for mania

A 
antidepressants (induce mania)
lamotrigine
gabapentin
topiramate
carbamazepine + antipsychotics metabolised by CYP3A4 (interaction)
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9
Q

treatment of bipolar depression

A

psychological

antidepressant monotherapy NOT recommended

  • fluoxetine + olanzapine
  • atypical antipsychotic
  • lamotrigine (no response)
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10
Q

What to avoid for tx of bipolar depression?

A

antidepressant monotherapy

TCAs

venlafaxine

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11
Q

LT bipolar management

A

1st line

  • Lithium
  • valporate
  • olanzapine

2nd line

  • lamotrigine (adjunct)
  • carbamazepine
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12
Q

When to start LT management for bipolar?

A
  • after manic episode with significant risk
  • 2+ acute episodes bipolar 1 disorder
  • significant functional impairment/suicide risk
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13
Q

How long is LT treatment continued for?

A

at leat 2yrs after episode

reduce gradually on withdrawal

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14
Q

How to Rx lithium?

A

by brand

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15
Q

how long to see efficacy of lithium

A

at least 6mths

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16
Q

therapeutic effects of lithium

A

acute mania

prophylactic agent for mania and depression

antidepressant properties

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17
Q

therapeutic effects of lithium

A

acute mania

prophylactic agent for mania and depression

antidepressant properties

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18
Q

What is lithium 1st line for?

A

LT pharmacological tx to prevent relapse

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19
Q

when to monitor other things on lithium

A

at least every 6mths during treatment

more frequently at start

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20
Q

monitoring for lithium

A 
serum electrolytes (Na)
eGFR (declines, levels inc, toxicity)
body weight/BMI/waist circumference
lipids
thyroid function
calcium levels
FBC/ECG on initiation
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21
Q

When to monitor lithium levels?

A

initially weekly

additional tests if concerns (signs of toxicity)

additional test 5-7 days sfter every dose change or start/stop interacting drugs

22
Q

How to measure lithium levels?

A

take levels 12hrs after dose

23
Q

lithium levels for initial treatment

A
  1. 6 - 0.8 mmol/L
  2. 6 - 1 mmol/L

-> higher range for pts who relapsed previously

24
Q

toxic lithium levels

A

> 1.5 mmol/L

25
side effects of lithium
``` fine tremor sedation impaired co-ordination GI disturbances polyuria, polydipsia QT prolongation LT effects - weight changes - thyroid disorders - hyperparathyroidism - renal impairment ```
26
signs of lithium toxicity >1.5mmol/L
``` lack of appetite diarrhoea vomiting blurred vision marked tremor unsteadiness slurred speech drowsiness, confusion ```
27
signs of lithium toxicity >2mmol/L
muscle twitches more severe drowsiness/confusion convulsions unconsciousness
28
interactions with lithium
``` drugs impacting on renal fxn - diuretics - NSAIDs - ACEIs - antidepressants (serotonin syndrome (monitor kidney fxn if co-Rx) ``` carbamazepine haloperidol
29
lithium bioavailability
narrow therapeutic index | liquid/tabs not interchangeable
30
tabs/liquid forms of lithium
lithium carbonate = tabs lithium citrate = liquid
31
counselling for lithium
- take every day, don't miss a dose - carry lithium card - same brand - tell pharmacist when buying OTC (NSAIDs) - adequate fluid intake - avoid dietary changes that inc/dec Na intake - regular blood tests - reliable contraception - common s/e - recognise toxicity symptoms - med advice if dehydrated/sickness/diarrhoea for >2 days
32
common s/e of lithium
``` dry mouth metallic taste in mouth thirsty weight gain fluid retention ```
33
Why to have adequate fluid intake with lithium?
renal fxn important to maintain steady serum levels -> fxn declines serum levels will increase dehydration/diarrhoea/stomach bug will dec renal function -> risk of lithium toxicity
34
When is lithium given?
at night -> trough serum lithium levels taken in morning 12hrs after dose
35
What is valporate prescribed for?
acute mania prophylactic agent
36
3 forms of valproate
sodium valproate valproic acid semi-sodium valproate
37
Which form of valproate is active?
valproic acid -> semisodium valporate and sodium valporate are metabolised to valproic acid
38
valproate risk
major human teratogen
39
valoroate and pregnancy
not used in women/girls of childbearing potential unless pregnancy prevention programme in place - patient cards every time dispensed - dispensed with copy of PIL and warning on container if repackaged - remind of risks in pregnancy and need for effective contraception - annual specialist review
40
s/e with valproate
``` weight gain GI irritation blood disorders impaired liver function panreatitis fatigue nausea sedation hair loss suicidal thoughts teratogenic ```
41
What to measure before starting valproate?
weight/BMI FBC LFTs
42
valproate interactions
highly protein bound (94%) and can be displaced from albumin precipitating toxicity other protein bound drugs can be displaced by valproate - higher free levels, inc therapeutic effect/toxicity of the other drug metabolised in liver, drugs that inhibit CYP450 can inc valproate levels
43
atypical antipsychotics used for bipolar
olanzapine quetiapine aripiprazole
44
When are atypical antipsychotics used?
preferred tx for acute mania improved s/e profile in ST use
45
LT s/e with atypical antipsychotics
``` weight gain dyslipidaemia hyperprolactinaemia hypertension reduced seizure threshold impaired glucose tolerance QT prolongation stroke risk VTE ```
46
Why is hypertension s/e with atypical antipsychotics?
small steady inc in BP over time (may be associated with weight gain) OR unpredictable sharp inc in BP starting new drug
47
What is lamotrigine used for?
prevention of depressive disorders in bipolar I disorder -> NOT for acute mainc/depressive episodes
48
s/e with lamotrigine
``` skin rashes headache dizziness nausea drowsiness insomnia blood disorders (rare) small risk of suicidal thoughts/behaviours ```
49
lamotrigine interactions
phenytoin, primidone, carbamazepine, oestrogens, progestogens (dec plasms conc of lamotrigine) -> inc lamotrigine dose valproate (inc lamotrigine plasma conc)
50
non-pharmacological inteventions for bipolar
patient education - regular routine, sleep hygiene, detecting early warning symptoms CBT - individual/group psychosocial support ECT therapy

PHA333 (27 decks)

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