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PMHNP > Bipolar Disorder: Mood Stabilizers and treatment choices > Flashcards

Bipolar Disorder: Mood Stabilizers and treatment choices Flashcards

1
Q

Mood stabilizers used in bipolar disorder

A

Lithium

Anticonvulsants
-VPA (Valproic acid, valproate, divalproex)
-Carbamazepine (tegretol)
-Lamotrigine (lamictal)

Atypical Antipsychotics

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2
Q

Lithium

A

MOA: not fully known

effective in manic epi and in maintenance of recurrence

monotherapy or in combo

reduce suicide

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3
Q

Lithium dosing

A

600-900mg/day

2-3 divided doses

inc 300-600mg every 1-5 days based on response/tolerability

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4
Q

Lithium therapeutic index

A

Acute tx: 0.8-1.2
Maint tx: 0.6-1

Draw trough 12 hrs post dose

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5
Q

Lithium AE Acute

A

GI
sedation
fine tremor
polyurea
polydipsia

take with food to help

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6
Q

Lithium AE chronic

A

weight gain
hair loss
acne
tremor
sedation
decreased cognition
incoordination
hypothyroid (6-18 mo after start)

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7
Q

Lithium monitor

A

thyroid
renal
plasma calcium
plasma lithium
urinalysis
CBC
weight

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8
Q

Mild lithium toxicity

A

> 1.5

nausea
diarrhea
blurred vision
marked tremor
vertigo
confusion

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9
Q

Moderate lithium toxicity

A

> 2.5

severe neuro complications
seizures
coma
cardia dysrhythmia
permanent neuro impairment

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10
Q

Severe lithium toxicity

A

> 3.5

potentially lethal

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11
Q

lithium toxicity risk inc

A

high dose
dehydration
renal impairment
drug interactions

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12
Q

lithium toxicity tx

A

hold dose, IV normal saline, supportive care

if severe: hemodialysis, lavage if not absorbed

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13
Q

Lithium Pharmacokinetics
clearance, elimination, half life, steady state

A

clearance dec:
NSAID
ACEI
diuretic

clearance inc:
methylxanthines: caffeine, theophylline

Elimination: 100% renal
Half life 18-36 hrs
Steady state: 3-5 days

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14
Q

Valproic acid

A

MOA: not well known
- prob inhibit VSSC, boost GABA

used for acute mania and mixed states and maintenance

monotherapy or combo

more efficacious than lithium for rapid cycling

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15
Q

Valproic acid dosing

A

500-750mg/day

inc 250-500mg every 1-3 days

weight based loading dose for rapid control

therapeutic level for mania 50-125 mcg/ml

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16
Q

VPA black box

A

Liver and pancreatic effects
avoid CrCl <30

fetal toxicities

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17
Q

VPA side effects

A

hair loss
wt gain
sedation
GI
dizzy
Thrombocytopenia (dose dependent)

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18
Q

VPA side effects women

A

menstrual disturbances
PCOS
hyperandrogenism

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19
Q

VPA monitoring

A

CBC
LFT
pregnancy
ammonia (if sx for hyperammonemia)

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20
Q

VPA pharmacokinetics
bound, metabolism, half life, peak

A

protein bound (80-90%)

predominantly hepatic metabolism

half life 9-19 hrs

time to peak: 4 hrs
ER: 4-17
DR: 2

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21
Q

Carbamazepine

A

MOA: inhibit VSSC, enhanced GABA

Tx acute mania and maintenance

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22
Q

Carbamazepine dosing

A

initial: 100-400 mg/day

inc 200mg/day every 1-4 days

usual dose: 600-1200mg/day

Max 1600mg/day

23
Q

Carbamazepine side effects
Common, serious, black box

A

Common:
GI, rash, sedation, anticholinergic, dizzy, transient LFT inc

Serious:
diplopia, hyponatremia, birth defects

Black box:
SJS
aplastic anemia
agranulocytosis

24
Q

Carbamazepine monitoring

A

baseline and periodic:
CBC
Fe
liver
renal
urinalysis
sodium
ophthalmic exam including intraocular pressure
rash
suicidal ideation

consider asian: HLA for SJS

25
Q

Carbamazepine pharmacokinetics
binding, interaction, half life

A

Protein binding 75-90%

CYP450
- Inducer of 3A4, 1A2, 2C19
-metabolized via 3A4

Autoinduction—>shorter half life over time (3-5 wks)

half life
25-65 hrs—>12-17 hrs

26
Q

Lamotrigine

A

MOA: block VSSC, reduce glutamate

bipolar depression and maintenance

preferred in bipolar depression

mono or combo

27
Q

Lamotrigine dosing

A

titrate slowly to minimize rash

dosing depends on concomitant rx

28
Q

Lamotrigine side effects
sx and black box

A

Sedation
headache
dizzy
ataxia
nausea

black box
Skin: usually non serious and self limiting
but: Can be SJS/TEN

titrate slowly

29
Q

Lamotrigine risk factors for serious AE

A

rapid titration
higher initial dosing
younger age
history of rash

30
Q

Lamotrigine pharmacokinetics
absorption, bioavailability, binding, half life, metabolism

A

Absorption: ~97.6%, rapid and complete

Bioavailability: 98%

Protein binding: ~55%

Half-life: 25-33 hours (may change depending on concomitant therapy)

Metabolism: hepatic and renal
○ >75% via glucuronidation

31
Q

Lamotrigine drug interactions

A

○ Valproic acid inhibits metabolism and can double serum lamotrigine levels

○ Carbamazepine and phenytoin can induce metabolism and decrease lamotrigine levels

○ Estrogen derivatives (including hormonal contraceptives) induce lamotrigine metabolism

32
Q

Atypical Antipsychotics possible MOA

A

5HT2A receptor antagonism
D2 antagonism
5HT1A partial agonism
D2 partial agonism

33
Q

Atypical Antipsychotics addition of 5HT2A receptor antagonism vs 1st gen

A

dec EPS and hyperprolactinemia

34
Q

Atypical Antipsychotics D2 partial agonism

A

balance between silent antagonism and full stimulation

35
Q

Atypical Antipsychotics for bipolar depression

A

FDA indicated for bipolar depression

Quetiapine
300mg/day

Lurasidone (latuda)
20-120mg/day

Olanzapine-fluoxetine (Symbyax)
6/25-12/50mg/day

36
Q

Atypical Antipsychotics for bipolar mania/mixed

A

Most are approved/FDA indicated

Quetiapine
risperidone
olanzapine
ziprasidone
aripiprazole
asenapine

37
Q

Atypical Antipsychotics side effects

A

weight gain
GI sx
renal toxicity
hematological effects

38
Q

Overall tx AE: wt gain

A

many

olanzapine
clozapine
risperidone
quetiapine
divalproex
lithium
asenapine (long term)
aripiprazole (long term)

39
Q

Overall tx AE: Gi symptoms

A

Lithium
Divalproex

40
Q

Overall tx AE: Renal toxicity

A

Lithium

41
Q

Overall tx AE: hematological effects

A

Carbamazepine (leukopenia)

Clozapine (Agranulocytosis)
- REMS program to monitor

42
Q

Overall tx AE: cardiovascular effects

A

Lithium (QT)

Antipsychotics (arrhythmia, QT)
- risperidone
-olanzapine
-ziprasidone
-asenapine

clozapine

43
Q

Overall tx AE: endocrine

A

Lithium (thyroid, parathyroid)

divalproex (PCOS, menorrhea, hyperandrogen)

antipsychotics (hyperprolactinemia)
-risperidone
-amisulpride
-paliperidone

44
Q

Overall tx AE: cognition

A

antipsychotics

lithium

anticonvulsants
- except lamotrigine

45
Q

Overall tx AE: sedation

A

divalproex

atypical antipsychotics
- quetiapine
-clozapine
-olanzapine

46
Q

Overall tx AE: neurological effects/EPS

A

lithium (tremor)

divalproex (tremor)

Antipsychotics (EPS)
-1st gen>2nd gen
- poss in higher dose 2nd gen
—-especially risperidone, aripiprazole, cariprazine, ziprasidone, lurasidone

atypical antipsychotics
- NMS

47
Q

Overall tx AE: derm

A

lamotrigine

carbamazepine

divalproex

lithium (many)

48
Q

Overall tx AE: metabolic syndrome

A

most
-clozapine and olanzapine

next
-high dose quetiapine
-risperidone

next
-aripiprazole
-ziprasidone
- asenapine
-lurasidone

49
Q

CANMAT acute mgmt of mania

A

1st line
-Monotherapy: lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, cariprazine

  • Combo: lithium or divalproex AND quetiapine or aripiprazole, or risperidone or asenapine

2nd line
- olanzapine, carbamazepine, ziprasidone, haloperidol, olanzapine + lithium/divalproex, lithium +divalproex, ECT

3rd line
- mult rx

50
Q

CANMAT acute mgmt of Bipolar 1 Depression

A

1st line
- quetiapine, lurasidone +lithium/divalproex
- lithium, lamotrigine, lurasidone, lamotrigine adjunctive

2nd line
- SSRI/buproprion adjunctive, cariprazine
- divalproex, symbyax, ECT

51
Q

CANMAT acute mgmt of Bipolar 2 depression

A

1st line:
-quetiapine

2nd line
- multiple rx

3rd line
- multiple rx

52
Q

CANMAT maintenance therapy

A

1st line
- lithium, quetiapine, divalproex, lamotrigine, quetiapine + lithium/divalproex
- asenapine, aripiprazole, aripiprazole + lithium/divalproex, aripiprazole once monthly

2nd line
- olanzapine, risperidone long acting injectible
-mult others

3rd line
- mult rx

Not recc
- perphenazine, tricyclics

53
Q
A

PMHNP (26 decks)

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