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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
Carbamazepine pharmacokinetics binding, interaction, half life
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
Lamotrigine
MOA: block VSSC, reduce glutamate bipolar depression and maintenance preferred in bipolar depression mono or combo
27
Lamotrigine dosing
titrate slowly to minimize rash dosing depends on concomitant rx
28
Lamotrigine side effects sx and black box
Sedation headache dizzy ataxia nausea black box Skin: usually non serious and self limiting but: Can be SJS/TEN titrate slowly
29
Lamotrigine risk factors for serious AE
rapid titration higher initial dosing younger age history of rash
30
Lamotrigine pharmacokinetics absorption, bioavailability, binding, half life, metabolism
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
Lamotrigine drug interactions
○ 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
Atypical Antipsychotics possible MOA
5HT2A receptor antagonism D2 antagonism 5HT1A partial agonism D2 partial agonism
33
Atypical Antipsychotics addition of 5HT2A receptor antagonism vs 1st gen
dec EPS and hyperprolactinemia
34
Atypical Antipsychotics D2 partial agonism
balance between silent antagonism and full stimulation
35
Atypical Antipsychotics for bipolar depression
FDA indicated for bipolar depression Quetiapine 300mg/day Lurasidone (latuda) 20-120mg/day Olanzapine-fluoxetine (Symbyax) 6/25-12/50mg/day
36
Atypical Antipsychotics for bipolar mania/mixed
Most are approved/FDA indicated Quetiapine risperidone olanzapine ziprasidone aripiprazole asenapine
37
Atypical Antipsychotics side effects
weight gain GI sx renal toxicity hematological effects
38
Overall tx AE: wt gain
many olanzapine clozapine risperidone quetiapine divalproex lithium asenapine (long term) aripiprazole (long term)
39
Overall tx AE: Gi symptoms
Lithium Divalproex
40
Overall tx AE: Renal toxicity
Lithium
41
Overall tx AE: hematological effects
Carbamazepine (leukopenia) Clozapine (Agranulocytosis) - REMS program to monitor
42
Overall tx AE: cardiovascular effects
Lithium (QT) Antipsychotics (arrhythmia, QT) - risperidone -olanzapine -ziprasidone -asenapine clozapine
43
Overall tx AE: endocrine
Lithium (thyroid, parathyroid) divalproex (PCOS, menorrhea, hyperandrogen) antipsychotics (hyperprolactinemia) -risperidone -amisulpride -paliperidone
44
Overall tx AE: cognition
antipsychotics lithium anticonvulsants - except lamotrigine
45
Overall tx AE: sedation
divalproex atypical antipsychotics - quetiapine -clozapine -olanzapine
46
Overall tx AE: neurological effects/EPS
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
Overall tx AE: derm
lamotrigine carbamazepine divalproex lithium (many)
48
Overall tx AE: metabolic syndrome
most -clozapine and olanzapine next -high dose quetiapine -risperidone next -aripiprazole -ziprasidone - asenapine -lurasidone
49
CANMAT acute mgmt of mania
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
CANMAT acute mgmt of Bipolar 1 Depression
1st line - quetiapine, lurasidone +lithium/divalproex - lithium, lamotrigine, lurasidone, lamotrigine adjunctive 2nd line - SSRI/buproprion adjunctive, cariprazine - divalproex, symbyax, ECT
51
CANMAT acute mgmt of Bipolar 2 depression
1st line: -quetiapine 2nd line - multiple rx 3rd line - multiple rx
52
CANMAT maintenance therapy
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

PMHNP (26 decks)

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