Bipolar Disorder Pharmacotherapy

Question 1

Medical Conditions that Cause Mania

Answer 1

Addison’s/Cushings Disease
AIDS
Epilepsy
Head injuries
Hyperthyroidism
Neurosyphilis
Post-stroke

Question 2

Substance Disorders that Cause Mania

Answer 2

Alcohol
Anabolic steroids
Hallucinogens: LSD, PCP
Methamphetamine and cocaine

Question 3

Medications that Cause Mania

Answer 3

ADHD Stimulants
Antidepressants
Benzodiazepine withdrawal
Beta 2 agonists
Caffeine and theophylline
Clonidine withdrawal
Corticosteroids
Parkinson’s medications
Sympathomimetics
Thyroid Supplements

Question 4

Mania DSM-5 Criteria

Answer 4

Greater than 1 week of abnormal increased mood (expressive or irritable) associated with 3 of the following (4 if mood is only irritable):
o	Decreased need for sleep
o	Increased activity or agitation
o	Increased self-esteem (grandiosity)
o	Increased talking or pressured speech
o	Poor attention
o	Racing thoughts
o	Excessive involvement in activities that are pleasurable but have a high risk for serious consequences

Question 5

Hypomania DSM 5 Criteria

Answer 5

DSM-5 criteria same as manic but symptoms are less severe.

The symptoms do not impair daily function nor does the patient have to be hospitalized.

Question 6

Define Bipolar 1

Answer 6

diagnosed if the patient has had a full manic episode in their lifetime.
- Impairs daily living

Question 7

Define Bipolar 2

Answer 7

diagnosed if the patient has had both hypomanic and depressive episodes in their lifetime

Question 8

Define Rapid Cycling

Answer 8

greater than or equal to 4 depressive or manic episodes in 12 months

Question 9

Define Mixed features

Answer 9

Switches back and forth nearly every day for at least 1 week

- Symptoms do impair daily function or pt has to be hospitalized

Question 10

Electroconvulsive Therapy

Answer 10

Mania and depressed
Treatment resistant, suicidal, pregnant
Electrical charge is applied to stimulate the brain and produce a seizure that last ~ 1 minutes. Treatment course: 6-12 treatments

Question 11

***Acute Manic Episode Treatment

Answer 11

Mood stabilizers (lithium and valproic acid) and 2nd generation antipsychotics
- Benzodiazipine can be used to induce sleep or treat agitiation

Question 12

***Acute Depressive Episode Treatment

Answer 12

Lithium, lamotrigine and quetiapine

Antidepressants can be used as adjunct only

Question 13

Acute Manic Episode First-line Drugs

Answer 13

Lithium or divalproex (valproate)
Olanzapine, quentiapine, asenapine
Risperidone, ziprasidone, paliperidone
Aripiprazole

Question 14

Acute Depressive Episode First-line Drugs

Answer 14

Lithium or lamotrigine

Quetiapine

Question 15

Acute Manic Episode First-line Combination Drugs

Answer 15

Lithium or divalproex + risperidone, quetiapine, olanzapine, asenapine, or aripiprazole

Question 16

Acute Depressive Episode First-line Combination Drugs

Answer 16

Lithium or divalproex + SSRI (fluoxetine, zoloft)
Olanzapine + SSRI
Lithium + Divalproex
Lithium or divalproex + bupropion

Question 17

Lithium Predisposing factors to toxicity

Answer 17

Decreased sodium levels
Dehydration
V/D

Question 18

Lithium Mild Toxicity

Answer 18

1.2-1.5

memory difficulty and tremor

Question 19

Lithium Moderate Toxicity

Answer 19

1.5-3.0

Confusion, ataxia, emesis, tremors

Question 20

Lithium Severe Toxicity

Answer 20

Greater than 3.0

Seizures, brain damage, coma, death

Question 21

Lithium Acute Monitoring Level

Answer 21

0.8-1.5

Acute has increased excretion of lithium

Question 22

Lithium Maintenance Monitoring Level

Answer 22

0.6-1.2

Question 23

Lithium Level monitoring

Answer 23

Always obtain a steady state concentration at 5 days → when desired blood levels have been achieved, obtain levels every 1-2 weeks for 2 months → once patient is maintained on a dose, obtain levels approximately every 6 months.

Question 24

Lithium Measure after 5 days for steady state when:

Answer 24

Dosage change
Add or d/c drugs that interacts
Renal changes
Predisposing factory for toxicity

Question 25

Lithium AE Monitoring

Answer 25

• CBC- leukocytosis
• Sodium
• Ca- hyperparathyroidism
• Thyroid- hypo
• SCr and BUN – dysfunction
• Urine osmolality- nephrogenic diabetes insipidus
• Weight gain!!!
• EKG- QT prolongation

Question 26

Lithium Interactions

Answer 26

Diuretics, ACEi, NSAIDs

Question 27

Lithium CI

Answer 27

Pregnancy

Renal and cardiac disease

Question 28

Divalproex/Valproic acid Level

Answer 28

50-125 mcg/mL

Measure right before dose (trough)

Question 29

Divalproex/Valproic acid AE Monitoring

Answer 29

• CBC- thrombocytopenia
• Liver function- hepato
• Weight gain!!!
• Ammonia levels

Question 30

Divalproex/Valproic acid Interactions

Answer 30

Hepatic enzymes inducer and inhibitors

- It is a slight hepatic inhibitor so it can decrease clearance of other hepatic drugs

Question 31

Divalproex/Valproic acid CI

Answer 31

Pregnancy
Thrombocytopenia pts
Liver disease
Pancreatitis

Question 32

Carbamazepine (Tegretol) Levels

Answer 32

4-12 mcg/mL

Trough

Question 33

Carbamazepine (Tegretol) PK

Answer 33

Food increased bioavailability and it is metabolized by 3A4

Question 34

Carbamazepine (Tegretol) AE monitoring

Answer 34

• CBC- agranulocytosis
• Liver function- hepato
• Sodium
• HLA-B 1502 in Asians = SJS

Question 35

Carbamazepine (Tegretol) Interactions

Answer 35

Hepatic inducers/inhibitors (valproate)

Increased oral contraceptive clearance (unwanted prego)

Question 36

Carbamazepine (Tegretol) CI

Answer 36

Pregnancy
Immunocompromised
Liver disease

Question 37

Lamotrigine (Lamictal) Levels

Answer 37

None

Question 38

Lamotrigine (Lamictal) AE

Answer 38

Rash- SJS

Question 39

Lamotrigine (Lamictal) Interactions

Answer 39

Hepatic inducer/inhibitors (valproate)

Oral contraceptives decrease its concentration

Question 40

Who is at a high risk of switching from depression to manic states

Answer 40

Bipolar 1
Recent manic of hypomanic episode within 6 months
Substance abuse
Greater number of mood episodes per year

Question 41

Antidepressants + BD

Answer 41

Used with mood stabilizer to decrease risk of switching

- Studies show that pts who respond quickly are more likely to relapse if antidepressant is d/c