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Psychiatry > Bipolar Disorder - Treatment > Flashcards

Bipolar Disorder - Treatment Flashcards

1
Q

What are the goals of treatment (desired outcome) of Bipolar Disorder?

A
  1. Prevent acute, hypomanic, or depressive episode
  2. Maintain mood functioning
  3. Promote treatment adherence
  4. Minimize side effects
  5. Prevent further episodes of mania or depression
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2
Q

What is the best predictor of level of function in patients with Bipolar Disorder?

A

Adherence to medications

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3
Q

What is the most important factor in stabilization of Bipolar Disorder?

A

Adherence to medications

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4
Q

What are the pharmacologic treatments for Bipolar Disorder?

A
  1. Lithium
  2. Anticonvulsants
  3. Antipsychotics
  4. Adjunctive (antidepressants, benzodiazepines)
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5
Q

What are the FDA-approved medications for acute mania?

A
  1. Lithium
  2. Valproate
  3. CBZ ER
  4. Aripiprazole
  5. Olanzapine
  6. Quetiapine
  7. Risperidone
  8. Ziprasidone
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6
Q

What are the FDA-approved medications for maintenance treatment of Bipolar Disorder?

A
  1. Lithium
  2. Divalproex
  3. Aripiprazole
  4. Olanzapine
  5. Lamotrigine
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7
Q

What are the first-line treatments for hypomania?

A 
1. Mood stabilizer (optimize/initiate):
A. Lithium
B. Valproate
C. CBZ
D. SGA
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8
Q

What medications should be considered for short-term adjunct treatment of agitation or insomnia if needed in hypomania?

A
  1. Lorazepam

2. Clonazepam

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9
Q

What are the second-line treatments for hypomania?

A
  1. Lithium + anticonvulsant/SGA

2. Anticonvulsant + anticonvulsant/SGA

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10
Q

What are the first-line treatments for mania?

A
  1. Lithium/valproate/SGA + benzo +/- antipsychotic for short-term agitation/insomnia
  2. No/inadequate response:
    A. CBZ/oxcarbazepine
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11
Q

What are the second-line treatments for mania?

A
  1. Lithium + anticonvulsant + antipsychotic

2. Anticonvulsant + anticonvulsant + antipsychotic

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12
Q

What are the third-line treatments for mania?

A
  1. ECT

2. Add clozapine

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13
Q

What are the treatments for severe depressive episode?

A
  1. Mood stabilizer (optimize/initiate):
    A. Lithium or quetiapine OR
    B. Fluoxetine/olanzapine combination
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14
Q

What are the treatments for mild to moderate depressive episodes?

A
  1. Mood stabilizer (optimize/initiate):
    A. Lithium or quetiapine OR
    B. Fluoxetine/olanzapine combination
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15
Q

What are the second-line treatments for severe depressive episode?

A

CBZ +/- antidepressant

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16
Q

What are the third-line treatments for severe depressive episode?

A
  1. Lithium + lamotrigine + antidepressant

2. Lithium + quetiapine + antidepressant

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17
Q

What is the initial dose of lithium in acute mania?

A

900-1200 mg/day

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18
Q

What is the prophylactic dose of lithium?

A

600-900 mg/day

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19
Q

What other medications increase the effectiveness of lithium in the treatment of Bipolar I?

A
  1. CBZ
  2. Lamotrigine
  3. Valproate
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20
Q

What are possible ways to minimize the adverse effects of lithium?

A
  1. Lower dose
  2. Smaller doses w/ food
  3. Use ER formulations
  4. Once daily dosing at bedtime
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21
Q

What are the initial adverse effects of lithium?

A
  1. GI distress
  2. Muscle weakness/lethargy
  3. Polydipsia/polyuria/nocturia (use once daily to minimize)
  4. HA
  5. Memory impairment/confusion/poor concentration
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22
Q

What serum levels of lithium are associated with lithium toxicity?

A
  1. Mild > 1.5 mEq/L
  2. Severe > 2.0 mEq/L
  3. Elderly patients can experience toxicity at therapeutic levels
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23
Q

What are the therapeutic levels of lithium?

A

0.6-1.4 mEq/L

24
Q

How many days does it take to reach steady state for lithium therapy?

A

~5 days

25
Q

What medications can elevate lithium levels?

A
  1. Thiazide diuretics
  2. NSAIDs
  3. COX-2 inhibitors
  4. ACE inhibitors
  5. Salt-restricted diets
26
Q

What medications can lower lithium levels?

A
  1. Caffeine

2. Theophylline

27
Q

What actions are taken to treat lithium toxicity?

A
  1. ER for monitoring
  2. Gastric lavage and IV fluids
  3. Monitor fluid/electrolyte balance
  4. Monitor neurological changes
  5. Hemodialysis for concentrations > 3.5-4 mEq/L (12 on, 12 off)
28
Q

What medications are not recommended to use with lithium?

A

Calcium channel blockers

29
Q

Does lithium clearance increase or decrease during pregnancy?

A

Clearance can be increased by 50-100% during pregnancy (check levels monthly during pregnancy and weekly the month before delivery)

30
Q

What medications can result in neurotoxicity w/ lithium?

A
  1. CBZ
  2. Non-dihydro CCBs
  3. ARBs
  4. Methyldopa
  5. Metronidazole
  6. Phenytoin
31
Q

What are the major counseling points for patients starting lithium therapy?

A
  1. Maintain adequate sodium intake
  2. Maintain adequate fluid intake
  3. Avoid excessive caffeine/alcohol intake
32
Q

What effect can lithium have on TSH?

A

Increase TSH

33
Q

What effect can lithium have on the parathyroid?

A
  1. Hypercalcemia

2. Hyperparathyroidism

34
Q

What are common side effects associated with lithium?

A
  1. Reduction in urine concentration
  2. Benign and reversible cardiovascular effects
  3. Benign and reversible leukocytosis
  4. Dermatologic
  5. Dry mouth
  6. Altered taste
  7. Changes in taste
  8. Weight gain
  9. Neurological disturbances
35
Q

What are the key symptoms of lithium toxicity?

A
  1. Worsening GI distress
  2. Worsening coordination
  3. Worsening cognition
36
Q

When can divalproex be used?

A
  1. Acute treatment of manic or mixed episodes

2. Maintenance monotherapy

37
Q

When can CBZ (or oxcarbazepine) be used?

A
  1. Acute and maintenance therapy

2. Generally for lithium-refractory patients, rapid cyclers, or mixed states

38
Q

When is lamotrigine used?

A
  1. Maintenance treatment of Bipolar I

2. Add-on monotherapy for refractory Bipolar depression

39
Q

What are the key points in starting lamotrigine?

A
  1. Requires slow titration

2. Hypersensitivity and rare life threatening skin reactions

40
Q

What is the initial dosing for valproate for adults with acute mania?

A
  1. 20 mg/kg/day in divided doses over 12 hours

2. Max is 60 mg/kg/day

41
Q

What is the initial dosing of valproate in outpatients who are hypomanic, euthymic, or elderly?

A
  1. 5-10 mg/kg/day in divided doses
  2. Gradually titrated to avoid adverse effects
  3. ER divalproex can be administered once daily
42
Q

What are the recommended baseline and routine lab tests for valproate?

A
  1. Metabolic
  2. Hematologic
  3. LFTs
  4. Dermatologic
  5. Serum levels have not been established for Bipolar Disorder
43
Q

What are the dose related adverse effects for valproate?

A
  1. GI
  2. Fine hand tremors
  3. Sedation
  4. Ataxia, lethargy, platelet inhibition, increased appetite and weight gain
44
Q

What medications can be increase CBZ levels?

A

CCBs (requires close monitoring)

45
Q

What are the adverse effects with CBZ levels > 15 mpg/mL?

A
  1. Ataxia
  2. Choreiform movements
  3. Diplopia
  4. Nystagmus
  5. Cardiac conduction changes
  6. Seizures
  7. Coma
46
Q

What is the initial dosing of CBZ in acute manic episodes in hospitalized patients?

A
  1. 400-600 mg/day in divided doses w/ meals

2. Increase by 200 mg/day Q 2 to 4 days up to 10 to 15 mg/kg/day

47
Q

What is the initial dosing of CBZ in acute manic episodes in outpatients?

A

Initial doses are lower than hospitalized patients as well as more slowly titrated

48
Q

What are the monitoring parameters of CBZ?

A
  1. Serum levels every 1 to 2 weeks during first 2 months

2. Serum levels ever 3 to 6 months during maintenance (trough 10-12 hours after dose)

49
Q

How do when manage CBZ toxicity?

A
  1. Gastric lavage
  2. Hemoperfusion
  3. Symptomatic treatment
50
Q

What are common DDIs w/ CBZ?

A
  1. Inducers/inhibitors
  2. Oral contraceptives
  3. Avoid clozapine
  4. Valproate displaces CBZ from protein-binding sites (reduce CBZ dose)
51
Q

What is the major side effect associated with lamotrigine?

A

SJS, especially in combo w/ valproate

52
Q

What is the usual dose range of lamotrigine in Bipolar Disorder?

A

50-300 mg/day

53
Q

What is the target dose of lamotrigine?

A
  1. 100 mg/day in combo w/ valproate
  2. 400 mg/day in combo w/ CBZ
  3. Must be restarted after discontinuing for more than a few days
54
Q

What is the main DDI with lamotrigine?

A

Valproate (double half-life, decreases clearance)

55
Q

What are the side effects of benzodiazepines?

A
  1. CNS depression
  2. Sedation
  3. Cognitive/motor impairment
  4. Dependence
  5. Withdrawal
56
Q

What are the ISBD recommendations for antidepressants in Bipolar Disorder?

A
  1. Questionable risk/benefit
  2. Should not be used in mania or mixed episodes
  3. Do not use in patients w/ history of rapid cycling or mania
  4. Should only be used in patients with a good response history of antidepressants

Psychiatry (4 decks)

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