Bipolar Disorders Flashcards
What are the symptoms of mania?
Mania Sx ≥ 1 week and functional impairment
Criteria:
- At least 3 symptoms + Persistent Elevated / Expansive mood
OR
- At least 4 symptoms if Mood is only Persistently Irritable
DIG FAST Symptoms:
1. Distractibility and easily frustrated
2. Irresponsibility and erratic behavior
3. Grandiosity
4. Flight of Ideas
5. Activity increased (Psychomotor agitation)
6. Sleep < 3 hours
7. Talkativeness
What is and is not the role of medications in bipolar disorders?
DOES NOT reduce mood swings
REDUCES the frequency of mood swings
To avoid rapid cycling in bipolar disorders (Bipolar begets bipolar, like seizures beget seizures)
How do antidepressants induce mania?
Increase in NE and DA transmission in the first few days to 2 weeks
List the medications that induce mania
- Alcohol intoxication
- Drug withdrawal (BZD, antidepressant, opioids)
- Antidepressants
- DA and NE augmenting agents
- Steroids
- Thyroid preparations
List the medical conditions that induce mania
- CNS disorders (Stroke, trauma, multiple sclerosis)
- Cushing’s disease (Steroid)
- Hyperthyroidism (Thyroid)
What is the onset of effectiveness of starting mood stabilizer and what counseling benefit do you want to convey?
3 to 5 days onset
Better control and autonomy
Compare the antipsychotics used in bipolar disorders
Olanzapine has antimanic properties but less antidepressant effect, so fluoxetine may be needed in bipolar depression.
Risperidone has very good antimanic properties. It can be used for severe mania. Long acting injections can be used if non-adherent to PO meds and when there is relapse.
Quetiapine is cautioned due to orthostasis and strongly sedative effects
Haloperidol has EPSE
TDM Range for lithium, valproate, carbamazepine
Lithium in 5 days:
1. Acute mania = 0.8 to 1.0 mEq/L
2. Maintenance = 0.6 to 1.0 mEq/L
Valproate: 50 to 125 µg/mL in 3-5 days
Carbamazepine: 4 to 12 µg/mL in 4 weeks
Side effects for Lithium, valproate, carbamazepine, lamotrigine
Lithium: Tremor, polyuria, hypothyroidism, ECG changes, nausea, weight gain, fatigue, cognitive impairment, diabetes insipidus (Think 5HT, DA and 2nd messenger effect)
Valproate: SJS, TEN, Reduced platelet, pancreatitis, weight gain
Carbamazepine: SLE, TEN, Dyscrasias
Lamotrigine: Less sedation and less weight gain
DDIs of lithium, valproate, carbamazepine
Lithium toxicity: STAND up
Valproate & Lamotrigine: SJS
Carbamazepine & Clozapine: Agranulocytosis
What should you caution for lithium based on PK?
Renal impairment because 100% renal clearance
Monitoring Parameters for Li, VPA, CBZ, Lamotrigine, SGAs
Li: FBC, Renal panel, TFTs, Metabolic (FBG, lipid panel, BMI), TDM (12 hours after previous dose then 5-7 days after initiation, 2-weekly till stable, 3 to 6-monthly thereafter)
VPA: FBC, LFT, Metabolic, TDM (Trough sample needed, 2-3 days after initiation before next dose)
CBZ: FBC, LFT, Renal panel, TDM (Trough sample needed, 2-4 weeks to steady state), HLA*B1502
Lamotrigine: FBC (baseline), LFT, Renal panel (baseline)
SGAs: Metabolic parameters
Watch out for:
- Hyponatremia
- Pregnancy test, ECG, SJS/TEN
- FBC: Agranulocytosis (CBZ), Thrombocytopenia (VPA)
What is the course of therapy and next course of action if all else fails?
- Onset of effect is 3-5 days
- No response within 2-4 weeks require
- Augmentation with another first line
- Switching to a SGA
- ECT (For severe treatment-resistant) and omit Li, ASMs, BZDs at least 12 hours prior
If a bipolar patient has recurrent depressive episodes, what is required?
Long-term Lithium / Quetiapine / Olanzapine + Fluoxetine / Lamotrigine / Lurasidone / Cariprazine
What is bipolar disorder with rapid cycling and what to avoid?
≥ 4 mood episodes per year
Avoid antidepressants and stimulants
Evaluate labs (hypothyroidism, substance abuse)
