Bipolar Drugs Flashcards
Differences in Bipolar I and II
Bipolar I
- Fluctuate between phases of
>> acute mania
>> depression
>> euthymic (stable mood)
- Functionally Impaired
Bipolar II
- At least 1 episode of hypomania
»_space; milder manic episodes of short duration with or
without psychosis hospitalization
- At least 1 episode of depression
- More time in depressive state than Type I
Bipolar I MANIA Treatment
Acute Mania
- Monotherapy ( in order of preference )
1. lithium - mood stabilizer
2. quetiapine - 2nd gen antipsychotic
3. valproic acid - mood stabilizer/antiepileptic
4. asenapine - 2nd gen antipsychotic
5. aripiprazole - 2nd gen antipsychotic
»> Improve in 3-4 weeks
- Combo Therapy (not starred) May work better 1. quetiapine 2. aripiprazole 3. risperidone 4. asenapine WITH lithium or valproic acid > A/E or adherence can be a problem with combo > re-evaluate in 1-2 weeks
Bipolar I DEPRESSION Treatment
(all first line)
- quetiapine - 2nd gen antipsychotic
- lurasidone (2nd gen) + lithium OR valproic acid
- lithium - mood stabilizer
- lamotrigine - antiepileptic
- lurasidone - 2nd gen antipsychotic
- Expect improvement after 2 weeks
- Lamotrigine takes longer due to slower titration
Bipolar I MAINTENANCE Treatment
(all first line)
- lithium - mood stabilizer
- quetiapine - 2nd gen antipsychotic
- valproic acid - mood stabilizer/antiepileptic
- lamotrigine - antiepileptic
- lurasidone - 2nd gen antipsychotic
** The drug that is effective in acute phase is generally continued into maintenance phase
Bipolar II Treatment
Hypomania
- treatment probably not necessary
Depression
- 1st line: quetiapine
- 2nd line: lithium, lamotrigine, adjunctive quetiapine, select antidepressants
Maintenance
- 1st line: quetiapine (adjunct or mono), lithium, or lamotrigine
- 2nd line: venlafaxine
LITHIUM
Type
MOA
Indications (3)
Mood stabilizer
MOA: unknown
Indications:
- treatment of acute mania + mixed episodes in pts 7yo and older
- maintenance approved for 7yo and older
- only medication approved for bipolar that DECREASES risk of suicide
LITHIUM
Therapeutic Effect
Therapeutic Effect
- treatment mania: 7 days
- improving depression: 6-8 weeks
LITHIUM
Adverse Effects
Adverse Effects
- GI upset, diarrhea, nausea, bloating, abdominal pain, anorexia, fatigue, muscle weakness, headache, confusion, memory loss
^ ALL TRANSIENT - Polydipsia, polyuria
^ MAY PERSIST - intentional tremor
- reduced self perceived creativity
- weight increase, lethargy, sedation
- impaired coordination
- hypothyroidism
- leukocytosis
- acne
- edema
know transient vs long term
LITHIUM
Monitoring
Monitoring
- Contraindicated in preggos
- 100% eliminated in kidneys
- serum level after a dose or clinical status change (12 hours) and q6 months
> maintain a steady state of 0.8-1.2
> lower in elderly: 0.4-0.8 - monitor levels q5days after start or dosage change
> then q3-6months for maintenance - other labs to watch
> BUN, Cr, UA, TSH, EKG, CBC
** It can mask hyperthyroidism (same sx as manic state)
** lithium can cause hypothyroidism - also low Na diet can increase lithium levels
LITHIUM
Drug Interactions
- Diuretics because Na loss and increase levels
- NSAIDs increase levels
- anticholinergics
> urinary hesitancy
> increase levels
Valproic Acid
- As effective as lithium for acute mania
> AND may be more effective if patient has rapid
cycling bipolar, substance abuse history, or
depressive symptoms occurring at the same time
as hypomania/mania (mixed episodes) - Check trough level 3-5 days after initiation or dosing change
> once 2 consecutive levels therapeutic (50-100)
then check q3-6 mo - TSH, LFTs frequently in first 6 mo
> TSH, LFTs, CBC, Plt q 6 mo once stable - CANNOT GET PREGNANT
NOTE: Lamotrigine is NOT effective for acute mania but still good for maintenance for bipolar depressive, depressive relapse, rapid cycling
Lamotrigine
- Indicated for long term maintenance
- Mono or combo therapy
- Not FDA approved for bipolar mania or depression
> BUT, clinically 1st choice for bipolar depression
> commonly used for mild hypomania symptoms
> not as effective for acute mania - Generalized pruritic rash (lamITCHtal)
- Rare but can cause SJS
> particular concern if also taking valproic acid
Second Generation Antipsychotics
- Atypical antipsychotics
- Used acutely to treat manic episodes
- Used long term to stabilize mood
- Benefits with or without psychotic symptoms
- CAN be combined with mood stabilizer
- Recommended antipsychotics
> quetiapine
> aripiprazole
> asenapine
> risperidone
> lurasidone
NOTE: Rapid cycling: 4 or more episodes/year
Quetiapine
- No extrapyramidal symptoms or prolactin elevation
- High incidence of weight gain, hyperlipidemia, hyperglycemia
- Moderate incidence of orthostatics and sedation
- ALL have QT prolongation
