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Nik essentials guidelines > Bipolar guidelines > Flashcards

Bipolar guidelines Flashcards

1
Q

First-line psychological treatment for maintenance for bipolar disorder

A

Psychoeducation

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2
Q

Second-line psychological treatment for bipolar disorder maintenance

A

CBT and FFT (family-focused therapy)

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3
Q

Third-line psychological treatment for bipolar disorder maintenance

A

IPSRT and Peer support

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4
Q

First-line psychological treatment for bipolar disorder depression

A

NONE !

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5
Q

Second-line psychological treatment for bipolar disorder depression

A

CBT and FFT

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6
Q

Third-line psychological treatment for bipolar disorder depression

A

IPSRT

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7
Q

First-line monotherapies for acute mania

A

1) Lithium
2) Quetiapine
3) Divalproex
4) Asenapine
5) Aripiprazole
6) Paliperidone
7) Risperidone
8) Cariprazine

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8
Q

First-line combination therapy for acute mania

A

1) Quetiapine + Li/DVP
2) Aripiprazole + Li/DVP
3) Risperidone + Li/DVP
4) Asenapine + Li/DVP

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9
Q

Second-line combination (?) therapies for acute mania

A

1) Olanzapine
2) Carbamazepine
3) Olanzapine + Li/DVP
4) Lithium + DVP
5) Ziprasidone
6) Haloperidol
7) ECT

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10
Q

First-line treatments for bipolar 1 depression

A

1) Quetiapine
2) Lurasidone + Li/DVP
3) Lithium
4) Lamotrigine
5) Lurasidone
6) Lamotrigine (adj.)

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11
Q

Second-line treatments for bipolar 1 depression

A

1) Divaloproex
2) SSRIs/buproprion (adj)
3) ECT
4) Cariprazine
5) Olanzapine-fluoxetine

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12
Q

Not recommended for bipolar 1 depression

A
  • Antidepressant monotherapy
  • Aripiprazole
  • Lamotrigine + folic acid
  • Mifepristone (adj)

** Ziprasidone mono and augmentation (level 1) in the text

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13
Q

First-line treatment for maintenance BAD 1

A

1) Lithium
2) Quetiapine
3) Divaloproex
4) Lamotrigine
5) Asenapine
6) Quetiapine + Li/DVP
7) Aripiprazole + Li/DVP
8) Aripiprazole
9) Aripiprazole OM (once monthly)

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14
Q

Second-line treatment for maintenance BAD 1

A
  1. Olanzapine
  2. Risperidone LAI
  3. Risperidone LAI (adj)
  4. Carbamazepine
  5. Paliperidone (>6 mg)
  6. Lurasione + Li/DVP
  7. Ziprasidone + Li/DVP
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15
Q

First-line treatment for bipolar II depression

A
  1. Quetiapine
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16
Q

Second-line treatment for bipolar II depression

A
  1. Lithium
  2. Lamotrigine
  3. Buproprion (adj)
  4. Sertraline
  5. Venlafaxine
  6. ECT
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17
Q

Not recommended treatment for bipolar II depression

A
  1. Paroxetine
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18
Q

First-line maintenance bipolar II disorder

A
  • Quetiapine
  • Lithium
  • Lamotrigine
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19
Q

Second-line maintenance for bipolar II

A
  • Venlafaxine
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20
Q

Baseline laboratory investigations in patients with bipolar disorder

A
  1. Prolactin (head)
  2. TSH (neck)
  3. CBC with platelets (arm)
  4. EKG (chest)
  5. Fasting glucose, fasting lipid profile (gut)
  6. Pregnancy test (uterus)
  7. Liver enzymes + serum bilirubin, PT and PTT (abdo organs)
  8. Electrolytes and calcium, serum creat + eGFR, 24h creatinine clearance if history of renal disease (kidney / back)
  9. Urinalysis + urine toxicology (post kidney)
21
Q

Which anticonvulsants reduce the efficacy of oral contraceptives?

A

Several anticonvulsants including

  • Carbamazepine
  • Topiramate
  • Lamotrigine
22
Q

Which anticonvulsant’s levels are reduced by oral contraceptives?

A

Lamotrigine

(Bipolar guidelines p.131)

23
Q

Preferred medications for breastfeeding in BAD

A
  • Quetiapine
  • Olanzapine

given their lower infant dosages

(Bipolar guidelines p.132)

24
Q

First-line in youth with acute mania

A
  • Lithium
  • Risperidone
  • Aripiprazole
  • Asenapine
  • Quetiapine

(QARLA is manic)

Risperidone may be preferable to lithium for non-obese youth, and youth with ADHD

25
Q

First-line for youth with bipolar depression

A
  • Lurasidone
26
Q

Second-line youth with bipolar depression

A
  • Lithium
  • Lamotrigine
27
Q

Third-line for youth with bipolar depression

A
  • Olanzapine-fluoxetine combination
  • Quetiapine
28
Q

First-line maintenance for youth with BAD

A
  • Aripiprazole
  • Lithium
  • Divaloproex (epival)
  • Combination therapy (e.g. risperdione + Li/DVP or Li + DVP or CBZ)

ALEC

29
Q

Second-line maintenance for youth with BAD

A

None

30
Q

Possible interaction from combination of carbamazepine and divalproex sodium

A

Decrease of divaloproex sodium levels

Epocrates interaction checker

31
Q

What are the target serum lithium levels for adults in acute treatment?

A
  • 0.8-1.2 mEq/L
  • Canmat bipolar p.142*
32
Q

What are the target serum lithium levels for adults for maintenance?

A
  • 0.6-1.0 mEq/L may be sufficient
  • Canmat bipolar p.142*
33
Q

What are the target serum lithium levels for older adults?

A
  • 0.4-0.8 mEq/L
  • Canmat bipolar p.142*
34
Q

What to suspect if new-onset neurological symptoms in patients taking Divalproex?

A
  • Hyperammonaemic encephalopathy
  • Canmat p.145*
35
Q

For which clinical features is Lithium the preferred medication over Divalproex for BAD?

A
  • Classical euphoric grandiose mania
  • Few prior episodes of illness
  • Mania-depression-euthymia course
  • Family history of BD (especially of lithium response)
36
Q

For which clinical features is Divalproex a recommended medication for BAD?

A
  • Multiple prior episodes
  • Predominant irritable or dysphoric mood
  • Comorbid substance abuse
  • History of head trauma

** Caution with women of childbearing age **

37
Q

For which clinical features is Carbamazepine an effective medication in BAD?

A
  • History of head trauma
  • Comorbid anxiety
  • Comorbid substance abuse
  • Schizoaffective presentations with mood-incongruent delusions
  • Negative history of bipolar illness in first-degree relatives
38
Q

Which medications may be useful in Mania with Anxious Features?

A

–> No studies specifically examining that, but post-hoc analyses have suggested that the following can be useful:

  • Divalproex
  • Quetiapine
  • Olanzapine
  • Carbamazepine
39
Q

What medications are prefered for mania with mixed features?

A
  • Atypical antipsychotics (asenapine, aripiprazole, olanzapine, ziprasidone are as good in classical manic as mania with mixed features)
  • Divalproex
  • Often a combination therapy
40
Q

What medications are recommended for mania with psychotic features?

A
  • No evidence of superiority of any first-line monotherapy treatment in comparison to other monotherapy options in treating patients with psychotic features.
  • For MOOD INCONGRUENT psychotic features, combination of lithium/DVP + AAP is suggested.
  • If possibility of schizoaffective disorder with manic symptoms: either use AAP or AAP + mood stabilizer
41
Q

What medications are preferred for rapid cycling bipolar?

A
  • No evidence of superiority of any first-line treatment
  • Combinations are more often necessary than monotherapies.
42
Q

What are the preferred medication for bipolar disorder with a seasonal pattern of manic episodes?

A
  • No evidence for superiority of any agent
43
Q

What are the recommendations for depressed bipolar patients with a need for rapid response?

A
  • Quetiapine and Lurasidone (have separated from placebo at week 1)

Second-line options include:

  • ECT
  • Cariprazine
  • OLZ-fluoxetine
44
Q

What are the treatment recommendations for depressed bipolar patient with:

  • Anxious distress
A
  • Quetiapine
  • Olanzapine-fluoxetine
  • Lurasidone (post-hoc analysis)

–> Effects of divalproex, risperidone and lamotrigine appear to be limited

45
Q

What are the treatment recommendations for depressed bipolar patient with:

  • Mixed features
A
  • Combination therapy often necessary
  • Atypical antipsychotics have a class effect
    Those that have demonstrated efficacy include:
  • Olanzapine-fluoxetine
  • Asenapine
  • Lurasidone (also useful in MDD with mixed features)
  • ** Avoid antidepressants **
46
Q

What are the treatment recommendations for depressed bipolar patients with:

  • Melancholic features
A
  • No specific studies
  • ECT very effective as per clinical experience
47
Q

What are the treatment recommendations for depressed bipolar patient with:

  • Atypical features
A
  • Some efficacy of tranylcypromine in anergic bipolar depression (but consider adverse effects)
  • However, to be used only with lithium or DVP or AAP
48
Q

What are the treatment recommendations for depressed bipolar patient with:

  • Psychotic features
A
  • Clinical experience suggests ECT and antipsychotics are highly effective
49
Q

What are the treatment recommendations for depressed bipolar patient with:

  • Rapid cycling
A
  • No evidence to support any specific agent
  • Li / DVP / OLZ / QUE all appear to have comparable maintenance efficacies in these patients (but not lamotrigine)
  • Antidepressants are not recommended

Nik essentials guidelines (6 decks)

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