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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
First-line for youth with bipolar depression
* Lurasidone
26
Second-line youth with bipolar depression
* Lithium * Lamotrigine
27
Third-line for youth with bipolar depression
* Olanzapine-fluoxetine combination * Quetiapine
28
First-line maintenance for youth with BAD
* Aripiprazole * Lithium * Divaloproex (epival) * Combination therapy (e.g. risperdione + Li/DVP or Li + DVP or CBZ) ALEC
29
Second-line maintenance for youth with BAD
None
30
Possible interaction from combination of carbamazepine and divalproex sodium
Decrease of divaloproex sodium levels ## Footnote *Epocrates interaction checker*
31
What are the target serum lithium levels for adults in acute treatment?
* 0.8-1.2 mEq/L * Canmat bipolar p.142*
32
What are the target serum lithium levels for adults for maintenance?
* 0.6-1.0 mEq/L may be sufficient * Canmat bipolar p.142*
33
What are the target serum lithium levels for older adults?
* 0.4-0.8 mEq/L * Canmat bipolar p.142*
34
What to suspect if new-onset neurological symptoms in patients taking Divalproex?
* Hyperammonaemic encephalopathy * Canmat p.145*
35
For which clinical features is Lithium the preferred medication over Divalproex for BAD?
* Classical euphoric grandiose mania * Few prior episodes of illness * Mania-depression-euthymia course * Family history of BD (especially of lithium response)
36
For which clinical features is Divalproex a recommended medication for BAD?
* Multiple prior episodes * Predominant irritable or dysphoric mood * Comorbid substance abuse * History of head trauma *\*\* Caution with women of childbearing age \*\**
37
For which clinical features is Carbamazepine an effective medication in BAD?
* 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
Which medications may be useful in Mania with Anxious Features?
--\> No studies specifically examining that, but post-hoc analyses have suggested that the following can be useful: * Divalproex * Quetiapine * Olanzapine * Carbamazepine
39
What medications are prefered for mania with mixed features?
* Atypical antipsychotics (asenapine, aripiprazole, olanzapine, ziprasidone are as good in classical manic as mania with mixed features) * Divalproex * Often a combination therapy
40
What medications are recommended for mania with psychotic features?
* 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
What medications are preferred for rapid cycling bipolar?
* No evidence of superiority of any first-line treatment * Combinations are more often necessary than monotherapies.
42
What are the preferred medication for bipolar disorder with a seasonal pattern of manic episodes?
* No evidence for superiority of any agent
43
What are the recommendations for depressed bipolar patients with a need for rapid response?
* Quetiapine and Lurasidone (have separated from placebo at week 1) Second-line options include: * ECT * Cariprazine * OLZ-fluoxetine
44
What are the treatment recommendations for depressed bipolar patient with: * Anxious distress
* Quetiapine * Olanzapine-fluoxetine * Lurasidone (post-hoc analysis) --\> Effects of divalproex, risperidone and lamotrigine appear to be limited
45
What are the treatment recommendations for depressed bipolar patient with: * Mixed features
* 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
What are the treatment recommendations for depressed bipolar patients with: * Melancholic features
* No specific studies * ECT very effective as per clinical experience
47
What are the treatment recommendations for depressed bipolar patient with: * Atypical features
* Some efficacy of tranylcypromine in anergic bipolar depression (but consider adverse effects) * However, to be used only with lithium or DVP or AAP
48
What are the treatment recommendations for depressed bipolar patient with: * Psychotic features
* Clinical experience suggests ECT and antipsychotics are highly effective
49
What are the treatment recommendations for depressed bipolar patient with: * Rapid cycling
* 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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