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Pharm - Psychiatry > Bipolar - Lithium > Flashcards

Bipolar - Lithium Flashcards

1
Q

What’s the first line treatment?

A

Lithium

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2
Q

Acute Mania: Bipolar 1, 2, or Both?

A

Bipolar 1

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3
Q

Acute Hypomania: Bipolar 1, 2, or Both?

A

Bipolar 2

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4
Q

Bipolar Depression: Bipolar 1, 2, or Both?

A

Both

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5
Q

Bipolar Maintenance: Bipolar 1, 2 or Both?

A

Both

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6
Q

Can you treat bipolar with just an antidepressant?

A

No because you worry that it could flip them into a manic episode, so you need to give a mood stabilizer

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7
Q

Lithium is used for what parts of bipolar?

A

Everything! So…Acute Mania/Hypomania, Bipolar Depression, and Maintenance

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8
Q

Lithium is used as an adjunct for?

A

Major depression (b/c of increased effects of 5-HT)

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9
Q

A unique aspect of lithium is?

A

Reduces risk of suicide

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10
Q

How long does it take for Lithium to exert it’s full therapeutic effect?

A

2-3 weeks (delayed onset partially due to need to make dose adjustment)

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11
Q

Lithium is treated similar to what ion in the body?

A

Na+

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12
Q

Lithium’s effect on 5-HT? NE? DA? ACh?

A

Inc 5-HT effects
Dec turnover of NE and DA
Inc ACh synthesis

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13
Q

% of blood protein binding for Lithium?

A

0%

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14
Q

Describe Lithium’s therapeutic window.

A

Narrow!
0.6-1.2 meq/L
(>1.2 gives toxic effects)

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15
Q

Lithium metabolism/excretion is?

A

RENAL!

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16
Q

Diuretics that act at PCT do what? What are the 2 classes of these diuretics and the specific drug names (5 total)?

A

Urinary Alkalization

Carbonic Anhydrase Inhibitors - Acetazolamide, Dichlorphenamide, Methazolamide

Osmotic diuretics - Mannitol, Urea

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17
Q

Li MOA?

A

Inhibits Inositol recycling enzymes
Inhibits GSK-3
Affects Protein Kinase C

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18
Q

What happens to Li in the Glomerulus? PCT? Collecting Duct?

A

Glomerulus - freely filtered
PCT - reabsorbed with Na+
Collecting Duct - reabsorbed by principal cells epithelial Na+ channel

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19
Q

With PCT diuretics, Li levels: increase, decrease, or no change?

A

Decrease

Inc Li excretion gives decreased Li level in the body

20
Q

With Loop of Henle diuretics, Li levels: increase, decrease, or no change?

A

No change (it’s controversial)

21
Q

Name a loop diuretic.

A

Furosemide

22
Q

With DCT diuretics, Li levels: increase, decrease, or no change?

A

Increases

23
Q

What’s the relationship between diuretic site of action and Li excretion?

A

As site of action moves from PCT to Loop of Henle to DCT, you go from increased Li excretion (PCT) to unclear changes (Loop) to decreased Li excretion (DCT)

24
Q

What diuretics act at the DCT?

A

Thiazide

25
Q

With Collecting Duct diuretics, Li levels increase, decrease, or no change?

A

Increases

26
Q

What are the classes of drugs that act on the Collecting Duct? What are the specific drugs in these classes

A

K+ sparing - Spironolactone, Amiloride

ACE Inhibitors and Angiotensin II Receptor Antagonists - Aldosterone

27
Q

What’s the MOA for Spironolactone?

A

K+ sparing diuretic

Antagonizes aldosterone receptors

28
Q

Is it okay to be on both Li and Diuretics?

A

It’s not really a problem with Furosemide but for other diuretics you have to monitor Li level to make sure it’s therapeutic because of potential Li toxicity.

29
Q

What other things can give decreased Li levels?

A

Aminophylline
Theophylline
Caffeine
Pregnancy (hold Li during labor and restart it after birth on half the dose given during pregnancy)

30
Q

What other things do not affect Li levels?

A

Amiloride
Acetaminophen
Aspirin
Sulindac

31
Q

What other things give increased Li levels?

A 
NSAIDs
COX-2 Inibitors
Dehydration
Na depletion (hyponatremia)
Renal impairment
Advanced Age
32
Q

Common Lithium Side Effects (7)

A 
Hypothyroidism (F 5x >M)
Nausea
Diarrhea
Fine Tremor (propanolol helps)
Decreased concentration
Sedation
Weight gain (F > M)
33
Q

Rare Li Side Effects (4)

A

Hyperparathyroidism
End Stage Renal Disease
Bradycardia
Sick Sinus Syndrome

34
Q

Other serious Side effects from Li

A

NDI - Nephrogenic Diabetes Insipidus
Mild Renal Insufficiency
End Stage Renal Disease

35
Q

What is NDI (Nephrogenic Diabetes Insipidus)?

A

Affects kidney’s ability to concentrate urine –> poluria gives polydipsia (inc fluid intake)
Is a long term risk of Li (10+ years of use)

36
Q

What increases the risk for NDI?

A

Episodes of Li toxicity

37
Q

What can be used to treat NDI?

A

Amiloride

38
Q

Li Toxicity: Levels for Mild, Moderate, and Severe

A

Mild: 1.5-2.0 mEq/L
Moderate: 2.0-2.5 mEq/L
Severe: >2.5 mEq/L

39
Q

If someone shows confusion, is there Li toxicity?

A

Assume so and try to rule it out

40
Q

Mild Li toxicity gives? (7)

A

Nausea, Vomiting, Diarrhea
Lethargy, Drowsiness
Muscle Weakness
Coarse Hand Tremor

41
Q

What do you do for mild Li toxicity?

A

Stop Li and resume lower dosage in a few days

42
Q

Moderate Li toxicity gives? (6)

A 
Confusion
Myoclonic Twitches
Dysarthria
Ataxia
Nystagmus
ECG Changes
43
Q

Severe Li toxicity gives? (5)

A 
Grossly Impaired Consciousness
Coma
Inc DTR's (deep tendon reflexes)
Seizures
Syncope
44
Q

Lab tests before Li treatment

A 
Pregnancy test
Renal Function
Thyroid Function
ECG if > 50 y/o
BMI
45
Q

Lithium levels and pregnancy

A

Lithium levels decreased during pregnancy and increase after delivery (due to GFR changes - in opp direction as Li level)

46
Q

1st trimester exposure to Lithium has what associated defect?

A

Ebstein’s anomaly - congenial cardiac defects

Pharm - Psychiatry (6 decks)

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