Bipolar - management Flashcards
Mania - treatment
- 1st line: trial of an oral antipsychotic (haloperidol, olanzapine, quetiapine, or risperidone).
- 2nd line: second antipsychotic (from one of the four antipsychotics listed above)
- 3rd line: lithium, or if not suitable, sodium valproate may be added (except for pre-menopausal women)
Antidepressant medication is usually tapered and discontinued if the person develops mania while taking an antidepressant.
Depression - treatment
- psychological therapies eg CBT Drugs - Quetiapine alone OR - Fluoxetine + Olanzapine OR - Olanzapine alone
Passmedicine: fluoxetine is the antidepressant of choice
Prevention of relapses
To prevent relapses, the person is usually offered a choice to:
- Continue their current treatment for mania, OR
- Start long-term treatment with lithium
- If lithium is not effective, valproate may be added to lithium treatment, OR valproate alone or olanzapine alone may be considered
Other aspects of care to consider
- Monitoring
- LPA, advanced statement or statement of wishes and feelings, especially if there are financial consequences resulting from mania or hypomania episodes.
- Write a care plan
- Driving - can’t drive during an acute episode, and they must tell the DVLA about their illness
Physical health review
- Ask about symptoms that could be due to adverse effects of medication.
- monitoring of lithium, valproate, and antipsychotics
- Ask about alcohol intake and substance misuse, and encourage people who smoke to stop. Note that smoking enhances the metabolism of olanzapine and clozapine.
- Ask about the person’s diet, and level of physical activity, check the weight and waist circumference
- Measure the pulse and BP, and assess CV risk.
- assess for respiratory conditions such as COPD
(there is a 2-3 times increased risk of diabetes, cardiovascular disease and COPD)
Review - blood tests
Fasting glucose, HbA1c. Lipid profile. Urea and electrolytes. Full blood count. Liver function tests. Thyroid function and calcium levels if the person is taking long-term lithium.
Lithium - CI
Cardiac disease associated with rhythm disorders.
- Clinically significant renal impairment.
- Untreated or untreatable hypothyroidism.
- Low sodium levels, including people that are dehydrated and those on low-sodium diets.
- Addison’s disease.
Lithium - Adverse effects
Initial adverse effects include nausea, diarrhoea, vertigo, oedema, muscle weakness, ‘dazed’ feeling/sedation.
Longer-term adverse effects include:
- Hypothyroidism, hyperthyroidism, or both
- Hyperparathyroidism –> hypercalcemia
- Nephrotoxicity - caused by diabetes insipidus (polyuria)
- Renal tumours: cases reported in people with severe renal impairment on lithium for more than 10 years.
- Rhabdomyolysis or muscle weakness
- benign leucocytosis
therefore need regular bloods –> U+Es, TFTs, FBC
Lithium - drug interactions
Because of lithium’s narrow therapeutic index, interactions with other drugs can be very important.
- Thiazide diuretics, NSAIDs and ACE Inhibitors — may increase serum lithium levels.
- Haloperidol — severe neurotoxicity has been reported
- Carbamazepine - can cause neurotoxic reactions
- Antidepressants with a serotonergic action (such as SSRI, TCA, venlafaxine, duloxetine) have rarely been linked to an increased incidence of CNS toxicity
- Drugs that cause hypokalaemia — potentially increased risk of torsade de points when co-administered.
Valproate - CI
- Active liver disease.
- Personal or family history of severe, drug-related, hepatic dysfunction.
- female children, female adolescents, women of childbearing potential, or pregnant women unless the illness is very severe and there is no effective alternative
Valproate - Adverse effects
- Gastric irritation, nausea
- Lethargy and confusion
- Weight gain/increased appetite
- ataxia, fine tremor
- Hair loss, with curly regrowth.
- Peripheral oedema.
- Very rarely, fulminant hepatic failure.
- Hyperandrogenism in women. This has been linked to the development of polycystic ovaries.
- Thrombocytopenia, leucopenia, red cell hypoplasia, and pancreatitis.
- teratogenicity
Monitoring –> LFT
Valproate - drug interactions
- Valproate is highly protein-bound, and other drugs that are also highly protein bound (e.g. aspirin) may displace valproate from albumin and precipitate toxicity.
- Valproate is a p450 inhibitor, so drugs that inhibit cP450 enzymes (eg erythromycin, fluoxetine, and cimetidine) can increase valproate levels.
