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Bipolar meds Flashcards

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1
Q

What drugs might exacerbate mania?

A
  • drugs that increase catecholamine related activity

- drugs that reduce activity of dopamine or NE relieve mania

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2
Q

Pts presenting with acute mania should be assessed for what?

What drugs should be d/c’d?

A
  • suicide risk
  • aggressiveness
  • risk of violence to others
  • ability to adhere to tx program
  • substance abuse eval and tx
  • alcohol, caffeine, and nicotine intake
  • antidepressants should be d/c
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3
Q

Do antipsychotic drugs cure bipolar disorder?

A
  • no, they tx the sxs!
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4
Q

Classes of meds used in bipolar?

A
  • lithium (mood stabilizer)
  • anticonvulsants (mood stabilizer)
  • FGAs
  • SGAs (atypical antipsychotics)
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5
Q

Mood stabilizing agents? Choice of mood stabilizer often based upon what?

A
  • lithium
  • valproate
  • carbamazepine
  • choice of mood stabilizer often based upon:
    previous hx
    side effect profiles
    co-existing medical illness
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6
Q

Common side effects of mood stabilizing meds?

A
  • drowsiness
  • dizziness
  • HA
  • diarrhea
  • constipation
  • heartburn
  • mood swings
  • stuffed or runny nose, or other cold like sxs
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7
Q

MOA and use of lithium?

A
  • sig decreases frequency and severity of both manic and depressive episodes in about 70% of pts
  • may decrease NE and dopamine turnover
  • blocks development of dopamine receptor supersensitivity
  • may augment synthesis of acetylcholine, by increasing cholamine uptake into nerve terminals
  • use less first line with new atypical antipsychotics
  • may work better in maintenance phase of therapy
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8
Q

Why is lithium use? What are things to monitor? SEs?

A
  • has low therapeutic index - doesn’t take much for it to work
  • required constant blood level measuring
  • renal clearance of lithium erduced about 25% by diuretics
  • tremor is common SE
  • decreased thyroid fxn
  • polydipsia, polyuria
  • edema, wt gain
  • labs:
    BUN, creatinine
    thyroid fxns
    lithium levels
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9
Q

Use of valproate (depakote)? SEs, labs to order?

A
  • becoming recognized as appropriate 1ST line tx for mania
  • SE profile less than lithium
  • quick onset
  • may increase dose more rapidly to increase therapeutic range
  • larger therapeutic window: 50-125
    -SEs:
    wt gain, N/V, hair loss, tremor (Not as sig as lithium)
  • labs:
    liver fxn
    platelets
    valproate levels
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10
Q

Use of carbamazepine? SEs, labs?

A 
- anticonvulsant 
 comparable efficacy to lithium
- therapeutic window: 3-14
- SEs: N/V, hyponatremia, rash (SJS and TENS), drowsiness, blurred vision, blood dyscrasias
- labs:
liver fxns
CBC, serum NA
carbamazepine levels
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11
Q

Use of lamictal? Drug class?

A
  • anti-epileptic
  • tx bipolar depression w/o triggering mania, hypomania, mixed states, or rapid cycling
  • it hasn’t demonstrated efficacy in tx of acute mania
  • ***can be used 1st line tx for acute depression in bipolar disorder as well as maintenance therapy!
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12
Q

1st line pharm therapy for pts with acute severe manic or mixed episodes?

A
  • antipsychotic agent combined with either lithium or valproate
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13
Q

For less severe manic or mixed episodes - tx?

A
  • monotherapy with either lithium, valproate, or antipsychotic med
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14
Q

When is lamotrigine first line?

A
  • for acute depression in bipolar disorder as well as maintenanace therapy, but not recommended for tx of acute mania
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15
Q

FGAs used in tx of shizophrenia and acute mania? Shortcomings?

A
  • dopamine antagonists
  • (haldol)
  • chlorpromazine (thorazine)
  • effective in tx of schizophrenia esp positive sxs (hallucinations, delusions)
  • shortcomings:
    only small % of pts (25%) are helped enough to recover a reasonable amt of normal mental fxning
  • assoc with both annoying and serious adverse effects
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16
Q

Adverse effects of FGAs?

A
  • more common annoying effects: akathisia (feeling of muscular tension which can cause restlessness, pacing, repeated sitting or standing) and parkinsonian like rigidity and tremor
  • potential serious effects include tardive dyskinesia, and neuroleptic malignant syndrome
  • check CPK for muscle breakdown - very common in FGAs
17
Q

EPS sxs - FGAs?

A
  • dyskinesia: movement disorders including any of number of repetitive, involuntary, and purposeless body or facial movements, they include:
    tongue movements
    lip smacking
    eye blinking
    movement of arms and legs
  • tardive dyskinesia: occurs after long term tx with antipsychotic med, sometimes can be permanent
  • akathisia: extreme form of internal or external restlessness:
    complete inability to sit still, with undeniable urge to be moving constantly
    an entirely inner feeling of jitteriness or shakiness. Can be exhausting and lead to suicide ideations
  • dystonia: muscle tension disorder involving very strong muscle contractions: uncontrollable muscle contractions can cause unusual twisting of parts of the body esp the neck
18
Q

Importance of extrapyramidal tracts?

A
  • found primarily in reticular formation of pons and medulla, and target neurons in spinal cord involved in reflexes, locomotion, complex movements, and postural control
  • tracts modulated by various parts of CNS - basal ganglia, nigrostriatal pathway (dopamine lives here)
  • extrapyramidal - modulate motor activity w/o directly innervating motor neurons
19
Q

Most common drugs that cause EPS?

A

-FGAs - haldol and thorazine

20
Q

What can be used to tx EPS?

A
  • cogentin!!
21
Q

What is cogentin?

A
  • anticholinergic med
  • blocks effects of NT acetylcholine:
    normal muscle movement control reqrs careful balance of dopamine and acetylcholine. In parkinsons (and extrapyramidal disorders caused by FGAs), dopamine levels decreased, creating imbalance b/t dopamine and acetylcholine
  • by blocking the effects of acetylcholine, cogentin helps to re-establish a normal balance b/t dopamine and acetylcholine
22
Q

What are SGAs? MOA? Tx indications?

A
  • referred to as atypical antipsychotics: seroquel, zyprexa, risperdal, abilify, clozaril, geodon
  • interact with diff subtypes of dopamine receptors than std antipsychotics
  • produce fewer neuro and endocrine side effects
  • effective in tx negative sxs - withdrawal and positive sxs
  • effective for broader range of pts
  • **causes very few, if any eps
  • it is suggested that antipsychotics may be slightly more effective than mood stabilizers as monotherapy for acute mania and may also be used as adjunctive therapy with mood stabilizers
23
Q

SEs of SGAs (serotonin dopanine antagonists - SDAs)?

A 
- wt gain
glucose intolerance
- diabetes mellitus
- hyperlipidemia
- drowsiness
- dizziness when changing positions
- blurred vision
- rapid heartbeat
- sensitivity to the sun
- skin rashes
- menstrual probs
24
Q

What labs do you want to monitor when pt is taking SGAs?

A
  • serum glucose (really monitor sugars close in zyprexa)
  • lipids
  • weight
  • waist circumference
25
Q

Main side effect of quetiapine (seroquel)?

A
  • drowsiness (think quiet - quetiapine)

- first SGA to receive FDA approval for tx of bipolar depressive episodes)

26
Q

Main side effect of Olanzapine (zyprexa)?

A
  • wt gain most pronounced
27
Q

Main side effects of clozapine (clozaril)? What should be monitored?

A
  • wt gain most pronounced

- most impt: agranulocytosis - CBC - monitor white count

28
Q

Pro of geodon use?

A
  • less wt gain
29
Q

Downside of abilify?

A
  • expensive
30
Q

Why shouldn’t a pt with acute depression assoc with bipolar use antidepressants to tx depressive episodes?

A
  • even though they occur more frequently than manic episodes - tx depressed phase hasn’t been extensively studied
  • antidepressants can increase person’s risk of switching to mania or hypomania, or developing rapid cycling sxs
  • recent study - showed that for most people, adding an antidepressant to mood stabilizer is no more effective in tx depression than using mood stabilizer
31
Q

When should you hospitalize a bipolar pt?

A
  • hospitalization for psychosis is indicated:
    for dx purposes
    for stabiliastion of meds
    for pts safety (suicidal or homicidal ideation)
    for grossly disorganized or inappropriate behavior
32
Q

PTs presenting with acute mania, mixed, or hypomania should be assessed for what?

A
  • suicide, homicide, aggressiveness, psychotic features, and poor judgement
33
Q

Mainstays of bipolar disorder tx?

A
  • lithium
  • anticonvulsants
  • antipsychotics
34
Q

What drugs can be used in acute phase of mania in bipolar pt?

A
  • lithium and depakote

Psych (20 decks)

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