Bipolar meds Flashcards
What drugs might exacerbate mania?
- drugs that increase catecholamine related activity
- drugs that reduce activity of dopamine or NE relieve mania
Pts presenting with acute mania should be assessed for what?
What drugs should be d/c’d?
- 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
Do antipsychotic drugs cure bipolar disorder?
- no, they tx the sxs!
Classes of meds used in bipolar?
- lithium (mood stabilizer)
- anticonvulsants (mood stabilizer)
- FGAs
- SGAs (atypical antipsychotics)
Mood stabilizing agents? Choice of mood stabilizer often based upon what?
- lithium
- valproate
- carbamazepine
- choice of mood stabilizer often based upon:
previous hx
side effect profiles
co-existing medical illness
Common side effects of mood stabilizing meds?
- drowsiness
- dizziness
- HA
- diarrhea
- constipation
- heartburn
- mood swings
- stuffed or runny nose, or other cold like sxs
MOA and use of lithium?
- 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
Why is lithium use? What are things to monitor? SEs?
- 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
Use of valproate (depakote)? SEs, labs to order?
- 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
Use of carbamazepine? SEs, labs?
- 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
Use of lamictal? Drug class?
- 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!
1st line pharm therapy for pts with acute severe manic or mixed episodes?
- antipsychotic agent combined with either lithium or valproate
For less severe manic or mixed episodes - tx?
- monotherapy with either lithium, valproate, or antipsychotic med
When is lamotrigine first line?
- for acute depression in bipolar disorder as well as maintenanace therapy, but not recommended for tx of acute mania
FGAs used in tx of shizophrenia and acute mania? Shortcomings?
- 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
Adverse effects of FGAs?
- 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
EPS sxs - FGAs?
- 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
Importance of extrapyramidal tracts?
- 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
Most common drugs that cause EPS?
-FGAs - haldol and thorazine
What can be used to tx EPS?
- cogentin!!
What is cogentin?
- 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
What are SGAs? MOA? Tx indications?
- 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
SEs of SGAs (serotonin dopanine antagonists - SDAs)?
- wt gain glucose intolerance - diabetes mellitus - hyperlipidemia - drowsiness - dizziness when changing positions - blurred vision - rapid heartbeat - sensitivity to the sun - skin rashes - menstrual probs
What labs do you want to monitor when pt is taking SGAs?
- serum glucose (really monitor sugars close in zyprexa)
- lipids
- weight
- waist circumference
Main side effect of quetiapine (seroquel)?
- drowsiness (think quiet - quetiapine)
- first SGA to receive FDA approval for tx of bipolar depressive episodes)
Main side effect of Olanzapine (zyprexa)?
- wt gain most pronounced
Main side effects of clozapine (clozaril)? What should be monitored?
- wt gain most pronounced
- most impt: agranulocytosis - CBC - monitor white count
Pro of geodon use?
- less wt gain
Downside of abilify?
- expensive
Why shouldn’t a pt with acute depression assoc with bipolar use antidepressants to tx depressive episodes?
- 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
When should you hospitalize a bipolar pt?
- 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
PTs presenting with acute mania, mixed, or hypomania should be assessed for what?
- suicide, homicide, aggressiveness, psychotic features, and poor judgement
Mainstays of bipolar disorder tx?
- lithium
- anticonvulsants
- antipsychotics
What drugs can be used in acute phase of mania in bipolar pt?
- lithium and depakote
