Bipolar & Related Disorders

Question 1

1st line agents for BID MDE

Answer 1

From highest to lowest recommendations: 
Quetiapine
Latuda (lurasidone) + Li/DVP
Lithium
Lamotrigine 
Lurasidone
Lamotrigine adjunct 

Quetiapine + Li possible but not studied

Question 2

2nd line agents for BID MDE

Answer 2

Divalproex
SSRI or bupropion adjunct (+Li/DVP/AAP)
ECT
Cariprazine
Olanzapine + fluoxetine

Question 3

Lithium toxicity levels

Answer 3

1.5 (2.5 = lethal)

Question 4

Lithium investigations (including frequency)

Answer 4

Baseline -> q3mo x 1 yr -> q6mo thereafter
- Li levels
- CBC
- Cr, lytes +/- full chem panel
Ca, albumin, +/- Mg, PO4
- TSH +/- T3
- Vitals, ht/wt/waist circumference
Baseline only: ECG if cardiac RF or > 50 yo
- Baseline only: Beta-hcg if childbearing age

Question 5

Target lithium level for acute MDE

Answer 5

0.8-1.2

Question 6

Target lithium level for acute mania

Answer 6

1-1.5

Question 7

Target lithium level for maintenance tx of bipolar disorder

Answer 7

0.7-1 (0.6-0.7 to min long-term renal damage)

Question 8

When to check lithium levels

Answer 8

Check lithium levels when

• Dose changes
• New med interactions
• Suspected Li toxicity, flu-like symptoms, aLOC, new SE

Question 9

How to order lithium level

Answer 9

Check trough levels i.e. 5 days after dose + 12 hrs after last dose