Bipolar -Test 2 Flashcards
What are the bipolar disorders?
¨Bipolar I Disorder
¨Bipolar II Disorder
¨Cyclothymic Disorder
¨Substance/medication induced bipolar disorder
¨Bipolar disorder due to another medical condition
What constitutes bipolar I?
patients with 1 or more episodes of mania hypomania
What are different mood patterns that may be associated with bipolar I?
specify if course is characterized by rapid cycling or a seasonal pattern and whether the mood episodes are marked with psychotic features, catatonia, anxious distress, mixed features, or peripartum onset.
What constitutes bipolar II?
patients with at least 1 episode of hypomania and at least 1 major depressive and no instances of mania
What happens if you have diagnosed a pt with bipolar I and they have a manic episode?
Switch diagnosis to type I
What are the primary drugs used to treat bipolar?
Lithium, Carbamazepine, Valproic acid, antidepressants, and antipsychotics
How are mania and hypomania tx?
Lithium
Anticonvulsants
Antipsychotics*
Benzodiazepines- primarily adjunct therapy for insomnia, agitation, and anxiety
How are depressive episodes tx?
Antidepressants
Lithium
Anticonvulsants- Lamotrigine
Second generation antipsychotics*
What are the indications for lithium?
Acute manic episodes
Prophylaxis of affective disorders
Acute depressive episodes
Other psychiatric disorders : Schizoaffective disorder/Schizophrenia, Aggressive/violent behaviors, Impulse control disorders, Self-injurious behavior, Mania secondary to brain injury
What baseline and continued monitoring needs to be done when your pt is taking lithium?
CBC with differential Urinalysis BMP TSH, T4, T3 Pregnancy test BASELINE AND Q 3 MONTHS
How often should serum lithium levels be obtained?
twice weekly until clinical status and level are stable then obtain every 1-3 months
What are the trough levels that need to be maintained for lithium?
Acute mania: 0.6-1.2 mEq/L
Protection against future episodes: 0.8-1 mEq/L
Elderly maintained at 0.6-0.8mEq/L
Toxic Concentration: >1.5mEq/L
What are the ADRs of lithium associated with specific levels?
GI complaints/tremor: 1.5-2mEq/L
Confusion/somnolence: 2-2.5mEq/L
Seizures/Death: >2.5mEq/L
What are the acute side effects of lithium?
N,V,D Muscle weakness Polyuria, polydypsia Fine hand tremor Edema typically transient
What are the s/s of acute lithium toxicity?
Persistent vomiting Impaired renal function Diarrhea Lethargy/confusion Course hand tremor Somnolence Dysarthria Seizures Muscle weakness Coma Hyperactive deep tendon reflexes (DTR) Vertigo
How is lithium toxicity measured?
D/C lithium
Obtain lithium serum concentrations, renal panel, vitals, & EKG
Supportive Care
Maintain fluid and electrolyte balance
Gastric lavage if within 1 hour
Whole bowel irrigation with delayed release preparations
Hemodialysis
What are the chronic effects of lithium?
¨Weight gain
¨Hypothyroidism (monitor function)/ Teratogenic- hypothyroid
¨Diabetes insipidus (tx with amiloride)
¨Leukocytosis
¨Rash (acne, psoriasis exacerbation)
¨ECG changes (T wave flattening, QRS inversion
¨Nephrotoxicity
What are some lithium drug interactions?
¨Thiazide diuretics ¨Osmotic diuretics, acetazolamide ¨Aminophylline, Theophylline ¨SSRIs, Fluoxetine ¨Haloperidol ¨clozapine ¨Carbamazepine ¨Metronidazole ¨ACE Inhibitors ¨NSAIDS ¨Calcium channel blockers, verapamil
What are the advantages of lithium therapy?
Normalizes mood and can control manic pt without “drugged” effect, relapses less likely less severe and shorter in duration, cheap drug
What are the disadvantages of lithium therapy?
Narrow range of therapeutic blood concentrations, requires close monitoring to prevent toxicity.
Patient compliance and understanding of the warning signs of toxicity is important.
Lag period before therapeutic effect in manic patients.
Prophylactic effect may take 6 months to 1 year to maximize.
Rapid cyclers are poor responders.
Expense of blood tests
When is carbamazepine indicated?
Acute manic episodes
Usually in patients who are treatment resistant, rapid cyclers, lithium intolerant.
Prophylaxis of affective disorders
What are some other psych disorders that carbamazepine may be effective for?
Impulse control disorders
Schizoaffective disorder/schizophrenia
Neuropsychiatric disorders in the mentally retarded/developmentally disabled.
Trigeminal neuralgia
Mania secondary to head injury
Aggressive and violent behaviors/rage reactions
What is the therapeutic range for carbamazepine for anti-mania effects? Prophylactic effects?
1) Plasma concentration 8-12 mcg/mL
2) Plasma concentrations 6-12 mcg/mL
What are the neuro ADRs of carbamazepine?
sedation dizziness nystagmus ataxia fatigue tingling diplopia headache tremor
What are the derm ADRs of carbamazepine?
Rash
Stevens Johnson Syndrome
What are the heme ADRs of carbamazepine?
Transient leukopenia Thrombocytopenia Eosinophilia Aplastic anemia Agranulocytosis
What are the GI ADRs of carbamazepine?
N,V,D
What are some other ADRs of carbamazepine?
SIADH
slowed cardiac conduction
Hepatotoxic
Teratogen
What is the routine monitoring for carbamazepine?
Every 2 weeks for 2 months, then every 3 to 6 months
What needs to be monitored?
¨Chemistry profile
¨CBC w/diff. and platelets
¨Liver profile
Urinalysis
Why are blood levels needed?
- initial stabilization of a pt
- therapy failure, inadequate response, worsening of symptoms
- complex drug regimens—dose related side effects, drug interactions
- Compliance issues differing plasma levels with stable prescribed doses
Carbamazepine is a potent liver enzyme inducer that can decrease levels of other drugs. What other drugs are affected by carba?
Antipsychotics Tricyclic antidepressants Theophylline Steroids Warfarin Chloramphenicol Isoniazid Thyroid Hormones Methadone
What drugs increase the concentrations of carbamazepine?
Erythromycin Fluoxetine Theophylline Cimetidine Verapamil Diltiazem Propoxyphyne(Darvon)
What drugs are able to decrease carba concentrations?
Phenobarbital
Phenytoin
Primidone
Theophylline
When is valproic acid/ divalproex sodium indicated?
Bipolar affective disorder (esp. rapid cyclers and mixed states) Aggression and impulse control disorder Mania secondary to head injury Bulimia Schizoaffective disorder/schizophrenia
What is the therapeutic range for valproic acid/ divalproex sodium?
50-100 mcg/mL
What are the ADRs of valproic acid/ divalproex sodium??
- Gastrointestinal: N,V, D, stomach cramps, Constipation, Anorexia, wt. loss/gain, Hemorrhagic pancreatitis
- Neurologic: sedation/drowsiness, Tremor, Nystagmus/diplopia
- Endocrine: Breast enlargement, galactorrhea, irregular menses
What drugs decrease valproic acid concentrations?
Phenobarbital
Phenytoin
Primidone
Carbamazepine
Which drugs are increased when taken with valproic acid?
Phenytoin
Phenobarbital
What can happen if valproate and phenobarb are taken together?
Severe CNS depression
What can happen if clonazepam and valproate are taken together?
Absence seizures
Which drug groups may be potentiated by valproate?
MAO inhibitors and tricyclic antidepressants
When is lamotrigine indicated?
bipolar disorder
Is approved for other pain indications as well
Does lamotrigine need to be monitored?
Drug levels no! no therapeutic level monitoring but need to monitor for skin rash- d/c promptly if appears
What are the ADRs of lamotrigine?
Nausea, dyspepsia, pain, insomnia, skin rash
Can cause SJS
What are the typical antipsychotics that are indicated in tx of bipolar I?
Haloperidol, chlorpromazine, thiothixene
What are the atypical antipsychotics used to tx both type I and II bipolar?
Aripirazole, olanzapine, quetiapine, risperidone, ziprasidone
What is the specific tx for acute mania?
Generally combination required
Lithium plus antipsychotic
Valproate plus antipsychotic
What is the specific tx for bipolar depression?
Start therapy with lithium ,valproate or lamotrigine
Fail to respond consider addition of 2nd generation antipsychotic
Consider adjunctive antidepressants (with antipsychotic)
—Fluoxetine and olanzapine (best established combo)
What are 1st line maintenance drugs?
Lithium, Valproate, Lamotrigine, Risperidone IM injections
What are 2nd line maintenance drugs?
Aripiprazole, Quetiapine, Olanzapine (all antipsychotics)
What are good maintenance combos?
¨Lithium Plus second generation antipsychotic
OR
¨Lithium Plus valproate or carbamazepine or lamotrigine
