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PR3153 > Bipolar - Treatment > Flashcards

Bipolar - Treatment Flashcards

1
Q

What are the general goals of treatment for bipolar disorder?

A
  • Reduce frequency, severity & duration of mood episodes
  • Prevent suicide
  • Maximize adherence with therapy
  • Minimize adverse effects i.e. employ medications w the most acceptable tolerability & fewest DDIs
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2
Q

What are the goals of treatment for an acute episode of bipolar disorder?

A

Eliminate mood episode with remission of symptoms

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3
Q

What are the goals of treatment in the continuing phase of bipolar Tx?

A
  • Reduce frequency, duration & severity of recurring mood episodes
  • Reduce suicidal ideation or attempts
  • Regain psychosocial functioning
  • Avoidance of stressors or substances that may precipitate an acute mood episode
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4
Q

What are the non-pharm Tx options?

A
  • Psychoeducation about the disorder, treatment and monitoring for the patient and caregiver
  • Psychotherapy – to help individual, group and family members
  • Stress reduction techniques, relaxation therapy etc
  • Sleep hygiene – regular bedtime and wake schedule, avoid alcohol or caffeine prior to bedtime
  • Nutrition – balanced nutrition (normal requirements for general health)
  • Exercise (normal requirements for general health)
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5
Q

How should initial treatment of an acute bipolar episode be done?

A
  • Short course of PRN BZD – to help the patient relax and sleep
  • Onset of effectiveness: within hours
  • Taper off when condition improved and mood stabiliser has been optimised
  • Start mood stabilizer
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6
Q

What are the mood stabilizer options for manic episodes?

A
  • Antipsychotics
    (2nd gen: Olanzapine, Quetiapine, Risperidone, Aripiprazole|1st gen: Haloperidol)
  • Lithium (should only be initiated by specialists)
  • Valproate (least preferred, should only be initiated by specialists)
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7
Q

What are the mood stabilizer options for depressive episodes?

A
  • Lithium (should only be initiated by specialists)
  • Antipsychotics (2nd gen only) – Quetiapine, Olanzapine + Fluoxetine
  • Lamotrigine (does not treat mania, can result in rash)
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8
Q

At what serum concentrations is lithium considered toxic?

A

Mild= 1.5-2.0
Moderate= 2.0-2.5
Severe >3.0

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9
Q

What are the symptoms of lithium toxicity?

A

GI: N/V/D (gets worse with increasing toxicity levels)

CNS:
* Mild: Lethargy, confusion, coarse hand tremors, drowsiness, lightheadedness
* Moderate: Slurred speech, ↑confusion, ataxia, blurred vision, profound lethargy, tinnitus, apathy
* Seriously impaired consciousness, ↑deep tendon reflexes, stupor, coma, seizures, death

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10
Q

What are the DDIs predisposing to lithium toxicity?

A
  • Sodium depletion
  • Thiazides
  • ACEi/ARBs
  • NSAIDs
  • Dehydration
  • Neurotoxicity may occur when Li+ is combined w CBZ, diltiazem, losartan, methyldopa, metronidazole, phenytoin, verapamil
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11
Q

What are the monitoring parameters for lithium?

A
  • TDM: 0.6-1.0 mmol/L (highest 1.2mmol/L)
  • FBC: baseline and Q6-12/12
  • Renal panel & electrolytes: baseline and Q6-12/12
  • TFT: baseline and Q6-12/12
  • Metabolic parameters: baseline and Q6-12/12
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12
Q

What are the monitoring parameters for valproate for bipolar?

A
  • TDM: 50-125 mg/L
  • FBC: baseline and Q6-12/12
  • LFTs: baseline and Q6-12/12
  • Metabolic parameters: baseline and Q6-12/12
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13
Q

What are the monitoring parameters for carbamazepine for bipolar?

A
  • TDM: >7mg/L for bipolar (limited evidence), 4-12mg/L for epilepsy
  • FBC: baseline and Q6-12/12
  • LFTs: baseline and Q6-12/12
  • Renal panel & electrolytes: baseline and Q6-12/12
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14
Q

What are the monitoring parameters for lamotrigine for bipolar?

A
  • baseline FBC
  • LFTs: baseline and Q6-12/12
  • baseline renal panel and electrolytes
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15
Q

What are the monitoring parameters for 2nd gen APs for bipolar?

A
  • Metabolic parameters: baseline and Q6-12/12
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16
Q

How long is an adequate trial for manic episode medications?

A

2-4/52

17
Q

When should carbamazepine be used for bipolar mania?

A

Used when following lines of defence are all ineffective
→ Mania has not responded within 2-4/52 w an established (1st line) mood stabilizer
→ Augment with a second first line agent (ie add on)
→ Switch to a 2nd gen AP e.g. Olanzapine

18
Q

How should bipolar disorder with rapid cycling be handled?

A
  • Avoid antidepressants/stimulants in rapid cycling or Hx of antidepressant-induced mania
  • Evaluate and treat underlying hypothyroidism, hormonal imbalance, substance abuse
  • For antidepressant-induced rapid cycling – avoid and taper off antidepressant and other agents that inc NE or DA activity (e.g. CNS stimulants, sympathomimetics, caffeine)
  • Optimize mood stabilizer treatment – Valproate, Lithium, Lamotrigine
19
Q

What are the considerations in treating bipolar during pregnancy?

A
  • Pregnancy should be planned in consultation w psychiatrist and OBGYN to weight risks vs benefits – e.g. whether to gradually taper medications, avoid a drug in 1st trimester or throughout pregnancy, risks of mood episodes after stopping
  • ?Safer options: Quetiapine, Olanzapine, Risperidone, 1st gen APs – monitor for SEs
  • Avoid valproate – risk of neural tube defects
  • Lithium – small risk of Ebstein anomaly, but likely need dose adjustments
  • Carbamazepine also implicated with teratogenicity
  • Consider ECT for severe mania, mixed episode, depression or psychosis
20
Q

What are the considerations for treating bipolar disorder during breast-feeding?

A

Weight risks vs benefits – all mood stabilizers are secreted into breastmilk

21
Q

What are the possible options for bipolar pts with cardiac disease?

A

Consider Valproate – monitor ↑BP, ↑HR, peripheral edema

22
Q

What are the possible options for bipolar pts with renal impairment?

A

Lithium

23
Q

What are the possible options for bipolar patients with renal impairment?

A

Consider Valproate – monitor serum levels closely

24
Q

What are the possible options for pediatric patients with bipolar disorder?

A

Lithium, Valproate

25
Q

What are the considerations for bipolar treatment in elderly patients

A
  • All psychotropics ↑risks of SEs, avoid renally-excreted drugs
  • Avoid CBZ – many DDIs, risk of hyponatremia
  • Lamotrigine is not significantly influenced by age
26
Q

How should suicidal behaviours in bipolar patients be handled?

A

Hospitalisation – optimize dose and levels of Lithium during stay

27
Q

How should aggression/violence in bipolar patients be handled?

A

Hospitalisation – optimize dose and levels of existing Lithium or Valproate, consider adding antipsychotic

PR3153 (16 decks)

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