Bipolar treatment Flashcards
Collaboration with the patient
Discuss
- Available treatment options
- Target symptoms
- Potential side effects
- Drug interactions
- Dosing strategies
- Potential toxicity
- Costs
- Past trials of medications
- Involvement of family or friends
Treatment - acute mania
- Likely hospitalization
- Mood stabilizer (Lithium, Valproic Acid, Carbamazepine)
- Add an antipsychotic
- You may also add a benzodiazepine for insomnia or continued agitation
- Eliminate any mood de-stabilizing agents
- Decrease stimuli
Immediate goals:
- Sleep
- Decrease the thought disorganization
- Address any psychotic symptoms
- Prevent dangerous behavior
- Contact family or support system with permission
- Support patient in taking time from work and decreasing role responsibilities
- Understand the treatment and support level when the manic episode occurred (taking meds?, frequency of office visits, family stress, relapse with drugs or ETOH?…)
- Be sure to address each of the factors that may have increased the likelihood of the manic episode
Treatment - bipolar depression
- Lithium has antidepressant properties, so maximize the lithium dose (Li level of > 0.8 mEq/L)
- If pt is on valproic acid or carbamazepine, make sure their dose is appropriate
- Consider augmenting with lamotrigine first
I- f this doesn’t work, switch to quetiapine monotherapy or olanzapine/fluoxteine combo - If the above doesn’t work, consider a mood stabilizer + an antidepressant
- Include individual therapy
If you treat the patient with only an antidepressant and no mood stabilizer, you may precipitate a manic episode, cause rapid cycling and make their bipolar illness more refractory to treatment
- ECT is an option for severe bipolar depression
- Support patient in taking time from work and decreasing role responsibilities
- Patient and family education
- Contact family or support system with permission to collaborate care
Treatment - maintenance
- Mood stabilizer (lithium, valproic acid, carbamazepine)
- Lamotrigine is particularly helpful for bipolar depression, but does not prevent manic episodes
- Patients may be able to come off of the antidepressant and or antipsychotic medication during this phase
- Patient education
- Family involvement
- Review early signs and symptoms that a depressive or manic episode is starting
- Individual therapy
- Contact family or support system with permission to collaborate care
Lithium
Mood stabilizer
- naturally occurring cation
Mechanism of action possibly via second messenger system (G Proteins, PIP), enhances serotonergic transmission
30-40% of patients do not respond to lithium
Lithium decreases the risk of suicide
Pregnancy Category D
- Ebstein’s anomaly (malformation of tricuspid valve) –> HOWEVER, the incidence of Ebstein’s is over-reported and Li is actually the mood stabilizer of choice during pregnancy
Lithium - possible side effects
- Nausea, diarrhea, metallic taste
- EKG changes, conduction delay
- Thyroid abnormalities, goiter, hyperglycemia***
- Tremor, sedation
- Polydipsia & polyuria (25% of pts)***
- Nephrogenic Diabetes Insipidus***
- Mild leukocytosis
- Wt Gain, edema, dry mouth
- Cognitive dulling
Dehydration, NSAIDS, thiazide diuretics, ACE inhibitors, Ca-Channel blockers can increase the lithium level due to decreased renal clearance
Lithium - signs and symptoms of toxicity
Levels 1.2-1.5: Ataxia, dysarthria, incoordination , increased GI & renal sx, increased tremor
Levels 1.5-2: Confusion, nausea, vomiting, diarrhea, slurred speech, course tremor, ataxia
levels 2-2.5: Delirium, abnormal ECG, cardiac arrhythmias, ataxia
Levels 2.5-3: Change in consciousness, acute renal failure, seizure, coma, death
***Hemodialysis can decrease a toxic Li level
Target Lithium level 0.8-1.2 meq/L
Aim for lower in elderly pts
Narrow therapeutic index
Valproic acid
Mood stabilizer
- May be more effective for rapid cyclers and mixed states
- Check for drug-drug interactions
- MOA: Increases brain levels of Gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter
Usual Dose Range ~500mg-1500mg/day
Target Blood Level: 75-100ng/dL
Valproic acid - side effects
Common…
- Nausea
- Diarrhea
- Tremor
- Sedation
- Hair loss
- Weight gain
- Increased ammonia levels
Rare…
- Thrombocytopenia ***
- Pancreatitis
- Polycystic ovary disease (studies are mixed)
- Hepatotoxicity***
Pregnancy Category D
- Neural tube defects (4%)
- Liver disease
- Dysmorphic facial features
- Cardiac abnormalities
- Reduced IQ in the infant
Valproic acid - symptoms of toxicity
- You can see toxicity at a level >125 ug/ml
- Deep sleep
- Coma
- Hemorrhagic pancreatitis
***Hemodialysis can decrease toxic levels
Carbamazepine
- Many drug-drug interactions (decreases serum levels of oral contraceptives!!)
- Not as good as lithium for bipolar depression
- May be more effective for rapid cyclers and mixed states
- Inhibits voltage-dependent sodium channels (thus decreasing repetitive neuron firing)
- Inhibits presynaptic sodium channels (preventing depolarization and neurotransmitter release)
Carbamazepime - side effects
- nausea
- AV block (rare)
- afib (rare)
- ataxia
- sedation
- SIADH ***
- aplastic anemia
- agranulocytosis
- weight gain
- autoinduction
- hepatitis
Pregnancy Category D
- Spinal malformations
- Dysmorphic facial features
- Cardiac defects
- Cranial defects
