Bipolar Treatments- AEDs Used

Question 1

AEDs used in BPD

Answer 1

VPA, LTG, CBZ

Question 2

AEDs are most likely used in patients with what PMH?

Answer 2

Substance abuse history or active misuse- it can result in additive hepatotoxicity and increased suicide risk

Question 3

When to use VPA in BPD

Answer 3

Used alone or in combo with other drugs (Li, CBZ, APS) for acute treatment of manic or mixed episodes

Question 4

VPA BBW

Answer 4

Pancreatitis and/or liver toxicity, hepatotoxicity, urea disorders

Question 5

What should you have patients report (in relation to the VPA BBW)

Answer 5

Flu-like symptoms, GI pain, yellowing of skin, dark urine

Question 6

VPA side effects that are dose-related

Answer 6

GI upset, tremor, sedation, alopecia

Question 7

How to manage VPA dose-related complications

Answer 7

GI symptoms can go away on their own, but try taking it with food, give ER formulations, and/or move to HS dosing to reduce sedation. Alopecia is reversible if you switch to another med

Question 8

Other VPA side effects (the ones that aren’t dose-related)

Answer 8

Prolonged bleeding, weight gain, hyperammonemia

Question 9

VPA monitoring

Answer 9

CBC with diff
Baseline LFTs
Baseline renal function (Screen and BUN)
Serum drug concentrations 3-5 days after initiation or when stable dose established
Weight
Ammonia if hyperammonemia is suspected

Question 10

When to use LTG in BPD

Answer 10

Alone or in combo with other drugs for long-term maintenance treatment of BP-I

Question 11

VPA vs. LTG for BP depression: which one’s better?

Answer 11

LTG

Question 12

LTG dosing: what’s the caveat?

Answer 12

It needs slow titration and missing doses require re-titration

Question 13

What happens to the dose of LTG when combining with VPA?

Answer 13

The dose gets cut in half!

Question 14

LTG’s worst side effect

Answer 14

SJS!!!!!!!!!

Question 15

Other LTG side effects (besides SJS)

Answer 15

Aseptic meningitis, prodrome chills, sore throat, fever, increased risk of heart arrhythmias in patients with heart disease, abnormal ECG, chest pain, loss of consciousness, cardiac arrest

Question 16

LTG monitoring

Answer 16

CBC with diff
LFTs
Renal function (SCr and BUN)
Weight
Rash development (SJS)

Question 17

Only CBZ formulation used for BPD

Answer 17

Equetro (CBZ ER)

Question 18

When to use CBZ in BPD

Answer 18

Used alone or in combination with other drugs (Li, VPA, APS) for acute and long-term maintenance treatment of mania or mixed episodes for BP-I

(Not supported for maintenance use and it’s off-label???)

Question 19

What patients should you use CBZ in?

Answer 19

Reserve CBZ for patients who aren’t able to tolerate or have an inadequate response to PTG or VPA

Question 20

CBZ DDIs

Answer 20

Strong inducer of many CYP enzymes and can affect the metabolism of SSRIs, TCAs, MAOIs, and other mood stabilizers

Question 21

That one weird feature about CBZ

Answer 21

It auto induces its own metabolism

Question 22

CBZ side effects

Answer 22

Neutropenia, agranulocytosis, BONE MARROW SUPPRESSION, leukopenia, hematologic disease, SJS/TEN risk, hyponatremia, increased ADH release, porphyria

Question 23

Because of CBZ’s risk of leukopenia, what’s CI’ed?

Answer 23

MAOI therapy, nefazodone, lurasidone

Question 24

How can you find out if a patient is at risk of getting SJS/TEN from CBZ?

Answer 24

Genomic testing for HLA-B*15:02 – if the test is positive, don’t give them CBZ

Question 25

CBZ monitoring

Answer 25

CBC with diff
ECG
LFTs
TSH
renal function
serum electrolytes
weight
HLA-B*1502
rash development