Bipolar Tx Flashcards
Mania
-abnormal elevates, expansive, irritable mood
-grandiosity, flight of ideas, distractibility, pressured speech, need for sleep, agitation, xs involvement in pleasurable activities
-hospitilization generally required
-severe episode may involve psychosis
-change in sleep pattern often initiate episodes
Bipolar disease course
-depression is the mood pole experienced most often (can lead to misdiagnoses)
-alc and substance use common (50-60%)
-anxiety disorders common comorbidity that can impact remission if untreated
Hypomania
-less severe form of mania
-hospitilization not required
-elevated, or irritable mood symptoms
-inflated self-esteem, dec need for sleep , distractibility
-no psychotic features
Rapid-cycling
-4+ mood episodes in 1 year
Bipolar I classification
-1+ MANIC episodes
Bipolar II classification
-HYPOmanic episodes
Bipolar Tx overview
-1st line: lithium or valproic acid (mood stabilizers)
-atypical antipsychotics may be used first line as mono or combo
Lithium
-NTI (make sure pt will not OD)
-associated w dec suicidiality
-1:1 conversion between citrate and carbonate forms
Lithium NTI dosing
-acute: 0.9-1.2 mEq/L
-maintenance: 0.6-0.9 mEq/L
-toxicity 1.5-3+
-draw trough serum concentration 72h after dose initiation, 12h after last dose
Lithium toxicity
-GI
-ataxia
-hand tremor
-altered mental status
-seizure
-lethargy, confusion, agitation
Lithium side effects
-hand tremor
-HYPOthyroidism
-polyuria/dipsia
-acne
-dry mouth
-weight gain
-ECG changes
-teatogenic
Lithium in pregnany
-AVOID in 1st trimester, caution 2nd and 3rd
-cardiac structural abnormality (Ebstein’s anomaly
Lithium monitoring
-SCr, BUN (renal)
-urine specific gravity
-Na, K, Ca
-ECG esp >40
-thyroid (TSH, T4)
-parathyroid hormone
-CBC w differential
-weight
-pregnancy test
Lithium Drug Interactions
-dec Li renal cl (inc Li levels): ACE/ARBs, thiazides, NSAIDs, dehydration
-inc renal cl: caffeine, osmotic, loops
-inc excretion (dec levels): sodium bicarb, high Na intake
-toxicity related to Na depletion (thiazides)
Valproate dosing
-ER is 10-15% less bioavailable than delayed release
-1:1 conversion, lower concentration w ER (not that significant)
-syrup (IR) and capsule sprinkle form = higher GI ulceration (esophagus) risk
-serum levels 80-125mcg/ml associated w most efficacy in mania, obtain level at least 96h after first dose or dose inc
Valproic acid adverse effects
-GI: anorexia, N/V/D, dyspepsia, ulcers
-inc appetite/wt gain
-thrombocytopenia, platelet dysfunction
-hyperammonemia
-teratogenic
-PCOS
Valporic acid in pregnancy
-AVOID
-obtain baseline pregnancy test
Valproic acid PCOS
-upto 50% of women
-assess menstrual cycle
Valproate monitoring
-baseline: preg, LFTs, CBC
-serum ammonia only if suspected
Valproate drug interactions
-sig concern w combo ise w lamotrigine (inc lamotrigine = inc SJS risk)
-many interactions
Other mood stabilizers
-carbamazepine
-oxcarbamazepine
-lamotrigine
-topiramate
Carbamazepine
-CYP450 inducer, auto-induction of metabolism
-steady state 14 days
-thrombocytopenia/hematologic effects
oxcarbamazepine
-CYP450 3A4 inducer (no auto-induction)
-hyponatremia but less hematologic effects compared to carbamazepine
Lamotrigine
-1st line for DEPRESSIVE sx in bipolar
-NOT useful for mania
Lamotrigine dose titration
-go to seizure notes
Topiramate
-may cause wt loss
-heat intolerance/oligohidrosis
-metabolic acidosis and kidney stones
-possible teratogen (cardiac structural defects)
Antipsychotics in bipolar
-NOT brexpiprazole, clozapine, iloperidone, paliperidone
-can use as monotherapy or combo
-all monitoring parameters for metabolic disorder and movement side effects
Bipolar treatment considerations
-mood stabilizer tx long-term and considered to be maintenance tx to reduce time between episodes
-suicide attempt risk is high in both poles, monitor closely, use lithium cautiously
Bipolar treatment during pregnancy
-AVOID lithium, valproate, carbamazepine, topiramate
Antidepressants in bipolar
-linked to switch to mania
-need to have maintenance mood stabilizer in combo w antidepressant tx
-use SSRI/SNRI for anxiety
-prefer to use mood stabilizers that target depressive pole (lamotrigine, lithium, lurasidone, quetiapine)
