BPD Flashcards
What drugs are not recommended for Acute Mania
Gabapentin, lamotrigine, topiramate, verapamil, tiagabine, combos (risperidone + CBZ & olanzapine + CBZ)
What drugs are not recommended Depressive episodes
Gabapentin, Abilify, ziprasidone, combos (adjunctive ziprasidone, adjunctive keppra)
What drugs are not recommended for maintenance therapy
Gabapentin, topiramate, or antidepressants, adjunct: fluphenthixol
Which drugs are FDA approved for acute major depressive episodes
Lithium, lamotrigine, quetiapine
Which drugs are used for agitation
Abilify, lorazepam, loxapine, olanzapine
LAI’s approved for BPD
Abilify Maintena and Risperdol Consta
What drugs are FDA approved for acute mania and mixed episodes
Lithium, VPA, CBZ IR/ER, Abilify, asenapine, cariprazine, olanzapine, quetiapine, risperidone, ziprasidone
What drugs are FDA approved for maintenance of BPD
Lithium, Lamotrigine, Abilify, olanzapine, quetiapine, risperidone, ziprasidone (adjunct Li/VPA)
What drugs are FDA approved for acute depression monotherapy
cariprazine, lurasidone, olanzapine (w/ Prozac), quetiapine
Lithium interactions
-NSAIDs: inc levels of Li
-ACE/ARB: inc levels of Li
-Diuretics: Li levels inc with thiazide use and dec with mannitol use
-Methylxanthines (caffeine): Li levels dec
-Clozapine (blood dyscrasia)
Lithium AE
-Polydipsia, polyuria w/ or w/o nephrogenic diabetes insipidous (NDI)
-May unmask Brugada syndrome
Lithium CI
-Breastfeeding (also crosses placenta, floppy baby syndrome), severe renal or cardiac disease (or w/ dehydration or Na depletion)
-Avoid drugs/things that effect renal function (NSAIDs, ACE/ARB, Diuretics, CCB, ECT)
-ECT: d/c 2 days before and after procedure
Lithium monitoring
-Renal and thyroid function
-Eliminated entirely, no hepatic metabolism
Lithium SE
-Dose related
-Maintain at lowest effective dose
-1 daily dose at bedtime
-Take with food
-Use liquid formulation if pt has diarrhea
-Muscle weakness/lethargy (tremor)
-If tremor occurs switch to long acting drug, dec dose, or add a beta blocker (propranolol)
Normal Lithium serum concentration
-0.6-1.2 mEq/L
-toxic: >1.5 mEq/L
Lithium levels
8 hours after dose (trough), 5-7 days after initiation (steady state)
Anticonvulsants FDA approved for BPD
VPA, Lamotrigine, CBZ ER (equetro only)
VPA dose related problems
-GI, tremor, sedation
-Give with food, lower doses, or ER version for GI effects
-Beta blockers reduce tremor
-Alopecia (up to 25% of pt, reversible)
VPA ER
lower bioavailability, more may be needed (required for seizures)
VPA prolonged bleeding
-Elderly inc risk
-Thrombocytopenia
VPA BBW
Pancreatitis &/or liver toxicity, urea disorders
VPA hyperammonemia
treat with lactulose if severe
Lamotrigine
-slow titration to prevent SJS
-preferred over VPA for bipolar depression
-not effective for acute depression
-must use 1/2 the dose if combined with VPA
-Interruption >48 hours requires retitration
-Aseptic meningitis, prodrome chills, sore throat, fever
-Lamictal/VPA = less drowsiness than others
CBZ CI
-MAOI therapy, nefazodone, lurasidone
-porphyria, agranulocytosis, Asian HLA-B 1502 (10 x risk SJS/TEN)
-Inc ADH release (SIADH)
-bone marrow suppression
-Hematologic disease (TCA/CBZ hypersensitivity)
-Stronger inducer of many CYP enzymes and can effect metabolism of SSRIs, TCAs, MAOIs, and other mood stabilizers
-VPA can inc concentration
BZD
-High potency agents: clonazepam and lorazepam used for anxiety, panic, agitation drug acute mania
-Short term use
-Avoid in sub abuse pt
CCB
-Not FDA approved
-verapamil, nimodipine
-interact with Li
Lybalvi
-BP-1
-Acute treatment of manic or mixed episodes, monotherpay or adjunct to Li or VPA
-CI: opioid use
Drugs in pregnancy
-Divalproex: neural tube defects & irreversible cognitive impairment (use folic acid to mitigate NT defects)
-CBZ: inc risk of spina bifida
-Lamotrigine: Lower levels during pregnancy, cleft palate reported
Li: abnormal tricuspid valve, inc doses needed during pregnancy
