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PHA333 > Bpolar Disorder (PB) > Flashcards

Bpolar Disorder (PB) Flashcards

1
Q

What is bipolar?

A

the occurrence of one or more manic episodes usually followed by episodes of major depressive disorder

it is a cyclical mood disorder

abnormally elevated mood or irritability alternates with depressed mood

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2
Q

bipolar I

A

at least one manic or mixed episode

-> typical form of BP

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3
Q

bipolar II

A

at least one major depressive episode plus one milder manic syndrone called hypomanic episode

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4
Q

cyclothymic disorder

A

alternation in mood between hypomania and mild depression

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5
Q

2 criteria for diagnosis of BP

A
  1. elevated or irritable mood for > 1 week
  2. impairment/incapcitation and at least 4 of:
    - distractibility
    - racing thoughts
    - grandiosity
    - inc activity
    - inc talking
    - dec need to sleep
    - inappropriate/reckless behaviour
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6
Q

features of bipolar disorder

A 
mania
hypomania
depression
rapid cycling
mixed states
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7
Q

mania vs hypomania

A

mania - elevated/expansive/irritable mood, w/wo psychotic symptoms, marked impairment in functioning

hypomania - elevated/expansive/irritable mood, no psychotic symptoms, less impairment of functioning

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8
Q

key features of depression in BP

A

mild/mod/severe

w/wo psychotic symptoms

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9
Q

typical age of onset of BP

A

15 - 19 years

1st episode usually before 30yrs

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10
Q

women: men BP

A

both equally at risk

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11
Q

reasons for BP presentng later in life

A

family history of psychiatric disorder and medical comorbidities

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12
Q

ethnic groups and BP

A

higher in black and other minority ethnic groups than white population

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13
Q

comorbidities and BP

A

anxiety

substance misuse disorders (drugs/alcohol)

personality disorders esp. borderline personality disorder

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14
Q

What is pharmacological therapy dependent on for BP?

A
  • whether the patient has mania or depressed
  • severity of symptoms
  • patient prefernece
  • balance of benefit vs risk of adverse effects
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15
Q

drugs used in BP

A 
lithium
semisodium valporate
carbamazepine
lamotrigine (antiepileptic)
olanzapine
risperidone
quetiapine
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16
Q

What does seisodium valporate contain?

A

equal amounts of sodium valporate and valporic acid

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17
Q

treatment for acute mania

A

1st line

  • lithium
  • atypical antipsychotics (olanzapine, risperidone, quetiapine)
  • semisodium valporate

2nd line

  • benzodiazepines
  • carbamazepine
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18
Q

maintenance treatment of BP

A

lithium
carbammazepine
semisodium valporate
atypical antipsychotics

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19
Q

What NTs does lithium inhibit release of?

A

DA
NAD

(not 5-HT)

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20
Q

What antiepeleptic drugs NOT to give for BP?

A

gabapentin (dec Ca)

topiramate (inc GABA, blocks Na and Ca channels)

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21
Q

important factors for antipsychotic treatment

A
  • weight/BMI
  • pulse
  • BP
  • fasting blood glucose/HbA1c
  • blood lipid profile
  • ECG
  • > if physical exam has ID specific CV risk
  • > FHx of CVD/Hx of sudden collapse
  • > CV RF (arrhythmia)
  • > admitted as an inpatinet
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22
Q

What to monitor during titration and then regularly throughout treatment?

A
  • pulse and BP after each dose change
  • weight/BMI weekly for 1st 6 weeks, then at 12 weeks
  • blood glucose/HbA1c and blood lipid profie at 12 weeks, inc changes in symptoms/behaviour
  • s/e and their impact on physical health and functioning
  • emergence of movement disorders
  • adherence
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23
Q

What does secondary care need to monitor for 1st 12mths or until condition stabilised?

A

efficacy and tolerability of antisychotic medication

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24
Q

Can you start regular combined antipsychotic medication?

A

no expect for short periods eg. when changing medication

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25
How to stop an antipsychotic drug and why?
reduce dose gradually over at least 4 weeks minimise the risk of relapse
26
How does lithium work?
it is a monovalent cation minics role of Na in the excitable tissues penetrates the voltage gated Na channels responsible for AP generation not pumped out by Na/K ATPase pump Li might interfere with phosphatidyl-inositol pathway and negativelly affect hormone induced cAMP production
27
Lithium's affect on inositol monophosphatase
Li inhibition leads to depletion of substrate for IP3 production
28
Lithium's affect on inositol phosphophate-1-phosphatase
Li inhibition leads to depletion of substrate for IP3 production
29
Lithium's affect on bisphosphate nucelotidase
may be target that results in Li induced nephrogenic diabetes insipidus
30
Lithium's affect on fructose 1,6-bisphosphatase (glucogenesis) and phosphoglucomutase (glucogenolysis)
Li inhibition of unknown relevance
31
Lithium's affect on glycogen synthase kinase 3
inhibition by Li
32
How is lithium administered?
oral administration
33
therapeutic index of Li
narrow 0.5-1.5 mmol/L
34
When should Li samples be taken?
12hrs after dose to achieve a serum-Li conc of 0.4-1 mmol/L -> low end of the range for maintenance and elderly
35
When are peak Li levels reached?
3-5hrs
36
What does Li half life vary with?
age
37
When does Li reach strady state?
days
38
How is Li eleminated?
renally
39
measurement of Li -> when/how to check serum Li levels
- serum levels checked after 5-7 days of initial dose - once safe dose establised check every 4 weeks then every 3mths - 5ml of blood required - timing is important for accurate monitoring - blood sampled 12hrs after last dose - no patient perparation
40
GI s/e of lithium
dyspepsia -> minor and reversible (0.4-1) anorexia, n&v, diarrhoea -> early signs of toxicity (1.5-2.5)
41
CV s/e of lithium
benign ECG changes (0.4-1) hypotension, arrhythmias (1.5-2.5) circulatory failure -> toxicity (>2.5)
42
renal s/e with lithium
polyuria, polydipsia, oedema (0.4-1) persistent polyuria (1.5-2.5) renal danage, renal failure
43
CNS and neuromuscular s/e of lithium
fine tremor, incoordination, muscle weakness coarse tremor, muscle weakness/twitch, lethargy, dysarthria, ataxia convulsions, coma, permanent neurological damage, death
44
other s/e of lithium
non-myxodemic goitre, neurtophilia, exacerbation of psoriasis hypothyroidism
45
counselling points for lithium
- maintain adequate fluid intake - avoid dietary changes relating to Na intake - don't exceed alcohol limits - brand prescribing - don't take NSAIDs - symptoms of hypothyroidism (lethargy, feeling cold, weight gain) referral, women > men - fluid loss due to diarrhoea/vomiting can lead to discontinuation of treatment (contact prescriber) - aware of signs of toxicity and report them urgently
46
brand Rx and lithium
2 forms: lithium carbonate tabs and lithium liquid - tabs and liquid aren't equivalent - doses are not interchangeable between preparations - need to Rx by brand - bioavailability differences
47
signs of lithium toxicity
``` excessive thirst excessive urination tremor lack of coordination n&v ```
48
c/i with lithium
dehydration untreated hypothyroidism -> sample taken 12hrs after dose
49
monitoring for lithium
renal function thyroid function on initiation and every 6mths
50
How long does it take to see effects of lithium?
3-4 weeks
51
predisposing factors for lithium toxicity
dehydration reduced renal perfusion infections
52
drugs that can cause lithium toxicity
diuretics ACEIs ARBs
53
NSAIDs and lithium
reduced lithium excretion
54
lithium and amiodarone
increases risk of ventricular arrhythmias
55
What to check before initiation of lithium?
U&Es LFTs TFTs
56
How often does Li conc need to be measured?
every 3 months
57
How often to monitor U&Es and TFTs when taking lithium?
every 6-12 months on stable regimens
58
What needs to be done before starting valporate (antiepeleptic)?
weight/BMI FBC LFTs
59
Who can valporate not be prescribed to?
women of childbearing age without pregnancy prevention programme
60
interactions with valporate
other anticonvulsants (carbamazepine, lamotrigine) olanzipine smoking
61
When to monitor valporate levels?
not routinely unless evidence of ineffectiveness, poor adherence or toxicity
62
monitoring for valporate
weight/BMI LFTs FBC -> after 6mths and then annually
63
What to monitor carefully in older people with valporate?
monitor sedation, tremor and gait disturbance
64
How to stop valporate?
reduce dose gradually over at least 4 weeks to minimise risk of relapse
65
What to monitor before starting lamotrigine?
FBC urea and electrolytes LFTs
66
What does lamotrigine interact with?
valporate
67
s/e when lamotrigine dose being increased
rash -> contact doctor
68
When to monitor plasma levels of lamotrigine?
not routinely unless evidence of ineffectiveness, poor adherence or toxicity
69
How to stop lamotrigin?
reduce dose gradually over at least 4 weeks to minimise risk of relapse

PHA333 (27 decks)

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