CANMAT Guidelines: Bipolar Disorder Part 3 + general Bipolar DSM Flashcards
what are the most common comorbid conditions with BD
SUB
anxiety
personality disorder
impulse control disorder (ODD, ADHD, CD)
what is the prevalence of SUDs in BD
33%-45%
what is the only treatment for alcohol use disorder co-morbid with BD in the guidelines with level 2 evidence (theres none higher)
lithium + divalproex (compared to lithium alone)
*watchout for electrolyte imbalances and liver function issues
theres level 3 and 4 evidence for other tx like disulfiram, naltrexone, gabapentin etc
is quetiapine recommended for treatment of AUD co-morbid with BD
no–lack of efficacy shown
what % of people with BD have cannabis use disorder
20%
what affect does cannabis have on course of BD
associated with more time in affective episodes and rapid cycling (as well as a bunch of other stuff like more psychotic features)
what medication showed benefit in treating cocaine use disorder co-morbid with BD
citicoline
also lithium and/or divalproex alone or in combo
buprioprion has anecdotal evidence
which medication has the most evidence of efficacy for treating OUD comorbid with BD
methadone
but lack of research in this area and there is concern with risk of overdose so should consult CRISM guidelines
what non-BD related medication may be reasonable to consider using to treat anxiety when comorbid with BD? why this med? do we have evidence for this?
pregabalin
effective and not associated with risk of mood destabilization and is well tolerated
not tested in BD population
list medications that have evidence for treating anxiety symptoms/GAD in those with BD
quetiapine
lamotrigine or olanzapine + lithium in those who are euthymic and already on lithium
olanzapine + fluoxetine
gabapentin adjunctive therapy
does OCD have higher rates in those with BD compared to the general population
yes
*“some researchers have posited that the high rate of co-occurrence might reflect a distinct bipolar phenotype rather than separate disorders.”
what % of those with BD also have a co-morbid personality disorder
42% per a meta analysis
what was the most prevalent co-morbid personality disorder with BD
obsessive compulsive PD
then borderline, then avoidant, then paranoid, then histrionic
what medications may provide relief for those with borderline PD co-morbid with BD
divalproex and lamotrigine
what % of adults with ADHD also meet the criteria for BD
up to 20%
what % of patients with BD also meet criteria for adult ADHD
10-20%
how do you approach treatment of comorbid ADHD and BD
treat the mood symptoms first then treat ADHD
reduced risk of mania with use of methylphenidate when treated concurrently with a mood stabilizer
treatment with lithium was associated with reduced risk of what diseases
stroke and cancer
what baseline lab investigations should be done in patients with bipolar disorder
+ prolactin
+pregnancy test (if relevant)
what medical monitoring should be done for those on lithium therapy
thyroid function
renal function
plasma calcium
–assessed at 6 months then at least annually thereafter
what medical monitoring should be done for those on divalproex therapy
menstrual hx (to assess for PCOS)
hematology profile
liver function tests
–assessed at 3-6 month intervals during 1st year then at least annually thereafter
what patient education should be done for those on carbamazepine or lamotrigine therapy
routine education about risks of skin rashes or potential for stevens johnson syndrome or toxic epidermal necrolysis
patients should contact healthcare professional if develop rash or mucosal ulcers
which population should receive genetic screening before starting carbamazepine? why?
high risk populations like Han Chinese and other asian populations
make sure do not have human leukocyte antigen (HLA)-B*1502 allele–> confers high risk for SJS/TEN with carbamazepine
what medical monitoring should be done for those on carbamazepine therapy
serum sodium levels at least annually due to risk of hyponatremia
how often should you do serum levels for lithium and divalproex?
(note-should also do serum levels of carbamazepine, but just to check adherence)
two consecutive serum trough levels should be established in the acute phase
then q3-6 months or more frequently if clinically indicated
what is the target serum level in acute treatment for lithium
0.8-1.2mEq/L
what is the target serum level for lithium in maintenance treatment
0.6-1mEq/L (“may” be sufficient)
how many days after the most recent dose titration should you get a level of lithium
about 5 days
what is the target serum level of divalproex in the acute phase of treatment
350-700mM/L
(same during acute and maintenance)
when should you get a divalproex level after the most recent dose change
3-5 days after
can lithium cause weight gain
yes
so can divalproex
can gabapentin cause weight gain
yes
what is the effect of lurasidone on weight gain
minimal
what GI side effects are commonly associated with lithium and divalproex
nauseu
vomiting
diarrhea
(35-45% of people experience this)
particularly pronounced during lithium initiation or rapid dose increases
what % of patients on lithium report nephrogenic diabetes insipidus (NDI)
20-40%
what % of patients on lithium will experience polyuria
upwards of 70%
what long term effects can lithium have on the kidneys
i.e 10-20+ year admin of lithium can cause:
decrease glomerular filtration rate
chronic kidney disease (2x increased risk in older adults)
what diseases can lithium cause due to renal toxicity
nephrogenic diabetes insipidus
chronic tubulointerstitial nephropathy
acute tubular necrosis
when should you consult nephrology for your patient on lithium
if rapidly declining eGFR
if eGFR falls below 45 in two consecutive readings
if clinician is concerned
can lithium cause QT prolongation
yes
why do you screen for serum calcium in people on lithium
because lithium can cause hyperparathyroidism and serum calcium screens for this
if serum Ca elevated–> further investigate
is hypothyroidism an indication for lithium cessation in a patient who has responded well to lithium
no not normally–> recommend thyroid supplementation instead
what 3 APs are more likely to cause hyperprolactinemia
risperidone
paliperidone
amisulpride
how might hyperprolactinemia persent
amenorrhea
sexual dysfunction
galactorrhea
gynecomastia
osteoporosis
is lithium, lamotrigine or divalproex most likely to cause sedation
divalproex
tremor is experiences by what % of those on lithium or divalproex
10%
what should you rule out if your patient on divalproex presents with new onset neurological symptoms
hyperammonemic encephalopathy
can be fatal
what % of patients being treated with lamotrigine will experience a non-serious rash
10%
what % of patients being treated with lamotrigine will experience a serious rash like TEN or SJS
0.3-1%
risk MUCH lower with starting dose of 25mg and slow titration
what skin conditions can be associated with lithium treatment
acne, psoriasis, eczema, hair loss, hidradenitis suppurativa, nail dystrophy and mucosal lesions
overall estimates ranging from 3% to 45% depending on the criteria applied
most cases can be managed without treatment discontinuation
based on DSM V, is bipolar II still considered to be a “milder” form of bipolar I?
no–> this is because of the amount of time individuals with this condition spend in depression + because instability of mood w bipolar II typically accompanied by SERIOUS IMPAIRMENT in work and social functioning
