Chapter 65 - Bipolar Disease Flashcards
Bipolar disorder is classified as bipolar I or bipolar II, which differ primarily by
the severity of mania experienced
BIPOLAR 1
- At least one episode of mania, and usually, bouts of intense depression (a depressive episode is not required for diagnosis).
- Mania is associated with at least one of the following:
1) significant impairment in social/work functioning,
2) psychosis/delusions or
3) requires hospitalization.
BIPOLAR II
- At least one episode of hypomania (lasting >= 4 consecutive days) and
- At least one depressive episode (lasting >= 2 weeks).
- Hypomania does not affect social/work functioning, does not cause psychosis nor require hospitalization.
BIPOLAR DEPRESSION
Predominant symptoms of a depressive episode include
- Feelings of sadness or depressed mood and/or
- Loss of interest in previously enjoyed activities.
PSYCHOSIS
Severe mental condition where there is a loss of contact with reality, involves abnormal thinking and perception (e.g.,hallucinations and delusions).
Cyclothymia
is a related disorder consisting of periods of hypomanic and depressive symptoms without meeting criteria for a major depressive, manic or hypomanic episode.
Symptoms of mania
Symptoms
■ Inflatedself-esteem
■ Needs less sleep
■ More talkative than normal
■ Jumping from topic to topic
■ Easilydistracted
■ Increase in goal-directed activity
■ High-risk,pleasurableactivities
(e.g.,buying sprees, sexual indiscretions, gambling)
Definition of mania
Definition
Abnormally elevated OR irritable mood for at least a week (or any duration if hospitalization is needed)
Diagnosis of mania
Diagnosis
- Exhibits >= 3 symptoms
- If mood is only irritable, exhibits >= 4 symptoms
Should you do any screening before diagnosis?
A toxicology screen should be done prior to starting treatment to rule out drug- induced mania.
Goal of treatment
The goal of treatment is to stabilize the mood without inducing a depressive or manic state.
What are the traditional mood stabilizers?
What do they treat?
The traditional mood stabilizers, such as:
- Lithium and
- Antiepileptic drugs (valproate, lamotrigine and carbamazepine),
treat both mania and depression without inducing either state.
What can help stabilize mood when mania occurs with psychosis?
Antipsychotics, while not traditional mood stabilizers, can help stabilize the mood when mania occurs with psychosis.
Can you give antidepressants as a monotherapy?
Antidepressants can induce or exacerbate a MANIC episode when used as monotherapy, so they should only be used in combination with a mood stabilizer.
To select treatment, consider the following:
■ The side effect profile of the drug.
■ The patient’s medication history and first-degree relatives’ medication history;
if the patient or a family member responded well to a drug, the same drug might be a reasonable option.
■ The drug formulations available and cost.
Acute Manic episode:
first-line treatment is:
- Valproate,
- Lithium or
- An antipsychotic.
A combination of an antipsychotic + lithium or valproate is preferred for SEVERE episodes.
Acute Depressive episode:
- First-line treatment is lithium,
- Lamotrigine can be used as an alternative.
Maintenance
1) Preferred monotherapy:
- Lithium
- Valproate
2) Alternatives:
- Lamotrigine,
- carbamazepine
- second-generation antipsychotics (SGAs)
3) Antipsychotics or antidepressants may be added to lithium or valproate
MedGuides are required with all antidepressants (primarily due to —) and with all antipsychotics (primarily due to—).
MedGuides are required with all antidepressants (primarily due to suicide risk) and with all antipsychotics (primarily due to increased risk of death in elderly patients with dementia- related psychosis).
Pregnancy and Valproate
Valproate exposure in pregnancy can increase the risk of fetal anomalies, including:
- neural tube defects,
- fetal valproate syndrome
- long-term adverse cognitive effects.
Avoid in pregnancy, if possible, especially during the first trimester.
Pregnancy and Carbamazepine
Carbamazepine exposure in pregnancy can cause:
- Fetal carbamazepine syndrome,
which can result in facial abnormalities and other significant issues.
Avoid in pregnancy, if possible, especially during the first trimester.
Pregnancy and Lithium
Lithium exposure in pregnancy can cause:
- An increase in congenital cardiac malformations and other abnormalities.
During pregnancy, — is a safer option relative to the other mood stabilizers mentioned in this section.
lamotrigine
— are safer choices than valproate, carbamazepine or lithium.
SGA
— has the most favorable safety profile in pregnancy, but its use is limited since it is only approved for —
Lurasidone
bipolar depression.
Lamotrigine
- Lamictal,
- Lamictal ODT,
- Lamictal XR,
- Lamictal Starter Kit:
Requires a slow titration due to the risk of a severe rash.
Do not use for acute mania.
For Acute depressive episode and for maintenance
antiepileptic
Valproate/ Valproic Acid Derivatives brand names
- Depakote
- Depacon
- Depakene
antiepileptic
Carbamazepine brand
- Equetro
- Antiepileptic drug
Antipsychotics can be used only in combination?
alone or in combination with one of the traditional mood stabilizers
A major concern with anti psychotics is
the risk of extra pyramidal symptoms (EPS).
do we prefer FGA or SGA?
The first-generation antipsychotics (e.g., haloperidol) have a higher incidence of EPS than SGAs,
- so SGAs are preferred.
The following are the more common SGAs that can be used alone or in combination with mood stabilizers for acute mania and/or maintenance treatment:
■ Aripiprazole (Abilify, Abilify Maintena)
■ Olanzapine (Zyprexa, Zyprexa Relprevv, Zyprexa Zydis)
■ Quetiapine (Seroquel, Seroquel XR)
■ Risperidone (Risperdal, Risperdal Consta, Perseris)
■ Ziprasidone (Geodon)
Other common SGAsused for bipolar disorders include:
■ Lurasidone (Latuda): can use alone or in combination with mood stabilizers for bipolar DEPRESSIVE episodes.
■ Olanzapine/Fluoxetine (Symbyax): can use alone for acute DEPRESSIVE episodes.
Lithium brand
Lithobid
Lithium dosing
Start: 300-900 mg/day, divided BID or TID
Usual range: 900 - 1,800 mg/day, divided BID-TID
Extended-release: take BID
Titrate slowly, as tolerated
Should you take lithium with or without food?
Take with or after meals to reduce nausea
Therapeutic range of lithium
Therapeutic Range:
- Trough level: 0.6 - 1.2 mEq/l
- Acute mania may require up to 1.5 mEq/l initially
BBW of lithium
Serum lithium levels should be monitored to avoid toxicity
Toxicity with lithium:
> 1.5 mEq/l:
- Ataxia,
- Coarse hand tremor,
- Vomiting,
- Persistent diarrhea,
- Confusion,
- Sedation
> 2.5 mEq/l:
- CNS depression
- Arrhythmia
- Seizure
- Coma
What can increase lithium toxicity?
- Renal impairment,
- Hyponatremia
- Dehydration
warning with lithium and other serotonergic drugs?
Serotonin syndrome
SIDE EFFECTS of lithium Within therapeutic range:
- GI upset (nausea/diarrhea),
- Cognitive effects,
- Cogwheel rigidity,
- Fine hand tremor,
- Thirst,
- Polyuria/polydipsia,
- Weight gain,
- Hypothyroidism,
- Hypercalcemia,
- Cardiac abnormalities,
- Edema,
- Anorexia,
- Worsening psoriasis,
- Blue-gray skin pigmentation,
- Impotence
What should you monitor with lithium?
- Serum lithium levels,
- Renal function,
- Thyroid function (TSH, FT4),
- Electrolytes (calcium, potassium, sodium)
How is lithium cleared?
Renally cleared; no CYP450 interactions
Lithium in preg and breastfeeding?
Avoid in pregnancy; associated with cardiac malformations in first trimester; avoid in breastfeeding
Lithium levels INCREASE with:
LOW salt intake, sodium loss
- with ACE inhibitors,
- ARBs,
- thiazide diuretics
NSAIDs:
- Aspirin and sulindac are safer options
Lithium levels DECREASE with:
- INCREASE salt intake,
- Caffeine
- Theophylline
Inc risk of serotonin syndrome if lithium is taken with:
- SSRis,
- SNRis,
- triptans,
- linezolid
- other serotonergic drugs
Inc risk of neurotoxicity (e.g., ataxia, tremors, nausea} if
lithium is taken with:
- Verapamil,
- diltiazem,
- phenytoin
- carbamazepine
Converting between lithium formulation
5 ml lithium citrate syrup = 8 mEq of lithium ion
8 mEq of lithium ion = 300 mg lithium carbonate
tabs/caps
What to counsel pt on lithium?
■ Take with food or at end of meal to reduce nausea.
■ Maintain consistent salt intake. Changes in salt intake can alter lithium levels in the body.
- low salt - high drug level –> dec dose
- high salt - low drug level –> inc dose
■ Maintain adequate hydration with non-caffeinated fluids.
- Dehydration can inc drug level
- Caffeine can dec drug level
■ Avoid dehydration (e.g., excessive sweating, diarrhea, vomiting and prolonged heat/sun exposure). Can increase lithium levels and side effects.
■ Avoid in pregnancy/breastfeeding.
■ Notify healthcare provider immediately for worsening
nausea or diarrhea, slurred speech or confusion.
■ Can impair alertness, use caution while driving or during other tasks requiring you to be alert.
