Class 9 Flashcards
Haldol vs loxapine
Haldol has more SEP s/e. Haldol is more potent. Loxapine has more sedation (highly anticholinergic).
non pharmacological management of acute mania
Low stimulation, optimize Rx adherence, sleep, prevenir les gestes à risque, involve the family
normal range epival
750-3000 die
loading dose epival
20-30 mg/kg/day
chance of having bipolar if 2 parents are bipolar
50-75%
Chronic disease management model
Self-management support: Empower and prepare patients to manage their health and health care, Use effective self-management support strategies that include assessment,
goal setting, action planning, problem solving, and follow-up
Decision support: Promote clinical care that is consistent with scientific evidence and patient, preferences, Embed evidence-based guidelines into daily clinical practice and share this and other information with patients to encourage their participation. Use proven provider education materials
Community: Encourage patients to participate in effective community programs, Form partnerships with community organizations
Delivery system design: Provide clinical care and self-management support that patients understand and that fits with their cultural background, Ensure regular follow-up
by the care team, with defined tasks for different team members. Provide clinical case management services for complex patients
Clinical information systems: Provide timely reminders for providers and patients
Facilitate individual patient care planning. Share information with patients and providers to coordinate care.
Health system: Measure outcomes and use information to promote effective improvement strategies aimed at comprehensive system change. Develop agreements that facilitate care coordination within and across organizations.
Principles in the Treatment of Bipolar Disorders
Maintain dual treatment focus: (1) acute short term and (2)prophylaxis.
Chart illness retrospectively and prospectively.
Mania as medical emergency: Treat first; chemistries later.
Load valproate and lithium (Eskalith); titrate lamotrigine (Lamictal) slowly.
Careful combination treatment can decrease adverse effects.
Augment rather than substitute in treatment-resistant patient.
Retain lithium in regimen for its antisuicide and neuroprotective effects.
Taper lithium slowly, if at all.
Educate patient and family about illness and risk-to-benefit ratios of acute and prophylactic treatments.
Give statistics (i.e., 50 percent relapse in first 5 months off lithium).
Assess compliance and suicidality regularly.
Develop an early warning system for identification and treatment of emergent symptoms.
Contract with patient as needed for suicide and substance use avoidance.
Use regular visits; monitor course and adverse effects.
Arrange for interval phone contact when needed.
Develop fire drill for mania reemergence.
Inquire about and address comorbid alcohol and substance abuse.
Targeted psychotherapy; use medicalization of illness.
Treat patient as a coinvestigator in the development of effective clinical approaches to the illness.
If treatment is successful, be conservative in making changes, maintain the course, and continue full-dose pharmacoprophylaxis in absence of side effects.
If treatment response is inadequate, be aggressive in searching for more effective alternatives.
Seroquel in elderly
very anticholinergic
Epival and lamotrigine
Epival doubles the therapeutic level of lamotrigine
Non adherent treatments
In patients who are non-adherent, psychosocial strategies such as psychoeducation should be used to improve treatment adherence. If ineffective, long-acting injectable medications should be offered. Risperidone long-acting injectable monotherapy or adjunctive therapy (level 2) once every 2 weeks or aripiprazole once-monthly injectable monotherapy (level 2) has been shown to be effective in preventing relapse of mood episodes in patients with BD.
Pregnancy general management
Decisions should be made collaboratively on whether medications should be continued, discontinued, or switched; and whether any dosage changes are needed. Conventional antipsychotics and risperidone may need to be discontinued to increase the likelihood of conception, as these medications often increase serum prolactin levels and thus interfere with ovulation and decrease fertility. For women who wish
to have a medication-free pregnancy, it might be appropriate to have one or more psychotropic medications gradually tapered off prior to conception provided they have been clinically stable for a minimum of 4-6 months and are considered at low risk of relapse. If pharmacotherapy is required, monotherapy at minimum effective dose is recommended whenever possible.
Because of changes in physiology in the second and early third trimesters, such as increased plasma volume, hepatic activity, and renal clearance, patients may require higher doses of medications towards the later part of the pregnancy.
2 months before and first trimester without Rx.
Divalproex and pregnancy
Divalproex should be avoided during pregnancy due to elevated risk of neural tube defects (up to 5%), even higher incidences of other congenital abnormalities, and
evidence of striking degrees of neurodevelopmental delay in children at 3 years of age and loss of an average of nine IQ points.
Li and pregnancy
For planned pregnancies, use of lithium during the first trimester should be avoided if possible (Grandjean 2009). However, the absolute risk of Ebstein anomaly is small and treatment for bipolar disorder should not be withheld when clinically indicated (Larsen 2015). If lithium is needed during pregnancy, the minimum effective dose should be used, maternal serum concentrations should be monitored, and consideration should be given to start therapy after the period of organogenesis; lithium should be suspended 24 to 48 hours prior to delivery or at the onset of labor when delivery is spontaneous, then restarted when the patient is medically stable after delivery.
why don’t use Mood Disorders Questionnaire
Validated self-report instruments, such as the Mood Disorders Questionnaire (MDQ), may be used as a screening tool to flag patients for whom a more detailed assessment is needed. It is important to note, that such tools have poor sensitivity and specificity, especially in community or highly comorbid populations, and will thus have an elevated risk of also flagging those with borderline traits.
Acute lithium toxicity
no, vo, diarrhea, dehydration, sluggishness, ataxia, confusion or agitation, and neuromuscular excitability, which can manifest as irregular coarse tremors, fasciculations, or myoclonic jerks. Severe lithium intoxication can lead to seizures, nonconvulsive status epilepticus, and encephalopathy
