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Psychopharmacology 552 > Exam 1 - Mood Stabilizers > Flashcards

Exam 1 - Mood Stabilizers Flashcards

1
Q

Red flags for potential bipolar disorder:

  • Hx of abnormally elevated/irritable mood
  • Periods of persistent increased energy
  • Period of engaging in out-of-character behavior
  • Behavior that is a noticeable change from baseline
  • Impulsivity (APA, 2013)
  • Cognitive difficulties present even when not depressed (APA, 2013)
  • Multiple failed trials of antidepressants (Stahl, 2013)
  • Ask about periods of time when it seemed like ‘everyone was picking fights with you’ or conversely periods of time when the individual received feedback from multiple others that might indicate irritability
  • East-west travel issues (APA, 2013)
  • Sometimes, a lack of clear precipitants for mood episodes (Carlat, 2016)
  • Psychosocial history providing evidence of ‘erratic’ behavior over time
A

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2
Q

“DIGFAST”

  • Distractible
  • Indiscretion (excessive pleasurable activities with high potential for painful consequences)
  • Grandiosity
  • Flight of ideas
  • Activities (increased goal direction)
  • Sleep deficit (decreased need for sleep)
  • Talkativeness (pressured speech)

At least 3 of the above plus expansive mood, 4 of the above if mood is only irritable. In mania, psychosis may e present (APA, 2013; Carlat, 2016)

A

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3
Q

Mania vs Hypomania

MANIA

3- 4 DIGFAST x 7 days

Severe impairment in social or occupational functioning

Hospitalizing
is common to prevent harm to self and others

May have psychotic features

A

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4
Q

Mania vs Hypomania

HYPOMANIA

3- 4 DIGFAST X 4 days

No marked impairment in social or occupational functioning

No hospitalization required

No psychotic features.

A

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5
Q

BIPOLAR I

The only requirement is an occurrence of a manic episode (RED)

In between manic episodes – euthymia, major depressive episodes or hypomanic episodes

Age of onset before 30; mean age of first mood episode = 18

Chronic with relapses

Poorer prognosis than MDD

Lithium – gold standard (RED)

Tegretol and Valproic acid

SGA – Risperdal, Zyprexa, Seroquel, Geodon = monotherapy and adjunct therapy

No antidepressants - concerns with activating mania or hypomania (RED)

A

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6
Q

BIPOLAR I - RED PARTS

The only requirement is an occurrence of a manic episode

Lithium – gold standard

No antidepressants – concerns with activating mania or hypomania

A

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7
Q

BIPOLAR II

One or more major depressive episodes and at least 1 hypomanic episode.

A

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8
Q

ACUTE MANIA TREATMENT

Lithium - gold standard

Depakote

Carbamazepine

Additional benzos/typical/atypical antipsychotics

A

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9
Q

Maintenance treatment for mood

Lithium (”gold standard”), but tolerability concerns

A

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10
Q

Bipolar = ↑Serotonin; ↑NE

A

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11
Q
  • Acute mania
    Prevent relapses of manic episodes (maintenance treatment) in bipolar and schizoaffective disorder.
  • Augmentation of antidepressants in patients with MDD
  • Potentiate antipsychotics in patients with schizophrenia or schizoaffective disorder
  • Treatment of aggression and impulsivity (e.g., in dementias, intellectual disability, personality disorders, other medical conditions)
  • Enhancement of abstinence in treatment of alcoholism.
A

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12
Q

Etiology of Bipolar Disorder

  • GABA dysregulation
  • ↑ Noradrenergic activities

Lithium (Eskalith Lithobid)

Carbamazepine (Tegretol)

Valproic acid (Depakote and Depakene)

Lamotrigine (Lamictal)

Oxcarbazepine (Trileptal)

Gabapentin (Neurontin)

Pregabalin (Lyrica)

Tiagabine (Gabitril)

Topiramate (Topamax)

A

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13
Q

Red Parts on Lithium:

  • Has antisuicidal properties (The only mood stabilizer shown to ↓ suicidality)
  • Epstein anomaly – cardiac defect in babies
  • Lithium Toxicity: Narrow therapeutic index(0.6-1.2 mEq/L); Toxic >1.5; Potentially Lethal =>2.0
  • Emphasize the need for reliable birth control in women of childbearing age
  • Good prognostic indicator for Lithium = episode pattern of mania, depression and euthymia
A

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14
Q

Lithium Carbonate (Eskalith)

Gold standard for the treatment of Bipolar (acute mania)

Has antisuicidal properties (The only mood stabilizer shown to ↓ suicidality)

Metabolized by the kidney = Special consideration in renal impaired patients

Symptom reduction 2 weeks tx 60 to 80% of manic patients

Effective preventing future manic & depressive episodes; reducing suicide: 6 to 7-fold decrease

Onset of Action= 5-7 days

Has a narrow therapeutic index

Check level 4-5 days after initiation and after every dose change

Before starting: TSH, Creatinine, BUN, pregnancy testing , EKG (over age 50 or risk); CBC, Chemistries

Regular Monitoring: Lithium levels, TSH, Kidney function.

Note: Well documented evidence of causing hypercalcemia and hyperparathyroidism.

A

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15
Q

Lithium SE:

SE: Weight gain, cognitive slowing or dulling; Impaired thyroid function, GI disturbance, Sedation, fine tremor, ECG changes(T-wave inversion), Leukocytosis; hypothyroidism; Epstein anomaly – cardiac defect in babies

A

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16
Q

Lithium Toxicity:

Narrow therapeutic index(0.6-1.2 mEq/L); Toxic >1.5; Potentially Lethal =>2.0

Early: Nausea, vomiting, diarrhea, coarse tremors, ataxia

Late: Seizures, Coma, death

A

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17
Q

Lithium

Patient Education: Drink @ least 6-8 glasses of water per day ; Caution in the summer – exercising outdoors

Emphasize the need for reliable birth control in women of childbearing age

A

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18
Q

Factors that can increase lithium levels

NSAIDS (e.g. ibuprofen)
Aspirin

Thiazide diuretics

Dehydration (especially in the elderly)

Salt deprivation

Sweating (salt loss)

Impaired renal functioning

Ace Inhibitors

Antihypertensives

A
19
Q

Lithium Adverse Effects

Renal

  • diabetes insipidus, nephrotic syndrome, interstitial fibrosis, renal failure

Thyroid

  • benign & transient decreases in thyroid hormone, goiter (5%), hyperthyroidism, hypothyroidism (10%)

Cardiac

  • T-wave flattening or inversion (benign), sinus dysrhythmias, heart block, ventricular arrhythmia & CHF (rare)

Weak teratogen: potential for Ebstein’s anomaly (congenital heart defect)

A

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20
Q

Lithium toxicity

Early signs: slight apathy, lethargy, decrease concentration, mild ataxia, muscle weakness, course tremor, slight twitching

Mod toxicity: severe diarrhea, N/V, ataxia, slurred speech, tremor, tinnitus, blurred vision, frank muscle twitch

Severe toxicity: nystagmus, muscle fasciculation, deep tendon hyperreflexia, V/T halluc, oliguria or anuria, imp consciousness, seizure, coma, death

A

-

21
Q

Carbamazepine (Tegretol) 800-1600 mg

Useful in treating mania w/ mixed features and rapid –cycling bipolar disorder

Gold Standard for = Rapid- cycling mania

Onset of Action: 5-7 days

Blackbox warning for Agranulocytosis & Aplastic Anemia

S/E: drowsiness; ataxia, nausea, dizziness, sedation, dry mouth, constipation

Therapeutic Level= 8-12 mcg/ml

Rare= Depakote induced thrombocytopenia

Elevation of liver enzymes causing hepatitis

Labs before initiating: Pregnancy test, CBC, LFTs

Regular Labs: CBC, LFTs

Associated w/ Neural tube defects

Note: Auto-induction of its own metabolism;

Starts 3-5 days after initiating

Translates as decrease plasma levels

May need a dose increase in the first few weeks to months

Potential for dangerous skin rash (Stevens Johnson Syndrome)

Toxicity: Confusion, stupor, motor restlessness, ataxia, tremor, nystagmus, twitching and vomiting

***Acute intoxication can produce Ataxia

A

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22
Q

Carbamazepine (Tegretol) Red Parts

  • Blackbox warning for Agranulocytosis & Aplastic Anemia
  • Therapeutic Level= 8-12 mcg/ml
  • Rare= Depakote induced thrombocytopenia
  • Elevation of liver enzymes causing hepatitis
  • Associated w/ Neural tube defects
  • Note: Auto-induction of its own metabolism;

***Acute intoxication can produce Ataxia

A

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23
Q

Valproic acid (Depakote and Depakene) 500mg -2000mg

MOA: Blocks sodium channels and increases GABA concentrations in the brain

PO (Depakote) Liquid (Depakene) and IV formulation

Blackbox warning for hepatotoxicity & pancreatitis

Therapeutic level = 80-120 ug/ml

Check level after 4-5 days

S/E: Nausea, diarrhea, Abdominal cramping, sedation, tremor

Rare= Depakote induced thrombocytopenia

Labs: CBC, LFTs

Associated w/ Neural tube defects specifically spina bifida, atrial septal defects, cleft palate and possible long-term developmental deficits
(Care with women at childbearing age) – Some studies have linked Depakote to PCOS.
S/E: GI distress, sedation, cognitive slowing, weight gain, LFT elevations, hyper ammonia, pancreatitis, hair loss

Fatal hepatotoxicity

Pancreatitis

Hyperammonemia-induced encephalopathy

Thrombocytopenia

Highly teratogenic (neural tube and other defects)

Concerning drug interaction

  • VPA more than doubled when taking lamotrigine, therefore increases risk Steven Johnson syndrome
A

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24
Q

Valproic Acid Red Parts

Therapeutic level = 80-120 ug/ml

Check level after 4-5 days

Rare= Depakote induced thrombocytopenia

Associated w/ Neural tube defects specifically spina bifida, atrial septal defects, cleft palate and possible long-term developmental deficits

A

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25
Q

Carbamazepine can cause ataxia even at a therapeutic dose

A

-

26
Q

Teratogenic risks common with psychiatric medications

Benzodiazepines: Floppy baby syndrome, cleft palate

Carbamazepine (Tegretol): Neural tube defects, Spina Bifida, Craniofacial defects, fingernail hypoplasia and developmental delays.

Lithium(Eskalith): Epstein anomaly

Divalproex sodium (Depakote): Neural tube deficits- specifically spina bifida, atrial septal defects, cleft palate and possible long-term developmental deficits

A

-

27
Q

Lamotrigine (Lamictal)
100-200mg

Efficacy for bipolar depression

No blood monitoring

S/E: dizziness, ataxia, headache somnolence, nausea, diplopia

Can cause idiosyncratic liver injury

RARE: Steven Johnson Syndrome (life threatening rash involving the skin and mucus membranes)- maculopapular rash

***Start low and go slow

A

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28
Q

Oxcarbazepine (Trileptal)

Less risk of rash and hepatic toxicity
Better tolerated as compared to Carbamazepine (Tegretol)

Monitor Na+ levels = hyponatremia

Risk factors

Increased age

Smoking

Low baseline sodium concentration

Diuretic use.

A

-

29
Q

Gabapentin (Neurontin)

Used as an adjunct to help w/ anxiety, sleep and neuropathic pain

A

-

30
Q

Pregabalin (Lyrica)

Used in GAD and fibromyalgia

A
31
Q

Topiramate (Topamax)

Use in impulse control disorders

Beneficial side effect = weight loss

Most limiting side effect= Cognitive slowing

“Dope-a-max”

A
32
Q

Most limiting side effect = Cognitive slowing

A. Pregabalin
B. Topiramate
C. Lamotrigine
D. Oxcarbazepine
E. Gabapentin

A

B. Topiramate

33
Q

Monitor Na+ levels = hyponatremia
Risk factors
Increased age
Smoking
Low baseline sodium concentration
Diuretic use.

A. Pregabalin
B. Topiramate
C. Lamotrigine
D. Oxcarbazepine
E. Gabapentin

A

D. Oxcarbazepine

34
Q

RARE: Steven Johnson Syndrome (life threatening rash involving the skin and mucus membranes)- maculopapular rash
***Start low and go slow

A. Pregabalin
B. Topiramate
C. Lamotrigine
D. Oxcarbazepine
E. Gabapentin

A

C. Lamotrigine

35
Q

(RED/BOLDED)

NOTE: Valproate will increase Lamictal levels; Lamictal will decrease valproate levels

A

-

36
Q

Concurrent dosing Depakote and Lamictal (CYP 450 strong inducers and inhibitors) = Lamictal dose must be halved when taken with Depakote

A
37
Q

Lamictal dose must be __________ when taken with Depakote

A. Halved
B. Doubled

A

A. Halved

38
Q
  • Depakote and Tegretol=Remember induce thrombocytopenia and can be hepatotoxic
  • What labs will you obtain?
  • What other medication might you consider?

Note: All the mood stabilizers particularly the antiepileptics are associated with hepatic side effects (Gabapentin and Lyrica are the safest)

Consider Lithium

A
39
Q

Concurrent dosing Depakote and Lamictal (CYP 450 strong inducers and inhibitors) = Lamictal dose must be halved when taken with Depakote

Adverse effect of Lamictal

Caution with rapid titration of Lamictal d/t ???

Side effects of Lamictal

Note: Remember always start low, maximize med, adjunct before switching= depending on side effect profile

A
40
Q

Atypical Antipsychotics used in the treatment of Bipolar disorder

Aripiprazole (Abilify)

Cariprazine (Vraylar)

Lurasidone (Latuda)

Olanzapine (Zyprexa)

Olanzapine/Fluoxetine (Symbyax)

Quetiapine (Seroquel)

Risperidone (Risperdal)

Ziprasidone (Geodon)

A
41
Q

Bipolar Treatment

Mild mania or Hypomania:

Lithium or Depakote or SGA

Severe Mania:

Lithium or Depakote + SGA

Rapid cycling:

Depakote or Lamictal

Psychotic mania”

SGA monotherapy

A
42
Q
A

Psychopharmacology 552 (7 decks)

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