Final Bipolar Disorder Flashcards
What are the symptoms of bipolar disorder?
Mania
Hypomania
Depression
Mixed Mania with Depression
What are the types of Bipolar disorder?
Bipolar I Disorder
Bipolar II Disorder
Cyclothymia Disorder
Unspecified Bipolar and Related Disorder
Substance-Induced Mood Disorder
What is hypomania?
Less severe mania
What is the primary drug used to treat bipolar disorder?
Lithium
What is the mechanism of Lithium?
Not completely understood
-Is an ion similar to Na, goes everywhere in the cell, and has lots of different effects
*Depletes PIP2 and associated signaling (membrane lipid that serves as a substrate for phospholipase c)
-Lithium blocks the recycling of PIP2 which causes the Phospholipase C (PLC) to have no substrate and be unable to signal
What are the anticonvulsant drugs used in Bipolar Disorder?
Valproic Acid
Sodium Valproate
Carbamazepine/Oxcarbazepine
Lamotrigine (Lamictal)
Topiramate (Topamax)
Which mood is experienced most in bipolar disorder?
Depression
*can lead to misdiagnosis
What are the comorbidities often associated with bipolar disorder?
Alcohol and substance use (50-60%)
Anxiety disorders (can significantly impact remission of mood episodes if left untreated or inadequately treated)
What is the criteria for Bipolar I Disorder?
> or = 1 manic episode
*only need one manic episode to be diagnostic
What is the criteria for Bipolar II Disorder?
Hypomanic Episodes
What is the main drug used in bipolar disorder treatment?
Lithium
True or False: Lithium is associated with increased suicidality
FALSE
-decrease in suicidality in bipolar disorder
What concern is there about lithium dosing?
Narrow Therapeutic Index (NTI) drug
*need to make sure patient does not plan on committing suicide by pill overdose
Above 1.2-1.5 mEq/L starts running into toxicity
What is the conversion between different lithium dosage forms?
1:1
What are the toxicities associated with Lithium?
GI
Ataxia
Course hand tremor
Altered mental status
Seizure
Lethargy
Confusion
Agitation
What are the side effects associated with lithium?
Fine hand tremor
Hypothyroidism
Polyuria
Polydipsia
Acne
Dry Mouth
Weight Gain
ECG Changes
Teratogen
-Ebstein’s abnormality
What drug should be avoided in the first trimester of pregnancy?
Lithium
What labs should be monitored with lithium use?
Na, K, Ca
Parathyroid hormone
What drugs interact with lithium?
-ACEi
-ARBs
-Thiazide Diuretics
-NSAIDs*
Dehydration
Besides lithium, what is another common first-line agent for bipolar disorder?
Valproate
What is a risk with the dosing of valproate?
Comes in many dosage forms so risk for med errors
How does the bioavailability of the extended release lithium form compare to the bioavailability of the delayed release form?
Extended release (ER) dosage form is 10-15% LESS bioavailable than the delayed release (DR) form
What is the conversion factor between the valproate dosage forms?
1:1
*Lower concentrations with ER dosage form but not clinically significant
What valproate dosage form has the highest risk for GI ulcerations (esophageal)?
Valproic acid syrup (IR) and capsule sprinkle form
What valproate serum level is associated with the most efficacy in mania?
180-125 mcg/ml
When should valproate levels be obtained?
96 hours (4 days) after first dose or dose increase
What are the side effects associated with valproate?
GI: anorexia, N/V/D, dyspepsia, ulceration
Increased appetite (weight gain of 6-8 kg)
Thrombocytopenia (platelet dysfunction)
Teratogenic (neural tube defects and lower IQ)
Hyperammonemia
PCOS in up to 50% of women
What trimester of pregnancy is valproic acid unsafe in?
ALL
-obtain baseline pregnancy test
What labs should be monitored with valproate use?
Baseline: Pregnancy test, LFTs, CBC with differential
Serum ammonia (if hyperammonemia suspected, not routine)
What drugs interact with valproate?
Lamotrigine
-increased lamotrigine serum concentrations increase risk for Stevens-Johnson syndrome
**Dose needs to be cut in half
What other mood stabilizers can be used in bipolar disorder?
Carbamazepine (Tegretol)
Oxcarbazepine (Trilepta)
Lamotrigine (Lamictal)
Topiramate (Topamax)
What important side effect are associated with Carbamazepine (Tegretol)?
Thrombocytopenia
Hematologic effects
What does oxcarbazepine induce?
CYP450 3A4
What side effect is associated with oxcarbazepine?
Hyponatremia
When is Lamotrigine the 1st line treatment in bipolar disorder?
For depressive episodes!
When is lamotrigine not a good drug option in bipolar disorder?
Not useful for acute treatment or manic episodes
What are the side effects associated with Topiramate?
-Weight loss
-Heat intolerance/ Hypohidrosis
-Metabolic acidosis/Kidney stones
*Possible teratogen (cardiac structural defects)
When would we use atypical antipsychotics for bipolar disorder?
As monotherapy or can be used in combination with other mood stabilizers (lithium or valproate)
What are the monitoring parameters for antipsychotics?
Metabolic syndrome and movement side effects
What combination therapies can be used in bipolar disorder?
Lithium + Valproate
Lithium + Antipsychotic
Valproate + Antipsychotic
Combination with antidepressants
**DO NOT USE TWO ANTIPSYCHOTICS TOGETHER*
How long do we use mood stabilizers in bipolar disorder?
Long-term
*Considered maintenance treatment to reduce time to subsequent mood episodes
What needs to be monitored closely when starting bipolar medications?
Suicide attempt risk is high in both poles of bipolar disorder
*monitor closely and use lithium cautiously
What are the teratogens used in bipolar treatment?
Lithium **first trimester
Valproic Acid
Carbamazepine
Topiramate
What is the first-line choice of drug for use during pregnancy?
Atypical antipsychotics
What are some things to keep in mind with antidepressant use in bipolar disorder?
-Need to have maintenance mood stabilizer therapy in combination with antidepressant therapy
-Use serotonergic antidepressants to treat anxiety
-Prefer to use mood stabilizers that target the depressive pole
What mood stabilizers target the depressive pole?
Lamotrigine
Lithium
Lurasidone
Quetiapine
