General Principles of Bipolar Treatment

Question 1

Bipolar treatment categories involve…

3 categories

Answer 1

Acute mania treatment
Acute depression treatment
Maintenance treatment

Question 2

A good approach to starting treatment in any phase in BD involve the following steps:

4 steps (Really we should be doing this when starting any treatment)

Answer 2

1. Review general principles and assess medication status; adherence
2. Initiate or optimize therapy
3. Add-on or switch therapy
4. Monitor/Maintain

Question 3

When assessing a patient in an acute manic episode, we need to assess some factors, such as…

Answer 3

Risk of aggressive behaviour, violence, suicide
Degree of insight
Ability to adhere to treatment
Co-morbidities
Physical condition and lab tests

Most appropriate treatment setting?

Question 4

In acute mania treatment, we should discontinue…

Answer 4

AD’s
Stimulants (caffeine, amphetamines, CS)
Alcohol
Nicotine

Question 5

We need to rule out other causes when assessing acute mania, such as…

Answer 5

Prescribed medication
Illicit-drug use/abuse
Endocrine/neurological disorders

Question 6

1st line monotherapy indicated for acute mania treatment include…

Mood stabilizers, AAP’s; how many respond, and when?

Answer 6

Lithium, valproic acid, divalproex, aripiprazole, low dose paliperidone, risperdone

All have level 1 evidence :) Asenapine also included, but is newer

50% respond to monotherapy with significant improvement in mania, in 3-4 weeks

Question 7

1st line combinations for acute mania treatment include…

___ + ___

Answer 7

Lithium/DVP + Quetiapine/risperidone/asenapine/aripiprazole

Question 8

Combo therapy for acute mania is recommended when…

Answer 8

A response is needed faster
Patients with a previous history of partial response to monotherapy, or more severe manic episodes

Question 9

In general, combination therapy is preferred to mood stabilizer monotherapy for acute mania treatment, because…

Answer 9

On average, about ~20% more patients will respond to combination therapy

Greater efficacy of combination compared to lithium/DVP alone

Question 10

Some second-line treatment monotherapy options for acute mania include…

Answer 10

Olanzapine
Carbamazepine
Ziprasidone
Haloperidol

Question 11

Some second-line combination options for acute mania include…

Answer 11

Olanzapine + lithium/DVP
Lithium + DVP

Question 12

Lithium is preferred over divalproex for individuals who…

Answer 12

Display classical euphoric grandiose mania
Few prior episodes of illness
Family history of BD, especially with family history of lithium response

Question 13

Divalproex is preferred over lithium for individuals who…

Answer 13

Have had multiple prior episodes
Predominant irritable/dysphoric mood, and/or comorbid substance abuse
History of head trauma

Question 14

Carbamazepine may be a better option for acute mania treatment in patients with specific factors, such as…

Answer 14

Hx of head trauma or neurologic symptoms
Comorbid anxiety/substance abuse, or schizoaffective presentations with mood-incongruent delusions

Question 15

Patients with mixed feature BD should use…

Answer 15

DVP +/- AP’s, especially effective in combination

Question 16

After starting a 1st line agent for acute mania, some therapeutic response is expected within…

Answer 16

1-2 weeks

Question 17

Switching therapy or add-on strategies in acute mania should be considered when…

Answer 17

No response is observed within 2 weeks, with therapeutic doses + other contributing factors are excluded

Either combination of 1st line agents, or 2nd line therapies

Question 18

ECT may be recommended in mania treatment, when…

Answer 18

Mania is refractory

Question 19

Agents NOT recommended for acute mania and should be avoided include…

Answer 19

Gabapentin
Lamotrigine
Omega 3 fatty acids
Topiramate

Question 20

With BD1 depression, we need to assess patient factors such as…

Answer 20

Severity of depression - risk of suicide/self-harm behaviour
Ability to function and adhere to treatment
Previous treatments

Consider appropriate treatment as well

Question 21

With BD1 depression, we should discontinue…

Answer 21

Stimulants
Nicotine, caffeine
Drug/alcohol use

Question 22

With BD1 depression, we need to rule out…

Answer 22

Symptoms due to alcohol/drug use, medications, and other treatments
General medical condition

Question 23

1st line therapies for BD1 depression include…

Answer 23

Quetiapine and/or lithium
Lurasidone monotx, or with Lithium/DVP
Lamotrigene monotx or adj

Question 24

Depressive symptoms in BD1 may take ____ for initial improvement to be observed…

Answer 24

4-6 weeks

No response - consider switch/add-on

Question 25

2nd line monotherapy for BD1 depression includes...

Answer 25

Divalproex

Question 26

2nd line add-on therapy/combo for BD1 depression includes...

Answer 26

Adjunctive SSRI/bupropion, added to lithium/DVP, or AAP Olanzapine-fluoxetine

Question 27

ECT could be considered for BD1 depression, when...

Answer 27

Treatment refractory patients Rapid response needed

Question 28

Agents that are NOT recommended and should be avoided for acute bipolar depression include...

Answer 28

Antidepressant monotx Aripiprazole monotx Ziprasidone Lamotrigine, + folid acid Mifepristone adj. ## Footnote AD has safety concern of mood switching when not used with mood stabilizer

Question 29

Good lithium levels for acute bipolar depression are...

Answer 29

0.8-1.2 mmol/L

Question 30

Effective maintenance treatment of bipolar, helps to...

Answer 30

Reserve cognitive impairment Preserve brain plasticity Improved prognosis + minimization of illness progression

Question 31

Even with treatment, recurrence rates are around...

Answer 31

19-25%

Question 32

Risk factors for recurrence of BD1 episodes include...

Answer 32

Younger age at onset, more previous episodes Comorbid anxiety + substance use Rapid cycling Psychotic features

Question 33

The only 1st line psychosocial intervention for maintenance therapy of BD that should be offered to all patients is...

Answer 33

Psychoeducation

Question 34

With maintenance of bipolar, we want to reassess the following continuously:

Answer 34

Medications effective in acute phase (usually effective in maintenance phase) History of illness, comorbidities Predominant illness polarity

Question 35

1st line monotherapy options for BD maintenance therapy to prevent any mood episodes include... ## Footnote Think of our mood stabilizers, and that acute options are usually good for maintenance as well

Answer 35

Lithium Quetiapine Divalproex Lamotrigine Asenapine Aripiprazole ## Footnote If patient's responded well to 1st line tx during acute episode, recommend to continue that agent

Question 36

1st line combination options for BD maintenance therapy to prevent any mood episodes, include...

Answer 36

Lithium/DVP + Quetiapine, or aripiprazole

Question 37

Second-line treatment options for BD maintenance therapy, to prevent any mood episodes include... | Similar to second line options for acute treatments

Answer 37

Olanzapine Risperidone monotx + adj. Carbamazepine Low dose paliperidone Lithium/DVP + lurasidone/ziprasidone

Question 38

Third-line treatment options for BD maintenance therapy may include...

Answer 38

Aripiprazole + lamotrigine Clonzapine (adj) Gabapentin (adj) Olanzapine + fluoxetine | Usually not used due to lack/lower level of evidence ## Footnote These would be the extremes of patients where all other options have been exhausted

Question 39

With antipsychotic usage in maintenance therapy, we could consider tapering off after ____ to...

Answer 39

6 months - reduce polypharmacy | Continuing for the 6 months is beneficial for maintenance therapy

Question 40

For mixed episodes of BD, we should discontinue...

Answer 40

Antidepressants, as they will worsen the overall condition

Question 41

Monotherapy and combination therapy recommended for mixed episodes of BD include...

Answer 41

Atypical antipsychotic +/- Lithium/divalproex

Question 42

The following drugs should be avoided in BD during pregnancy:

Answer 42

DVP, carbamazepine | Congenital malformations, neural tube defects ## Footnote If risk of discontinuation outweighs risk of defect, could continue; supplement with folate + vitamin K

Question 43

Drugs that appear safe in pregnancy for BD include...

Answer 43

Lamotrigine AAP's - quetiapine, risperidone, aripiprazole, olanzapine Lithium (small risk in 1st trimester)

Question 44

This drug has the most evidence of suicide prevention in patients with BD... | What is the proposed mechanism?

Answer 44

Lithium; reduced risk of depressive relapse, impulsivity/aggressive behaviour, and requires long-term monitoring

Question 45

Important roles as a pharmacist in BD treatment include...

Answer 45

Screening for presence/history of mania Avoiding AD monotx Patient education, supporting adherence Appropriate dosing