General Principles of Bipolar Treatment Flashcards
Bipolar treatment categories involve…
3 categories
Acute mania treatment
Acute depression treatment
Maintenance treatment
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)
- Review general principles and assess medication status; adherence
- Initiate or optimize therapy
- Add-on or switch therapy
- Monitor/Maintain
When assessing a patient in an acute manic episode, we need to assess some factors, such as…
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?
In acute mania treatment, we should discontinue…
AD’s
Stimulants (caffeine, amphetamines, CS)
Alcohol
Nicotine
We need to rule out other causes when assessing acute mania, such as…
Prescribed medication
Illicit-drug use/abuse
Endocrine/neurological disorders
1st line monotherapy indicated for acute mania treatment include…
Mood stabilizers, AAP’s; how many respond, and when?
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
1st line combinations for acute mania treatment include…
___ + ___
Lithium/DVP + Quetiapine/risperidone/asenapine/aripiprazole
Combo therapy for acute mania is recommended when…
A response is needed faster
Patients with a previous history of partial response to monotherapy, or more severe manic episodes
In general, combination therapy is preferred to mood stabilizer monotherapy for acute mania treatment, because…
On average, about ~20% more patients will respond to combination therapy
Greater efficacy of combination compared to lithium/DVP alone
Some second-line treatment monotherapy options for acute mania include…
Olanzapine
Carbamazepine
Ziprasidone
Haloperidol
Some second-line combination options for acute mania include…
Olanzapine + lithium/DVP
Lithium + DVP
Lithium is preferred over divalproex for individuals who…
Display classical euphoric grandiose mania
Few prior episodes of illness
Family history of BD, especially with family history of lithium response
Divalproex is preferred over lithium for individuals who…
Have had multiple prior episodes
Predominant irritable/dysphoric mood, and/or comorbid substance abuse
History of head trauma
Carbamazepine may be a better option for acute mania treatment in patients with specific factors, such as…
Hx of head trauma or neurologic symptoms
Comorbid anxiety/substance abuse, or schizoaffective presentations with mood-incongruent delusions
Patients with mixed feature BD should use…
DVP +/- AP’s, especially effective in combination
After starting a 1st line agent for acute mania, some therapeutic response is expected within…
1-2 weeks
Switching therapy or add-on strategies in acute mania should be considered when…
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
ECT may be recommended in mania treatment, when…
Mania is refractory
Agents NOT recommended for acute mania and should be avoided include…
Gabapentin
Lamotrigine
Omega 3 fatty acids
Topiramate
With BD1 depression, we need to assess patient factors such as…
Severity of depression - risk of suicide/self-harm behaviour
Ability to function and adhere to treatment
Previous treatments
Consider appropriate treatment as well
With BD1 depression, we should discontinue…
Stimulants
Nicotine, caffeine
Drug/alcohol use
With BD1 depression, we need to rule out…
Symptoms due to alcohol/drug use, medications, and other treatments
General medical condition
1st line therapies for BD1 depression include…
Quetiapine and/or lithium
Lurasidone monotx, or with Lithium/DVP
Lamotrigene monotx or adj
Depressive symptoms in BD1 may take ____ for initial improvement to be observed…
4-6 weeks
No response - consider switch/add-on
2nd line monotherapy for BD1 depression includes…
Divalproex
2nd line add-on therapy/combo for BD1 depression includes…
Adjunctive SSRI/bupropion, added to lithium/DVP, or AAP
Olanzapine-fluoxetine
ECT could be considered for BD1 depression, when…
Treatment refractory patients
Rapid response needed
Agents that are NOT recommended and should be avoided for acute bipolar depression include…
Antidepressant monotx
Aripiprazole monotx
Ziprasidone
Lamotrigine, + folid acid
Mifepristone adj.
AD has safety concern of mood switching when not used with mood stabilizer
Good lithium levels for acute bipolar depression are…
0.8-1.2 mmol/L
Effective maintenance treatment of bipolar, helps to…
Reserve cognitive impairment
Preserve brain plasticity
Improved prognosis + minimization of illness progression
Even with treatment, recurrence rates are around…
19-25%
Risk factors for recurrence of BD1 episodes include…
Younger age at onset, more previous episodes
Comorbid anxiety + substance use
Rapid cycling
Psychotic features
The only 1st line psychosocial intervention for maintenance therapy of BD that should be offered to all patients is…
Psychoeducation
With maintenance of bipolar, we want to reassess the following continuously:
Medications effective in acute phase (usually effective in maintenance phase)
History of illness, comorbidities
Predominant illness polarity
1st line monotherapy options for BD maintenance therapy to prevent any mood episodes include…
Think of our mood stabilizers, and that acute options are usually good for maintenance as well
Lithium
Quetiapine
Divalproex
Lamotrigine
Asenapine
Aripiprazole
If patient’s responded well to 1st line tx during acute episode, recommend to continue that agent
1st line combination options for BD maintenance therapy to prevent any mood episodes, include…
Lithium/DVP + Quetiapine, or aripiprazole
Second-line treatment options for BD maintenance therapy, to prevent any mood episodes include…
Similar to second line options for acute treatments
Olanzapine
Risperidone monotx + adj.
Carbamazepine
Low dose paliperidone
Lithium/DVP + lurasidone/ziprasidone
Third-line treatment options for BD maintenance therapy may include…
Aripiprazole + lamotrigine
Clonzapine (adj)
Gabapentin (adj)
Olanzapine + fluoxetine
Usually not used due to lack/lower level of evidence
These would be the extremes of patients where all other options have been exhausted
With antipsychotic usage in maintenance therapy, we could consider tapering off after ____ to…
6 months - reduce polypharmacy
Continuing for the 6 months is beneficial for maintenance therapy
For mixed episodes of BD, we should discontinue…
Antidepressants, as they will worsen the overall condition
Monotherapy and combination therapy recommended for mixed episodes of BD include…
Atypical antipsychotic +/- Lithium/divalproex
The following drugs should be avoided in BD during pregnancy:
DVP, carbamazepine
Congenital malformations, neural tube defects
If risk of discontinuation outweighs risk of defect, could continue; supplement with folate + vitamin K
Drugs that appear safe in pregnancy for BD include…
Lamotrigine
AAP’s - quetiapine, risperidone, aripiprazole, olanzapine
Lithium (small risk in 1st trimester)
This drug has the most evidence of suicide prevention in patients with BD…
What is the proposed mechanism?
Lithium; reduced risk of depressive relapse, impulsivity/aggressive behaviour, and requires long-term monitoring
Important roles as a pharmacist in BD treatment include…
Screening for presence/history of mania
Avoiding AD monotx
Patient education, supporting adherence
Appropriate dosing
