IC12 Bipolar Disorder Flashcards
What are some substances/drugs that induces mania? Which NTM are increased?
substances/medications esp. by ↑NE & DA, e.g. antidepressants, alcohol, drug withdrawal, DA-augmenting agents, NE-augmenting agents, steroids, thyroid preparations e.g. levothyroxine, pseudoephedrine
What medical conditions can induce mania?
other medical conditions e.g. strokes, head injuries, multiple sclerosis, Cushing’s disease, hyperthyroidism (mania), hypothyroidism (depression)
Is bipolar disorder curable?
no
What are the symptoms of Mania in bipolar disorder? How many to diagnose someone with mania?
Manic Symptoms:
- Abnormal & persistently elevated / expansive / irritable mood
-
DIGFAST (At least 3sx + elevated/expansive mood / 4sx if the mood is irritable)
o Distractable
o Irresponsible / impulsive
o Grandiose
o Flight of ideas
o Activity ↑
o Sleep need ↓
o Talkativeness
What is the duration of the different types of mood episodes of bipolar? Include whether there is functional impairment.
Mood episodes/duration:
- Depression (>2wks, functional impairment)
- Mania (>1wk, functional impairment)
- Hypomania (>4days, NO functional impairment, no psychosis)
Bipolar I = Depression + Mania
What lab tests need to be done to diagnose one with bipolar disorder? (optional)
Lab tests to do when diagnosing:
- FBC (infection, anemia)
- U/E/Cr (kidney function)
- LFTs (all mood stabilizers go through the liver except for lithium)
- TFTs
- ECG (lithium, antipsychotics can cause arrythmias)
- Fasting blood glucose
- Pregnancy test (many mood stabilizers are teratogenic esp. valproate and lithium)
- Urine toxicology (substance abuse)
What is the goal of treatment for bipolar disorder?
- Goal: Reduce frequency, duration, severity (and suicidality) of mood episodes
What are the possible non-pharm for bipolar disorder?
Non-pharmacological:
- Recognises early S&S using journal/diary
- Psychotherapy
- Stress reduction techniques
- Sleep hygiene
During acute phase, what meds should be given? Generally.
start BZD + mood stabilizers
What is the adjunctive therapy given to patients with bipolar disorder in the acute phase?
How does it help?
When to stop adjunctive meds?
Adjunctive Treatment: Benzodiazepines PRN during acute phase. Omit dose for ECT.
- Help patient relax and sleep
- Onset within hrs
- Taper off when condition improves and mood stabilisers are optimised
For bipolar mania, what are the possible meds that can be given? Order them
For mania (in order)
- Antipsychotic e.g. olanzapine, quetiapine, risperidone, aripiprazole, haloperidol
- Lithium (1st line for maintenance & relapse/suicide prevention) –> if poorly tolerated, then consider olanzapine, quetiapine, valproate
- Valproate (last line)
- Consider combining lithium and/or valproate +/- antipsychotics
For bipolar depression, what are the meds that can be given? Order them.
For depression (in order)
- Lithium (1st line for maintenance & relapse/suicide prevention)
- Quetiapine (but usually use this before lithium)
- Olanzapine + fluoxetine combination
- Lamotrigine
Which meds are usually for maintenance?
Maintenance phase:
- Lithium (1st line)
- Olanzapine, aripiprazole, quetiapine (all are off label use)
How to manage no response in 2-4wks?
- IF no response in 2-4wks
o Switch to another 1st line agent e.g. SGA olanzapine
IF severe/treatment resistant, then what?
- IF severe/treatment resistant
o ECT
o Ensure NO Li, anticonvulsants, BZD 12hrs before starting ECT
IF recurrent depressive episodes, then what?
- IF recurrent depressive episodes
o Long term lithium, quetiapine, olanzapine + fluoxetine –> counsel on risk of suicidality
IF bipolar disorder with rapid cycling, then what?
- IF bipolar disorder with rapid cycling (no normal periods)
o AVOID antidepressants (including combi drugs)
o USE lithium, lamotrigine or valproate
For pregnancy, liver impairment, suicidal/aggressive/violent, what meds should be given or avoided?
Special population:
- Pregnancy
o AVOID valproate
o USE quetiapine, olanzapine, risperidone
o ECT if severe symptoms - Liver impairment:
o USE lithium - Suicidal:
o Use lithium - aggressive / violent:
o USE lithium/valproate +/- anti-psychotics
What are the ADRs of Lithium? When do they usually occur (at what Li levels)?
1) Acne
2) Fine to coarse tremors
3) Polyuria
4) Hypothyroidism
5) ECG changes
6) Nausea
7) Weight gain
8) Fatigue
9) Cognitive impairment
10) Diabetes insipidus
SE more common when >0.8mEq/L
What things cause Lithium toxicity?
Li tox with (STAND-up)
- Sodium ↓
- Thiazides
- ACEi/ARBs
- NSAIDs
- Dehydration
What increases Li elimination?
Caffeine and theophylline
How is lithium cleared?
not affected by liver –> 100% cleared by kidneys
What to monitor for when using Lithium?
Monitoring:
Physical exam (pregnancy test, ECG), FBC, renal panel & electrolytes e.g. Ca, TFTs, FBG, lipids, BMI, TDM (serum Li levels)
What can lithium be used for?
Acute, long term maintenance, bipolar mania and depression, suicide prevention
Which SGA can be used for mania, depression and long term maintenance?
mania
–> reduce agitation
–> all can use (haloperidol, quetiapine, olanzapine, risperidone)
Depression
–> quetiapine, olanzapine + fluoxetine
Long term maintenance: all are off label e.g. Aripiprazole, Quetiapine, Olanzapine
What are the pros of antipsychotics compared to other mood stabilizers?
- quetiapine, olanzapine, risperidone safe in pregnancy but look out for gestational diabetes
- acute overdose safer than lithium
What are the cons and ADRs of antipsychotics?
- Haloperidol –> don’t help with depression & EPSE
- Quetiapine –> orthostatic hypotension
What is lamotrigine mainly useful for in bipolar disorders?
Bipolar depression
What is the precaution of using lamotrigine?
1) SJS risk with valproate –> due to longer t1/2 with valproate
What are the pros of lamotrigine?
Pros:
1) NOT as drowsy/sedating as other mood meds
2) does NOT cause weight gain
3) safe in pregnancy
What is the con of lamotrigine?
Cons:
- Don’t have anti-maniac effects
What is the place in therapy for lamotrigine?
2nd line, pregnancy, bipolar disorder with rapid cycling
What are the ADRs of sodium valproate?
1) Hepatotoxicity
2) SJS/TEN
3) Pancreatitis
4) Thrombocytopenia
5) weight gain
What are the precautions we need to take when using valproate?
1) Risk of SJS with lamotrigine
2) Teratogenic (avoid in pregnancy & women of child-bearing potential)
When do we use carbamazepine?
Very last line, don’t choose in exams:)
What are the interactions that CBZ has?
1) CYP1A2, 2C9, 3A4 inducer
2) Autoinduction
3) Agranulocytosis with clozapine
What mood episode is valproate usually used for in patients with bipolar disorders?
Mania
