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PR3153 FINALS > IC12 Bipolar Disorder > Flashcards

IC12 Bipolar Disorder Flashcards

1
Q

How does bipolar disorder usually manifest in males and females?

A

Manic episodes in males
Depressive episode in females

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2
Q

Describe bipolar disorder

A

lifelong cyclical mood disorder with a variable course, manifesting with recurrent fluctuations in mood, energy and behaviour

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3
Q

Which medications can induce mania in bipolar d/o? (8)

A
  1. Drugs of abuse (alcohol intoxication, hallucinogens)
  2. Drug withdrawal states (alcohol, barbituates, benzodiazepines)
  3. Antidepressants (MAOIs, TCAs, 5-HT and/or NE and/or DA reuptake inhibitors, 5HT antagonists)
  4. DA-augmenting agents (CNS stimulants like amphetamines, cocaine; sympathomimetics like DA agonists, releasers and reuptake inhibitors)
  5. NE-augmenting agents (α2-antagonists, β-agonsits, NE reuptake inhibitors)
  6. Steroids (anabolic, adrenocorticotropic hormone, corticosteroids)
  7. Thyroid preparations (T3 or T4 (T3 stronger))
  8. OTC decongestants (pseudoephedrine)
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4
Q

What is the key clinical feature of bipolar d/o?

A

History of mania or hypomania not caused by any other conditions or substances

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5
Q

What are the symptoms of mania? (7)

A
  • Abnormal and persistently elevated, expansive or irritable mood (DIGFAST acronym)
  • D: Distractabile and easily frustrated
  • I: Irresponsible and uninhibited erratic behaviour (resentful of actions when high)
  • G: Grandiosity and inflated self-esteem
  • F: Flight of ideas (say things faster than we can write, too many thoughts)
  • A: Activity increased (cannot sit still, psychomotor agitation)
  • S: Sleep need decreased, feel well rested after only 3h, don’t feel the need to sleep (not insomnia)
  • T: Talkativeness (difficulty in interpreting)
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6
Q

When is a patient considered to be having a manic episode in relation to the 7 DIGFAST mania symptoms?

A

at least 3 symptoms plus the elevated or expansive mood

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7
Q

What constitutes major depressive, manic and hypomanic states in terms of duration of symptoms, according to DSM-5?

A

major depressive if sx > 2 weeks
manic if sx ≥ 1 week (functional impairment)
hypomaniac if sx ≥ 4 days (no functional impairment)

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8
Q

What does Bipolar I and Bipolar II refer to?

A

Bipolar I refers to mania +/- depressive episodes
Bipolar II refers to hypomania + depressive episodes

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9
Q

Which labs are relevant to test for (general assessment) for bipolar d/o? (5)

A
  1. FBC, urea, electrolytes, creatinine, LFTs, TFTs → if liver fx not good, drugs can cause toxicity
  2. pregnancy test → many mood stabilisers are teratogenic like valproate and lithium
  3. urine toxicology → patients may lie, assess for barbituates, benzodiazepines, cocaine, ketaminoids (standard 23 items)
  4. exclude other general medical conditions or substance-induced or withdrawal symptoms
  5. test for HLA-B*1502 genotype mandated prior to starting carbamazepine
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10
Q

What are the 2 main treatment goals for bipolar d/o?

A
  • Reduce frequency, severity and duration of mood episodes
  • Prevent suicide
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11
Q

What are non-pharmacological management options for bipolar d/o? (5)

A
  1. Psychoeducation about the disorder, treatment and monitoring for the patient and the caregiver (recognise early signs and symptoms of mania and depression, keep a list of actions that they usually resort to (eg. excessive spending))
  2. Psychotherapy (individual, group or family) (iCBT or behavioural couples therapy
  3. Stress reduction techniques (relaxation therapy)
  4. Sleep hygiene (regular bedtime and awake schedule)
  5. Nutrition and exercise
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12
Q

What two main classes of drugs can be given for bipolar d/o and what symptoms do they help with?

A
  1. Benzodiazepines (help pt relax and sleep)
  2. Mood stabiliser
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13
Q

When should mood stabilisers be started and why?

A

start early as they usually take 3-5 days to work

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14
Q

Which 3 drugs can be given for mania in BPD?

A
  1. Antipsychotics (risperidone gd for severe mania)
  2. Lithium
  3. Valproate

(look at antipsychotics over lithium first in mania due to renal toxicity, hypothyroidism SE and DDIs)

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15
Q

Which 3 drugs can be given for bipolar DEPRESSION?

A
  1. Lithium (1st line for maintenance, relapse and suicide prevention)
  2. Antipsychotics (use quetiapine alone or combination of olanzapine + fluoxetine (olanzapine alone is not as good for MDD))
  3. Lamotrigene (no anti-manic properties)
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16
Q

When should valproate not be used?

A

female patients of childbearing potential < 55 years old due to risk of fetal malformation

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17
Q

What are the side effects of lithium? (9)

A
  1. hypothyroidism
  2. tremors
  3. polyuria
  4. ECG changes
  5. nausea
  6. weight gain
  7. fatigue
  8. cognitive impairment
  9. diabetes insipidus
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18
Q

What circumstances can increase lithium levels? (5)

A

STAND
1. sodium depletion
2. thiazide diuretics
3. ACEi/ARBs
4. NSAIDs
5. dehydration (salt-restricted diets)

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19
Q

What is the target serum level for valproate and how long does it take to reach steady state?

A

50-125 mcg/mL
3-5 days

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20
Q

What are the prominent side effects of valproate? (4)

A
  1. Decreased platelets
  2. Pancreatitis
  3. SJS/TEN
  4. Weight gain
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21
Q

Which prominent drug interaction should be taken note of with valproate?

A

Lamotrigene (risk of SJS)

22
Q

What is the target serum level for carbamazepine?

A

4-12 mcg/mL

23
Q

What is the most prominent side effect of carbamazepine?

A

SJS/TEN

24
Q

Which prominent drug interaction should be taken note of with carbamazepine?

A

Clozapine (risk of agranulocytosis)

25
Q

Which side effects are less prominent with lamotrigene?

A

Sedation and weight gain

26
Q

What are antipsychotics MOA in bipolar d/o?

A

D2 antagonism
SGA: 5-HT(2A) antagonism also

27
Q

What should be monitored for if antipsychotics are used in pregnancy?

A

monitor for gestational diabetes

28
Q

Which serum levels constitute mild lithium toxicity and what are the relevant side effects to remember?

A

1.5-2.0 mEq/L
GI: n&v
CNS: lethargy, confusion, coarse hand tremors

29
Q

Which serum levels constitute moderate lithium toxicity and what are the relevant side effects to remember?

A

2.0-2.5 mEq/L
GI: severe nausea and vomiting

30
Q

Which serum levels constitute severe lithium toxicity and what are the relevant side effects to remember?

A

> 3.0 mEq/L
CNS: coma

31
Q

How is lithium eliminated?

A

100% cleared by the kidneys (not affected by liver)

32
Q

What can prolong lamotrigene’s half life?

A

Hepatic impairment and co-administration with valproate

33
Q

What is different about hepatic metabolism of carbamazepine?

A

Induces its own metabolism and that of other drugs (autoinduction)

34
Q

Lithium monitoring parameters (5)

A

FBC
renal panel and electrolytes
TFTs
metabolic (FBG, lipids, BMI)
TDM

35
Q

Valproate monitoring parameters (4)

A

FBC
LFTs
metabolic (FBG, lipids, BMI)
TDM

36
Q

Carbamazepine monitoring parameters (4)

A

FBC
LFTs
renal panel and electrolytes
TDM

37
Q

Lamotrigene monitoring parameters (3)

A

FBC
LFTs
renal panel and electrolytes

38
Q

SGA monitoring parameters (1)

A

metabolic (FBG, lipids, BMI)

39
Q

Patients should undergo physical exam before starting all drugs in the table. What should physical exam entail?

A

ECG, pregnancy test (counsel on proper contraception, especially for VPA) and urine toxicology

Watch out for SJS/TEN and ensure HLA*B1502 allele genotyping before carbamazepine initiation

40
Q

Which electrolyte should be monitored for in the renal panel?

A

watch out for low sodium (risk for lithium toxicity)

41
Q

How should TDM for lithium be conducted?

A

Take samples 12h after prev dose, for 5-7 days after initiation or change in dose

42
Q

How should TDM for valproate be conducted?

A

Through sample needed
Take for at least 2-3 days after initiation or change in dose

43
Q

How should TDM for carbamazepine be conducted?

A

Through sample needed
Takes 2-4 weeks to reach steady state (due to autoinduction)

44
Q

What should you do if mania has not responded within 2 to 4 weeks with an established first-line mood stabiliser

A

consider augmenting with a second first-line agent or switching to a SGA (like olanzapine)

(reserve carbamazepine for after failing all of the above)

45
Q

What can be used in treatment-resistant mania or depression?

A

Electroconvulsive therapy (ECT) can help to reduce manic or depressive symptoms in severe or treatment-resistant mania or depression

(omit lithium, anticonvulsants and benzodiazepines at least 12h before ECT)

46
Q

What is indicated for recurrent depressive episodes in bipolar d/o?

A

long-term lithium

47
Q

What should be avoided in bipolar disorder with rapid cycling (≥ 4 mood episodes per year)?

A

Avoid antidepressants or stimulants

48
Q

What considerations have to be made for pregnant patients? (3)

A
  1. Pregnancy should be planned in consultation with a psychiatrist and obstetrician to weigh risks and benefits
  2. Avoid valproate in pregnancy
  3. Consider ECT for severe mania
49
Q

What considerations have to be made for pts with liver impairment?

A

Consider lithium

50
Q

What considerations have to be made for pts who are aggressive or violent?

A

Optimise dose and levels of existing lithium or valproate and consider adding antipsychotic

PR3153 FINALS (8 decks)

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