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53 Finals > IC13 Bipolar Disorder > Flashcards

IC13 Bipolar Disorder Flashcards

1
Q

describe bipolar disorder

A

Lifelong, cyclical mood disorder

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2
Q

Illness duration dominated by

A

depressive episodes (depressive state in bipolar is more depressive than in MDD)

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3
Q

pt with bipolar are more likely to…

A

commit suicide (15x more likely)

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4
Q

1st episode presentation

A

mania in males, depression in females

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5
Q

Type of delusions with bipolar mania

A

grandiose

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6
Q

primary cause of bipolar mania

A

drug induced - antidepressants (typically in the initial few days-2 weeks)

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7
Q

Medical conditions causing mania

A
  • CNS disorders (brain tumor, stroke, head injuries, multiple sclerosis)
  • Endocrine or hormonal dysregulation: Cushing’s disease (increase cortisone), hyperthyroidism (increase TH → mania), hypothyroidism (decrease TH → depression)
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8
Q

Medications causing mania

A
  • Alcohol intoxication
  • Drug withdrawal states (alcohol, antidepressants, barbiturates, benzodiazepines, opioid)
  • Antidepressants
  • DA-augmenting agents (CNS stimulants : amphetamines)
  • NE-augmenting agents (beta-agonist, NE reuptake inhibitors)
  • Steroids
  • Thyroid preparations
  • Pseudoephedrine
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9
Q

Key feature of bipolar disorder is…

A

hx of mania/hypomania not caused by any other conditions

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10
Q

Sx of mania

A

abnormal and persistently elevated/ irritable mood: D.I.G.F.A.S.T
- Distractibility
- Irresponsible (overindulgence)
- Grandiose
- Flight of ideas
- Agitation
- Sleep reduced
- Talkativeness

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11
Q

Manic episode is defined as

A

at least 3 sx + elevated/expansive mood (or 4 sx if mood is only irritable)

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12
Q

mania vs hypomania

A
  • Manic: sx ≥1 week (functional impairment)
  • Hypomanic: sx ≥4 days (no functional impairment, no psychosis)
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13
Q

Important assessment before starting pt on meds

A
  • Mental State Exam (MSE) to assess suicidal/homicidal ideations and risks
  • Labs and other investigations (FBC, U/E/Cr, LFTs, TFTs, pregnancy): to exclude other medical conditions
  • PGx: HLA-B1502 genotype test mandatory before starting carbamazepine
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14
Q

Goals of tx

A

reduce frequency, severity & duration of mood episode, prevent suicide

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15
Q

Non-pharm

A
  • Education: recognise early S/S of mania and depression
  • Psychotherapy/CBT — only when pt is in listening mood
  • Stress reduction techniques
  • Sleep hygiene
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16
Q

Adjunct tx for mania

A

Short course (~3-5 days) PRN benzodiazepine
- to help pt relax and sleep, taper off when condition improved and mood stabiliser optimised

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17
Q

when to start mood stabilisers

A

start ASAP dont wait (can take tgt with BZD)

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18
Q

for bipolar mania, what mood stabilisers are used?

A

Lithium, valproate, FGA/SGA (Olanzapine, Quetiapine, Risperidone, Aripiprazole, Haloperidol)

19
Q

for bipolar depression, what mood stabilisers are used?

A

Lithium, SGA (quetiapine, olanzapine + fluoxetine), lamotrigine

20
Q

CI of valproate

A

pregnancy

21
Q

does lamotrigine treat mania?

A

no

22
Q

can antidepressant be used for bipolar depression? what combination?

A

yes only as combination: olanzapine + fluoxetine

23
Q

SE of lithium

A

(HPENT)
1. fine to coarse tremors
2. polyuria
3. HYPOTHYROIDISM
4. cardiac effects (ECG changes)
5. nausea
- weight gain, fatigue, cognitive impairment, diabetes insipidus (make too much urine)

24
Q

CL of lithium

A

not affected by liver, 100% cleared in the kidneys

25
Q

Sx of lithium toxicity (>1.5mEq/L)

A

GI SE: nausea, vomiting
CNS SE: lethargy, confusion, coarse hand tremors, slurred speech, coma

26
Q

Lithium DDI

A

STAND up
- Sodium depletion
- Thiazides
- ACEi/ARBs — severe increase in Li levels
- NSAIDs
- Dehydration

27
Q

SE of valproate

A

SJS/TEN, thrombocytopenia, pancreatitis, increase weight

28
Q

valproate and lamotrigine DDI

A

Risk of SJS with lamotrigine (valproate decrease CL of lamotrigine)

29
Q

SE of carbamazepine

A
  • SJS/TEN
  • Agranulocytosis with clozapine
30
Q

PK of carbamazepine

A

induces own metabolism and that of other drugs

31
Q

Lamotrigine SE

A
  • Less sedation and less weight gain than other drugs listed
  • Risk of SJS with valproate (lamotrigine half life increased in hepatic impairment and DDI with valproate)
32
Q

Lithium TDM

A

take samples 12hrs after previous dose. 5-7 days after initiation or change dose.

33
Q

valproate TDM

A

trough sample needed (sample drawn morning before 1st dose of the day). At least 2-3 days after initiation or change dose.

34
Q

carbamazepine TDM

A

trough sample needed (sample drawn morning before 1st dose of the day). At least 2-4 weeks to reach steady state (autoinduction effect)

35
Q

tests before starting mood stabilisers

A
  • pregnancy test (VPA)
  • SJS/TEN (lamotrigine, VPA, carbamazepine)
  • HLAB1502 (carbamazepine)
  • low Na/ renal panel (Li toxicity)
36
Q

Mx of recurrent depressive episides

A

long term Li+, quetiapine, olanzapine + fluxoetine

37
Q

Mx of disorder with rapid cycling (≥4 mood ep per year)

A

avoid antidepressants/ stimulants (worsen mania)
- optimise valproate, lithium

38
Q

choice of drug for pregnancy

A
  • avoid VPA
  • safe choice: quetiapine, olanzapine, risperidone
39
Q

choice of drug for liver impairment

A

Li+

40
Q

choice of drug for renal impairment

A

valproate

41
Q

choice of drug for suicidal behaviour

A

Li

42
Q

choice of drug for aggression/ violence

A

optimise dose of lithium or valproate, consider adding antipsychotics (IM antipsychotics first then switch to PO)

43
Q

evaluation of tx response

A

Monitor target sx (mood sx), compliance

53 Finals (10 decks)

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