ic13 bipolar disorder Flashcards
what is bipolar disorder
lifelong cyclical mood disorder, fluctuating between mania and bipolar depression
why must bipolar disorder be treated urgently? (3 points)
1) Depression in BP is more severe than MDD, many times to commit suicide
2) If left untreated, fluctuations will be more frequent until no more normal mood anymore
3) Has many differential diagnosis eg. ADHD, depression, going through puberty, hence need to escalate to hospital for diagnosis
causes of bipolar disorder (6 points)
Genetic
Induced by treatment eg. Antidepressants that increase NE and DA
Bupropion, SNRI, Mirtazapine, TCA (aka all except SSRI)
Can induce mania
CNS disorders eg. trauma, tumor
Hyperthyroidism (mania), hypothyroidism (depression)
Steroids eg. Cushing syndrome (too much cortisol), IV methylprednisolone
Pseudoephedrine
clinical presentation of bipolar mania
DIGFAST
Distracted
Disorganised thoughts, psychosis
Irresponsible
Dont conform to social behaviors
Over indulge in activities that are pleasurable eg. shopping
Grandiosity
Think that they are very powerful, related to deities
Flight of ideas
Talk very fast
Activity increased
Eg. working non stop
Sleep (decreased need)
Talkative
Duration: 1 week + cause functional impairment
Which drug has lowest risk of agranulocytosis?
Lithium
What to do when patient is agitated, or cannot sleep?
Give benzodiazepines, together with mood stabilisers
Lorazepam (first choice), Clonazepam, Midazolam
What are examples of mood stabilisers
Lithium
Sodium valproate
Lamotrigine
Carbamazepine
Antipsychotics
Quetiapine
Olanzapine
Risperidone
Aripiprazole
which antipsychotics can be used for bipolar mania?
Which can be used for bipolar depression?
mania: all antipsychotics
depression: Quetiapine, fluoxetine + olanzapine only
What is the onset of mood stabilisers
3-5 days
best drug for suicide risk
Lithium, but highest risk of relapse if patient stop taking
Counselling points for mood stabilisers
This medication can help to stabilise your mood
May cause drowsiness, take at bedtime
See doctor if have rashes (SJS), tremors, nausea (toxicity), fever or sore throat (agranulocytosis)
What SGA can be used for both bipolar mania and depression
aka which SGA can be used for depression (cos mania can use any SGA)
Olanzapine (with Fluoxetine)
Quetiapine
What mood stabilisers can be used for both mania and depression?
Lithium (first line)
SGA
Sodium Valproate (not preferred due to teratogenicity)
Carbamazepine (not preferred cos need do genotyping)
Which mood stabiliser should not be offered to women of child bearing age
sodium valproate
What should be done when starting on Lithium?
TDM
Target level: 0.6 - 1.0mEq/L
Take samples 12hrs after previous dose, 5-7 days after initiation
What is the maintenance concentration of Lithium
What is the dose that will cause death
0.6 - 1.0 mEq/L
> 3 mEq
How is Lithium toxicity caused?
STAND up
Sodium depletion
Most common
In sodium depletion, body tries to uptake Na+, will confuse and uptake Li+ instead
Thiazides
Diuretic, lose water and make blood more concentrated with Lithium
ACE / ARB
Worst out of all
Most common
Increases Li+ conc by 2-3x
NSAID
Dehydration
Side effects of Lithium (7 points)
Fine to coarse tremors
Polyuria / Frequent urination
Hypothyroidism (do TFT)
ECG changes
Nausea, vomiting
Weight gain
Diabetes insipidus (pee alot and feel thirsty)
Monitoring for Lithium (5 points)
Renal panel (cos cleared by kidneys)
Serum Lithium level
Thyroid function test (can cause
hypothyroidism)
Metabolic (FBG, Lipids, BMI)
Can cause weight gain
ECG
TDM of Sodium Valproate (target level, when to take sample)
Trough sample needed, take trough sample before first dose of the day
Target: 50 - 125mcg/mL
What should not be used with Sodium Valproate? Why?
Dont combine with Lamotrigine
SV decreases breakdown of Lamotrigine, increase Lamotrigine concentration and risk of SJS / TEN
Drugs with SJS/TEN risk
Antiepileptics, example:
Carbamazepine
Lamotrigine
Sodium Valproate
Side effects of Valproate (5 points)
SJS / TEN
Pancreatitis
Weight gain
Thrombocytopenia (decreased platelets)
Hepatotoxicity in children
Monitoring for Sodium Valproate (4 points)
FBC (thrombocytopenia)
LFT (cos of hepatotoxicity)
Metabolic (due to weight gain)
TDM
What must be done before initiation of Carbamazepine
genotyping HLAB 1502
Side effects of Carbamazepine (3 points)
SJS / TEN (do genotyping)
Hyponatremia
Agranulocytosis
what drug cannot be used with Carbamazepine? (2 points)
Why?
Clozapine
Both have risk of agranulocytosis
Lithium
Carbamazepine has risk of hyponatremia, will increase toxicity of Lithium
which drug only indicated for mania only?
Which drug only indicated for bipolar depression?
Mania only: Valproate
Depression only: Lamotrigine
Benefit and risk of Lamotrigine compared to SGA
Better for SE than other -pines, Lithium (lesser metabolic SE, weight gain)
Risk of SJS / TEN, only for bipolar depression
Which SGA are indicated for bipolar depression?
FOQ
Olanzapine (combination with Fluoxetine)
Quetiapine
Monitoring for SGA (5 points)
ECG (risk of QTc prolongation)
Fasting blood glucose
Lipid panel
BMI
EPSE
FBC (agranulocytosis)
Side effects of SGA (3 points)
EPSE
Metabolic side effects eg. Weight gain
QTc prolongation
What drugs used to treat bipolar disorder will cause weight gain and hence need to monitor bmi? (3 points)
Lithium
Sodium Valproate
SGA “-pines”
When to change medication in bipolar disorder
If patient does not respond after 2 weeks
What is rapid cycling?
What should be done? (2 points)
More than 4 mood episodes in a year
Avoid all antidepressants
Optimise mood stabiliser treatment
What should be given for pregnancy
Use SGA Quetiapine, Risperidone, Olanzapine
Watch for gestational diabetes
Avoid Sodium Valproate
What to give for patients with liver impairment
Lithium
What to give for aggressive, violent patients?
Use IM Antipsychotic (Risperidone), then use oral Antipsychotic
