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3153 CNS - nat > ic13 bipolar disorder > Flashcards

ic13 bipolar disorder Flashcards

1
Q

what is bipolar disorder

A

lifelong cyclical mood disorder, fluctuating between mania and bipolar depression

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2
Q

why must bipolar disorder be treated urgently? (3 points)

A

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

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3
Q

causes of bipolar disorder (6 points)

A

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

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4
Q

clinical presentation of bipolar mania

A

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

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5
Q

Which drug has lowest risk of agranulocytosis?

A

Lithium

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6
Q

What to do when patient is agitated, or cannot sleep?

A

Give benzodiazepines, together with mood stabilisers

Lorazepam (first choice), Clonazepam, Midazolam

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7
Q

What are examples of mood stabilisers

A

Lithium

Sodium valproate
Lamotrigine
Carbamazepine

Antipsychotics
Quetiapine
Olanzapine
Risperidone
Aripiprazole

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8
Q

which antipsychotics can be used for bipolar mania?

Which can be used for bipolar depression?

A

mania: all antipsychotics

depression: Quetiapine, fluoxetine + olanzapine only

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9
Q

What is the onset of mood stabilisers

A

3-5 days

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10
Q

best drug for suicide risk

A

Lithium, but highest risk of relapse if patient stop taking

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11
Q

Counselling points for mood stabilisers

A

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)

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12
Q

What SGA can be used for both bipolar mania and depression

A

aka which SGA can be used for depression (cos mania can use any SGA)

Olanzapine (with Fluoxetine)
Quetiapine

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13
Q

What mood stabilisers can be used for both mania and depression?

A

Lithium (first line)

SGA

Sodium Valproate (not preferred due to teratogenicity)

Carbamazepine (not preferred cos need do genotyping)

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14
Q

Which mood stabiliser should not be offered to women of child bearing age

A

sodium valproate

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15
Q

What should be done when starting on Lithium?

A

TDM
Target level: 0.6 - 1.0mEq/L
Take samples 12hrs after previous dose, 5-7 days after initiation

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16
Q

What is the maintenance concentration of Lithium

What is the dose that will cause death

A

0.6 - 1.0 mEq/L

> 3 mEq

17
Q

How is Lithium toxicity caused?

A

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

18
Q

Side effects of Lithium (7 points)

A

Fine to coarse tremors
Polyuria / Frequent urination
Hypothyroidism (do TFT)
ECG changes
Nausea, vomiting
Weight gain
Diabetes insipidus (pee alot and feel thirsty)

19
Q

Monitoring for Lithium (5 points)

A

Renal panel (cos cleared by kidneys)

Serum Lithium level

Thyroid function test (can cause
hypothyroidism)

Metabolic (FBG, Lipids, BMI)
Can cause weight gain

ECG

20
Q

TDM of Sodium Valproate (target level, when to take sample)

A

Trough sample needed, take trough sample before first dose of the day

Target: 50 - 125mcg/mL

21
Q

What should not be used with Sodium Valproate? Why?

A

Dont combine with Lamotrigine

SV decreases breakdown of Lamotrigine, increase Lamotrigine concentration and risk of SJS / TEN

22
Q

Drugs with SJS/TEN risk

A

Antiepileptics, example:
Carbamazepine
Lamotrigine
Sodium Valproate

23
Q

Side effects of Valproate (5 points)

A

SJS / TEN
Pancreatitis
Weight gain
Thrombocytopenia (decreased platelets)
Hepatotoxicity in children

24
Q

Monitoring for Sodium Valproate (4 points)

A

FBC (thrombocytopenia)
LFT (cos of hepatotoxicity)
Metabolic (due to weight gain)
TDM

25
Q

What must be done before initiation of Carbamazepine

A

genotyping HLAB 1502

26
Q

Side effects of Carbamazepine (3 points)

A

SJS / TEN (do genotyping)
Hyponatremia
Agranulocytosis

27
Q

what drug cannot be used with Carbamazepine? (2 points)

Why?

A

Clozapine
Both have risk of agranulocytosis

Lithium
Carbamazepine has risk of hyponatremia, will increase toxicity of Lithium

28
Q

which drug only indicated for mania only?

Which drug only indicated for bipolar depression?

A

Mania only: Valproate

Depression only: Lamotrigine

29
Q

Benefit and risk of Lamotrigine compared to SGA

A

Better for SE than other -pines, Lithium (lesser metabolic SE, weight gain)

Risk of SJS / TEN, only for bipolar depression

30
Q

Which SGA are indicated for bipolar depression?

A

FOQ

Olanzapine (combination with Fluoxetine)
Quetiapine

31
Q

Monitoring for SGA (5 points)

A

ECG (risk of QTc prolongation)
Fasting blood glucose
Lipid panel
BMI
EPSE
FBC (agranulocytosis)

32
Q

Side effects of SGA (3 points)

A

EPSE
Metabolic side effects eg. Weight gain
QTc prolongation

33
Q

What drugs used to treat bipolar disorder will cause weight gain and hence need to monitor bmi? (3 points)

A

Lithium
Sodium Valproate
SGA “-pines”

34
Q

When to change medication in bipolar disorder

A

If patient does not respond after 2 weeks

35
Q

What is rapid cycling?

What should be done? (2 points)

A

More than 4 mood episodes in a year

Avoid all antidepressants

Optimise mood stabiliser treatment

36
Q

What should be given for pregnancy

A

Use SGA Quetiapine, Risperidone, Olanzapine
Watch for gestational diabetes

Avoid Sodium Valproate

37
Q

What to give for patients with liver impairment

A

Lithium

38
Q

What to give for aggressive, violent patients?

A

Use IM Antipsychotic (Risperidone), then use oral Antipsychotic

3153 CNS - nat (11 decks)

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