Lecture 5 - Bipolar Disorder Flashcards
DSM-5 Manic episode criteria
Criteria A = atleast 1 week of abnormal, mood that is elevated, expansive or irritable
Criteria B = 3 of those
Criteria C = sig social/occupational impairment or req hosp or psychtic features
Criteria D = not results of substances or med conditions
DSM-5 Hypomanic episode criteria
Criteria A = atleast 4 days of abnormal, mood that is elevated, expansive or irritable
Criteria B = 3 of those
Criteria C = moderate social/occupational impairment
Criteria D = not results of substances or med conditions
Drug/Med induced mania from….
Alc intox
antidepressants
Drug withdrawal
Weed
Steroids
Thyroid meds
Caffeine
DA-augmenting agents
NE-augmenting agents
Hallucinogens
OTC weight loss/decongestants
Bipolar I Disorder
Manic episode
+/- major depressive episode or HYPOmanic episode
Bipolar II Disorder
Hypomanic episode AND major depressive episode
no history of manic episode
Bipolar Specifies
Mixed features
Rapid cycling
Psychotic features
What are mixed features
full criteria met for manic or depressive episode in addition to 3 features of the other
What is rapid cycling
at least 4 separate episodes in the last 12 months
What are Psychotic features
delusions or hallucinations present
Kindling effect
acceleration of episode frequency with each episode becoming more difficult to treat
Acute Mania, Manic Episode TXM
1st = VPA, SGA, Lithium
2nd = CBZ or FGA
Severe or psychotic symptoms = Lithium or VPA + SGA
Acute Mania, Manic w/ Mixed Features TXM
1st = SGA, VPA, CBZ
SGA used as mono or in combo w/ mood stabilizers
Avoid antidepressants, Lithium doesnt work well mixed features
Acute Mania Considerations
Antidepressants = Taper or D/c
Benzo = used short term, avoid SUD
Acute Depression, Bipolar I Txm
SGA = Qutiapine, Lurasidone, Olanzapine/fluoxetine
Lithium, Lamotrigine
Acute Depression, Bipolar II TXM
Quetiapine**
Lurasidone
Cariprazine
Olanzapine/Fluoxetine
Acute Depression, Considerations
D/c if mixed symptoms
Always use with mood stabilizer
Can worsen some symptoms
Maintenance therapy Bipolar
SGA preferred over FGAs
Least number of meds if possible
Goals: achieve milder degree of mood instability
Continuation Phase Bipolar
optimize txm, prevent ADR, ensure adherence and prevent polarity switch or relapse
continue acute txm 2-4 months following response
Maintenance therapy meds
Lithium
LAM = takes 6-7wks to titrate up so not used for acute txm
VPA
CVZ
SGA
Lithium Monitoring Acute mania lvls
0.8 - 1.2 mEq/L
Lithium monitoring maintenance lvls
0.6-1 mEq/L
Lithium lvls 1.5-2 will cause….
N/V/D, drowsiness, muscle weakness, coarse tremor (cant hold pen to write name)
get more severe the higher the lvls are
How often should you do Lithium monitoring
12hrs after dose (usually given at night)
Steady state after ~ 5 days
1st order linear kinetics ( dble dose = conc double)
Lithium dosing info
start low divided doses to dec side effects
change to QHS to reduce polyuria and improve adherence
Lithium CI
Dehydration
Sodium depletion
unstable renal or CV disease
dont use acute renal failure and ESRD
** Diuretics**
Lithium place in therapy
Dec risk of suicidality
maintenance therapy (mania/depression)
few weeks for mania onset of action, > 1 month depression max effect
Ebstein’s anomaly
inc risk of fetal malformations w/ Lithium
Lithium ADE
75% can experience but most can be managed, such as taking in evening
dry mouth = stay hydrated n suck on candy
weight gain = 4-6kg
Check TSH lvls
Serious ADE of Lithium
Acute kidney injury
Chronic kidney disease
AV block or conduction issues
Bradyarrhytmia
Brugada syndrome = sudden cardiac death
Lithium DI info
avoid NSAIDs
ACEi/ARB can inc Li
Avoid Thiazides, others OK with caution
Lithium Monitoring Parameters
Renal function
TSH
ECG ( over 40yrs old)
Serum drug conc
Lithium counseling
Avoid excessive caffeine or abrupt changes in salt intake
Maintain adequate hydration, avoid dehydration
Report sign of Lithium toxicity (N/V/D/ Tremor)
Avoid OTC NSAIDs
Valproic Acid Dosing
No target dose, but titrate so control mania without significant effects
** Dosing forms not interchangeable **
Valproic Acid Monitoring lvls
Target = 50-125 mcg/mL
Maintenance: > 50mcq/mL
> 150 - inc adverse effects
Trough serum conc 3-5 days after initial dose or change in dose
Valproic Acid CI
Hepatic disease/dysfunction
Hyperammonemia
Pregnancy when used for migraines (but can use for other indications w/ caution)
hepatoxicity box warning
Valproic Acid Adverse effects
SJS/TENS
Pancreatitis ~ 5%
Hepatotoxicity if LFT > 3ULN intervene
Hyperammonemia
Thrombocytopenia
Common SE Valproic Acid
Alopecia
Weight gain ~ 6-8kg
Dizziness, Sedation, Nausea
toxicity = ataxia, tremor, CNS depression
Valproic Acid DDI
Carbapenem Antibiotics = dec VPA lvls, danger if used seizures
Lamotrigine = inc lamotrigine lvls
Phenytoin = can inc or dec
Warfarin = inc warfarin
Valproic Acid Monitoring parameters
CBC
LFTs
Serum drug conc
Valproic Acid counseling
Take same time every day
don’t chew, crush,spit ER
** Rarely, may cause damage to liver or pancreas **
** report unusual bleeding or bruising to provider **
Carbamazepine Dosing
Carbamazepine Place in therapy
Comorbid SUD or neurologic conditions
anti-kindling properties
Bipolar Disorder II
Carbamazepine have high risk of…
SJS/TEN…avoid if positive HLA-B*1502 allele
Test asian ppl
Carbamazepine auto induction
begins after 3-5 days** and is complete 3-5wks after stable dose maintained
obtain serum conc 4 weeks after initiation to adjust dose
test drug lvls 4 weeks out due to auto induction
Carbamazepine CI and warmings
CI = Bone marrow suppression
Boxed awning = SJS/TEN, Aplastic anemia and agranulocytosis
Carbamazepine Adverse Effects
Rare = rash, hyponatremia/SIADH, leukopenia
Fatal = SJS/TEN, agranulocytosis, aplastic anemia, thrombocytopenia, hectic failure
common = generally well tolerated (N/V/Dizziness)
Carbamazepine n osteoporosis
Prone due to auto induction, may inc Vit D metabolism leading to low lvls
Monitor BMD if pt is on therapy for > 5yrs
Carbamazepine DI
CYP3A4 or CYP1A2
Clozapine = dec serum conc, enhanced myelosuppressive effects
Grapefruit = inc CBZ lvls
hormonal contraception = dec effectiveness
Carbamazepine Monitoring
CBC = 2 wks for 2 month, then Q4-6 month
LFTs = 2wks for 2 months, then Q4-6 month
Electrolytes = baseline, 2wk, annually
Rash development, HLA-B*1502 if asian
Carbamazepine counseling
Grapefruit can inc conc
Med can cause change in blood cells that affect immune function
If rash, contact HCP
Rare, inc S/N/muscle weakness/falls
birth control maybe less effective
Lamotrigine dosing
If on inhibitor, target dose is half normal
if on inducer, target dose is twice normal.
Gets tapered over time
* if > 3-5 half lives missed drug, need to reiterate again*
Lamotrigine CI & Warnings
Box warning = life threatening rash includes SJS and TEN
usually occurs first 2-8wks but can happen any time
prodromal symptoms of chills, malaise, sore throat and fever
STOP at any sign of rash
Lamotrigine serious adverse effects
SJS/TEN rash
Agranulocytosis
Aspect meningitis
GI + other SE can be reduced by using ER formulation
Lamotrigine DDI
Estrogens = Dec Lamotrigine
Carbamazepine = Dec lamotrigine
Valproic acid = inc lamotrigine
Clozapine = inc lamotrigine
Lamotrigine Monitoring
Rash**
dont need therapeutic drug monitoring
Lamotrigine counseling
take time to start working
re-titrate if missed >5 doses/days in a row
risk of serious rash
oral contraceptives or estrogens can dec lamotrigine conc
Clozapine used for….
treatment resistant BD as monotherapy or with mood stabilizers
pts with affinity for manic polarity respond better to clozapine
Lithium in pregnancy….
avoid during 1st trimester
TDM during each trimester
epstein n floppy baby concern
Valproic acid in pregnancy…
Avoid, if using supplement with folic acid 4mg
neural tube defects concern
Carbamazepine in pregnancy…
Avoid, if using supplement w/ folic acid 4mg n Vit K 10mg during last month
neural tube defects concern
Lamotrigine in pregnancy….
clearance changes during pregnancy
Lithium in lactation….
contraindicated
Valproic acid/Carbamazepine in lactation
can use but have to monitor baby..most ppl dont wanna do that
presentation of Bipolar in Pets n Older adults
Manic or mixed states may present as short periods of intense mood lability or irritability rather than euphoria
