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CDM 4 Exam 2 > Lecture 5 - Bipolar Disorder > Flashcards

Lecture 5 - Bipolar Disorder Flashcards

1
Q

DSM-5 Manic episode criteria

A

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

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2
Q

DSM-5 Hypomanic episode criteria

A

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

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3
Q

Drug/Med induced mania from….

A

Alc intox
antidepressants
Drug withdrawal
Weed
Steroids
Thyroid meds
Caffeine
DA-augmenting agents
NE-augmenting agents
Hallucinogens
OTC weight loss/decongestants

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4
Q

Bipolar I Disorder

A

Manic episode
+/- major depressive episode or HYPOmanic episode

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5
Q

Bipolar II Disorder

A

Hypomanic episode AND major depressive episode

no history of manic episode

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6
Q

Bipolar Specifies

A

Mixed features
Rapid cycling
Psychotic features

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7
Q

What are mixed features

A

full criteria met for manic or depressive episode in addition to 3 features of the other

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8
Q

What is rapid cycling

A

at least 4 separate episodes in the last 12 months

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9
Q

What are Psychotic features

A

delusions or hallucinations present

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10
Q

Kindling effect

A

acceleration of episode frequency with each episode becoming more difficult to treat

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11
Q

Acute Mania, Manic Episode TXM

A

1st = VPA, SGA, Lithium
2nd = CBZ or FGA
Severe or psychotic symptoms = Lithium or VPA + SGA

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12
Q

Acute Mania, Manic w/ Mixed Features TXM

A

1st = SGA, VPA, CBZ

SGA used as mono or in combo w/ mood stabilizers

Avoid antidepressants, Lithium doesnt work well mixed features

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13
Q

Acute Mania Considerations

A

Antidepressants = Taper or D/c
Benzo = used short term, avoid SUD

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14
Q

Acute Depression, Bipolar I Txm

A

SGA = Qutiapine, Lurasidone, Olanzapine/fluoxetine

Lithium, Lamotrigine

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15
Q

Acute Depression, Bipolar II TXM

A

Quetiapine**
Lurasidone
Cariprazine
Olanzapine/Fluoxetine

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16
Q

Acute Depression, Considerations

A

D/c if mixed symptoms
Always use with mood stabilizer
Can worsen some symptoms

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17
Q

Maintenance therapy Bipolar

A

SGA preferred over FGAs
Least number of meds if possible

Goals: achieve milder degree of mood instability

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18
Q

Continuation Phase Bipolar

A

optimize txm, prevent ADR, ensure adherence and prevent polarity switch or relapse

continue acute txm 2-4 months following response

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19
Q

Maintenance therapy meds

A

Lithium
LAM = takes 6-7wks to titrate up so not used for acute txm
VPA
CVZ
SGA

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20
Q

Lithium Monitoring Acute mania lvls

A

0.8 - 1.2 mEq/L

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21
Q

Lithium monitoring maintenance lvls

A

0.6-1 mEq/L

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22
Q

Lithium lvls 1.5-2 will cause….

A

N/V/D, drowsiness, muscle weakness, coarse tremor (cant hold pen to write name)

get more severe the higher the lvls are

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23
Q

How often should you do Lithium monitoring

A

12hrs after dose (usually given at night)
Steady state after ~ 5 days
1st order linear kinetics ( dble dose = conc double)

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24
Q

Lithium dosing info

A

start low divided doses to dec side effects

change to QHS to reduce polyuria and improve adherence

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25
Lithium CI
Dehydration Sodium depletion unstable renal or CV disease dont use acute renal failure and ESRD ** Diuretics**
26
Lithium place in therapy
Dec risk of suicidality maintenance therapy (mania/depression) few weeks for mania onset of action, > 1 month depression max effect
27
Ebstein's anomaly
inc risk of fetal malformations w/ Lithium
28
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
29
Serious ADE of Lithium
Acute kidney injury Chronic kidney disease AV block or conduction issues Bradyarrhytmia Brugada syndrome = sudden cardiac death
30
Lithium DI info
avoid NSAIDs ACEi/ARB can inc Li Avoid Thiazides, others OK with caution
31
Lithium Monitoring Parameters
Renal function TSH ECG ( over 40yrs old) Serum drug conc
32
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
33
Valproic Acid Dosing
No target dose, but titrate so control mania without significant effects ** Dosing forms not interchangeable **
34
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
35
Valproic Acid CI
Hepatic disease/dysfunction Hyperammonemia Pregnancy when used for migraines (but can use for other indications w/ caution) hepatoxicity box warning
36
Valproic Acid Adverse effects
SJS/TENS Pancreatitis ~ 5% Hepatotoxicity if LFT > 3ULN intervene Hyperammonemia Thrombocytopenia
37
Common SE Valproic Acid
Alopecia Weight gain ~ 6-8kg Dizziness, Sedation, Nausea toxicity = ataxia, tremor, CNS depression
38
Valproic Acid DDI
Carbapenem Antibiotics = dec VPA lvls, danger if used seizures Lamotrigine = inc lamotrigine lvls Phenytoin = can inc or dec Warfarin = inc warfarin
39
Valproic Acid Monitoring parameters
CBC LFTs Serum drug conc
40
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 **
41
Carbamazepine Dosing
42
Carbamazepine Place in therapy
Comorbid SUD or neurologic conditions anti-kindling properties Bipolar Disorder II
43
Carbamazepine have high risk of...
SJS/TEN...avoid if positive HLA-B*1502 allele Test asian ppl
44
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
45
Carbamazepine CI and warmings
CI = Bone marrow suppression Boxed awning = SJS/TEN, Aplastic anemia and agranulocytosis
46
Carbamazepine Adverse Effects
Rare = rash, hyponatremia/SIADH, leukopenia Fatal = SJS/TEN, agranulocytosis, aplastic anemia, thrombocytopenia, hectic failure common = generally well tolerated (N/V/Dizziness)
47
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
48
Carbamazepine DI
CYP3A4 or CYP1A2 Clozapine = dec serum conc, enhanced myelosuppressive effects Grapefruit = inc CBZ lvls hormonal contraception = dec effectiveness
49
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
50
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
51
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***
52
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
53
Lamotrigine serious adverse effects
SJS/TEN rash Agranulocytosis Aspect meningitis GI + other SE can be reduced by using ER formulation
54
Lamotrigine DDI
Estrogens = Dec Lamotrigine Carbamazepine = Dec lamotrigine Valproic acid = inc lamotrigine Clozapine = inc lamotrigine
55
Lamotrigine Monitoring
Rash** dont need therapeutic drug monitoring
56
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
57
Clozapine used for....
treatment resistant BD as monotherapy or with mood stabilizers pts with affinity for manic polarity respond better to clozapine
58
Lithium in pregnancy....
avoid during 1st trimester TDM during each trimester epstein n floppy baby concern
59
Valproic acid in pregnancy...
Avoid, if using supplement with folic acid 4mg neural tube defects concern
60
Carbamazepine in pregnancy...
Avoid, if using supplement w/ folic acid 4mg n Vit K 10mg during last month neural tube defects concern
61
Lamotrigine in pregnancy....
clearance changes during pregnancy
62
Lithium in lactation....
contraindicated
63
Valproic acid/Carbamazepine in lactation
can use but have to monitor baby..most ppl dont wanna do that
64
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

CDM 4 Exam 2 (12 decks)

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