lecture 70 Flashcards
ott -- pharmacotherapy of BPD
what are the co-morbidities associated with BPD?
alcohol and substance use common (50-60%)
anxiety disorders (can significantly impact remission of mood episodes if left untreated)
what are the associations with BPD?
mania
hypomania
rapid-cycling (Characterized by four or more mood episodes in 1 year)
how is BPD 1 and 2 differ?
1 - manic
2 - hypomanic
how can the symptoms of mania be memorized?
DIG FAST
GIDDINESS
what are the DIG FAST symptoms?
distractibility, indiscretion, grandiosity
flight of ideas, activity increased, sleep deficit, talkative
what are the GIDDINESS symtpoms?
grandiosity
increased goal directed activity
decreased judgement
distractibility
irritability
need for sleep decreased
euphoria
speedy thoughts
speedy talk
what is the first line treatment of BPD?
usually lithium or valproic acid
atypical antipsychs can also be used as monotherapy or in combo with the other two
what is important to note about lithium?
associated with decrease in suicidiality
narrow therapeutic index
some differences between lithium content in dosage forms but still use 1:1 conversion
what are the toxicities associated with lithium?
GI
ataxia
coarse hand tremor
altered mental status
seizure
lethargy
confusion
agitation
what is the therapeutic index for lithium?
acute – 0.9 - 1.2
maintenance – 0.6 - 0.9
toxicity – 1.5 - 3.0+
what are the SE of lithium?
fine hand tremor
hypothyroidism
polyuria, polydipsia
acne
dry mouth
weight ECG changes
how should lithium be used in pregnancy?
teratogenic bc can cause cardiac structural abnormality
avoid in 1st trimester, use in caution in 2/3rd trimester
what lab values should be monitored with lithium?
SCr, BUN
urine specific gravitiy
electrolytes (Na, K, Ca)
ECG
Thyroid
PTH
CBC with differential
weight
pregnancy test
what are the drug interactions of lithium?
decrease Li renal clearance with ACEi, ARBs, TZ diuretics, NSAIDs, dehydration
increase Li renal clearance with caffeine, osmotic diuretics, maybe loop diuretics
Increase Li excretion – sodium bicarb, high Na intake
toxicity related to Na depletion - TZ diuretics
how do the dosage forms of valproate differ?
ER is 10-15% less bioavailable than DR (still use a 1:1 conversion but expecting a lower serum concentration with ER)
Valproic Acid syrup (IR) and capsule sprinkle form have higher risk for GI ulcerations (usually esophageal)
what should be the serum level of valproate?
between 8-125 mcg/mL is associated with most efficacy in mania
obtain level at least 96 hours/4 days after first dose/dose increase
how is valproic acid used in pregnancy?
unsafe in any trimester so need to obtain baseline pregnancy test
can cause neural tube defects and enduring negative effects on IQ of offspring
what are the AE of valproic acid?
polycystic ovarian syndrome (POS) in up to 50% of women
GI
increased appetite/weight gain (of 6-8kg)
thrombocytopenia, platelet dysfunction
teratogenic
hyperammonemia
what are the GI AE of valproic acid?
anorexia
NVD
dyspepsia
ulceration
what is the lab monitoring associated with valproate?
baseline – pregnancy, LFTs, CBC with differential
Routine - serum concentration
if suspect hyperammonemia – serum ammonia
what are the drug interactions of valproate?
significant concern combo use with lamotrigine (increases lamotrigine serum concentration thus increasing risk of SJS)
what is important to note about carbamazepine?
induces nearly all CYP 450 enzymes auto-induction of metabolism (steady state at 14 days)
associated with thrombocytopenia/ hematologic effects
what is important to note about oxcarbazepine?
CYP 450 3A4 inducer
associated with hyponatremia
what is important to note about lamotrigine (lamictal)?
1st line for depressive symptoms in BPD
not useful for acute treatment or for manic episodes
