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AC- CNS lectures > Management of bipolar affective disorder (mood stabilisers, anticonvulsants) > Flashcards

Management of bipolar affective disorder (mood stabilisers, anticonvulsants) Flashcards

1
Q

What are the management aims for BPAD?

A
  • Resolution of acute symptoms
  • Prevention of relapse (Individualise treatment)
  • Minimise ADRs
  • Encourage adherence
  • Patient education
  • Non-pharmacological interventions
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2
Q

Why do relapses often occur in BPAD that leads to acute mania?

A
  • poor medication compliance
  • substance abuse
  • antidepressants
  • stressful life events
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3
Q

What is used for primary treatment of elevated mood in acute mania?

A
  • lithium
  • sodium valproate
  • atypical antipsychotic- SGA
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4
Q

What is used for short-term management of associated behavioural disturbance in acute mania?

A
  • BZD
  • Atypical antipsychotics
  • Classical antipsychotics (only if other options have failed)
  • withdraw once settled
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5
Q

Which drugs to use?

A
  • 1 – Olanzapine or risperidone
  • 2 – haloperidol, aripiprazole, asenapine, paliperidone, quetiapine, ziprasidone, lithium, valproate, carbamazepine
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6
Q

What are the 2 steps in treating acute mania?

A
  • Stop antidepressant (if taking)
  • Commence mood stabiliser
    • if already on mood stabilsier:
    • check level
    • increase the dose
    • switch agents
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7
Q

Mood stabilisers have delayed of onset of action of around 1 week. What medication is used to calm/sedate the patient as an interim measure?

A
  • antipsychotic and/or benzodiazapine for short term treatment
  • Antipsychotics used for up to 6 months. May also be used as mood stabilisers
  • Benzodiazepines used for days-weeks
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8
Q

What do we use if a patient has poor sleep in mania for short term treatment?

A
  • temazepam 10-20mg nocte
  • If ongoing agitation/elevated mood, consider benzodiazepine use short term:
    • Clonazepam
    • Diazepam
    • Lorazepam
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9
Q

What are the 2 options of treatment of acute depression in BPAD? What is a precaution?

A
  1. Antidepressants –> DONT USE ANTIDEPRESSANTS ALONE IN TREATMENT OF BPAD

SSRIs. SNRIs, Mirtazapine = 1st line

+ mood stabiliser/atypical antipsychotic = lithium, olanzapine, quietapine, lamotrigine good choices

  1. Quietapine 300-600mg/day

monotherapy less commonly used than antidepressant/mood stabiliser combination

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10
Q

What are some other drugs that can be used in bipolar depression?

A
  • Fluoxetine + olanzapine
  • Lithium monotherapy and lithium + antidepressant
  • Lamotrigine
  • Lurasidone (2 trials with good effect)
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11
Q

What to do if there still no response to acute depression? What can antidepressants precipitate? When are they withdrawn?

A
  • Change antidepressant and/or mood stabiliser
  • Medication + psychological therapies (e.g. CBT)
  • Electroconvulsive therapy (ECT)
  • Antidepressants may precipitate manic episodes in the acute situation or provoke a rapid cycling pattern
  • Ideally withdrawn within 1-2 months of successful resolution of symptoms –> long term if depressive symptoms prominent
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12
Q

What is a mood stabiliser?

A
  • meds that have an anti-depressant & anti-mantic properties
  • effective for acute treatment of manic and/or bipolar depression
  • decreases chances of having further episodes of mania or depression
  • delay in onset of 1 week +
  • goal is to obtain and maintain remission
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13
Q

What is lithium carbonate used for? what effects does it have?

A
  • BPAD
  • schizoaffective disorder
  • chronic schizophrenia
  • augmentation for treatment-resistant depression
  • has anti suicidal effect
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14
Q

What is used more often and more tolerable than lithium?

A
  • sodium valproate
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15
Q

What are the precautions of lithium?

A
  • Acute hyponatraemia - increased risk of toxicity
  • Dehydration - increased risk of toxicity
  • Renal impairment - increased risk of toxicity
  • Elderly patients - age-related renal function decline and more sensitive to toxic effects
  • Psoriasis, acne - can be worsened
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16
Q

Which drugs interact with lithium & increase lithium level… so you get toxicity?

A
  • Loop diuretics
  • Thiazide diuretics
  • NSAIDs
  • ACE inhibitors
  • Sartans
  • Theophylline
  • Topiramate (high doses)
17
Q

What drugs interact with lithium & decrease lithium levels… so reduce efficacy?

A
  • Urinary alkalinisers (e.g. Ural sachets)
  • Potassium citrate
  • Antacids (with high sodium content)
18
Q

How do we prevent lithium toxicity?

A
  • Avoid dehydration – regular salt and fluid intake. Take care with major dietary changes
  • Do not change sodium intake
  • Avoid drinking large amounts of caffeinated drinks
  • Take extra care in hot weather and during activities causing you to sweat heavily ie. hot baths, saunas & exercise
  • Infection or illness that causes heavy sweating, vomiting or diarrhoea
  • Some patients experience toxic symptoms within normal range
19
Q

How should we counsel lithium?

A
  • Take with food to minimise gastric upset
  • Regular blood tests are required
  • Avoid dehydration- rink extra fluids on hot days, after exercise (sweating), spa/sauna or after vomiting/diarrhoea
  • Educate patient on symptoms of toxicity
    • Advise doctor if symptoms of toxicity arise (e.g. tremor, increased nausea
  • Many drug interactions. Always advise doctor/pharmacist you are taking lithium
20
Q

How do we monitor effects of lithium toxicity?

A
  • Patients should be aware that regular blood tests are important during treatment with lithium
  • Patients commencing lithium - U+E, TFT,PTH, ECG and pregnancy test
  • Li can cause hypothyroidism. If this occurs, often treated with Levothyroxine
  • Monitor serum lithium levels 5 to 7 days after starting or changing dose
  • Monitor lithium levels, U+E and TFT every 3-6 months and when clinically indicated
  • Blood samples for lithium serum levels should be taken 12 hours post dose (withhold morning dose of lithium if any until blood taken)
21
Q

Why is sodium valproate given in BAD? What are some side effects?

  • sodium valpoate = antiepileptic
A
  • Most commonly used mood stabiliser
    • lithium has narrow TI and can be toxic
    • also used to treat aggressive behaviours
  • take with food to reduce stomach upset
  • weight gain can be problematic
  • used to treat aggressive behaviours
  • considered 2nd line for prophylaxis but widely used
22
Q

What is sodium valproate used as in first line in?

A
  • generally used first line in bipolar maintenance as more tolerable than lithium
  • evidence for acute mania, maintenance, and acute depression in combination with antidepressant
23
Q

Which patients should sodium valproate be avoided in?

A
  • Avoid if possible in women of childbearing potential
  • Human teratogen
  • If necessary, active contraception must be used (i.e contraceptive pill, injection, implant or IUD)
24
Q

What are some precautions for soium valproate?

A
  • Hepatic impairment - avoid use
  • Surgery - check platelet count and INR before having any surgery
  • Pregnancy – do not use
    • increased risk of congenital malformations
  • Women of childbearing age must be on contraception
  • Lactation - safe to use at low dose
25
Q

What are some common ADV of sodium valproate?

A
  • GI upset
  • Increased appetite
  • weight gain
  • tremor
  • numbness
  • drowsiness, ataxia
  • elevated liver enymes
  • thinning or hair loss
  • rash
  • Menstrual Irregularities (polycystic ovaries)
26
Q

How do we monitor for sodium valproate? What tests do we need to do when commencing?

A
  • Patients commencing sodium valproate - FBC, LFT and pregnancy test
  • A minimum of 6-monthly thereafter
  • Monitor serum levels 3-5 days after each dose increase
  • Blood samples for serum levels should be trough levels (withhold morning dose if any until blood taken)
27
Q

What is the therapeutic range of sodium valproate?

A
  • Therapeutic range 50-100mg/L
  • In BPAD generally aim for this level
  • Can be used to monitor compliance
  • Toxicity generally >125mg/L
28
Q

How does lamotrigine interact with sodium valproate?

A
  • Valproate increases lamotrigine levels
  • increasing the risk of potentially dangerous rashes
  • If currently on valproate, start lamotrigine even more slowly
29
Q

What decreases sodium valproate levels?

A
  • Carbamezepine
  • phenytoin
30
Q

What increases sodium valproate levels?

A
  • Aspirin doses above 300mg increases­ valproate levels
  • Combination also increases risk of bleeding
31
Q

When is carbamezepeine used?

A
  • when lithium/valproate is ineffective or if unpleasant side-effects are experienced
  • some evidence in rapid cycling bipolar (4 episodes of mania, depression or a combination in one year)
  • not commonly used in BPAD
32
Q

How do we monitor for carbamezepine?

A
  • Therapeutic range 4-12mg/L (epilepsy)
  • trough level (immediately before morning dose)
  • Baseline: U&Es, FBP, LFTs, pregnancy
33
Q

What some ADVE of carbamazepine?

A
  • Dizziness, diplopia, drowsiness, ataxia, nausea, headaches
  • Hyponatraemia
  • Rash – more common in some people Chinese, Thai origin
  • Low WBC – do not use with clozapine
34
Q

What are some drug interactions for carbamezepine?

A

Carbamazepine induces enzyme cytochrome P450 3A4, therefore many interactions

  • Most antidepressants
  • Most antipsychotics
  • Benzodiazepines
  • Oral contraceptive pills – increased risk of pregnancy
  • Induces it’s own metabolism, dose increase required after a few weeks
  • Increased risk of hyponatraemia with diuretics
  • Clozapine – increased risk of agranulocytosis
35
Q

When is lamotrigine used?

  • expensive
A
  • One of the few agents effective for bipolar depression
  • Consider if depression a prominent feature
  • Used when there has been inadequate response to existing medications
36
Q

When is combination therapy done in BPAD?

A
  • May be beneficial when there is poor response to monotherapy n
  • Lithium + valproate more effective than either agent alone
  • Sodium valproate and carbamazepine combination is associated with high rates of adverse effects
  • Lithium/valproate + antipsychotic increasing in practice
  • Limited clinical trial evidence
  • Halve dose of lamotrigine if combining with sodium valproate to reduce risk of rash
37
Q

What do you do when there is failure in response to treatment?

A
  • Check blood level (if applicable)
  • Increase dose if required
  • Assess adherence with medication
  • Check for substance abuse
  • Implement psychological therapies
  • Combine treatments
38
Q

For antipsychotics that have PBS approvals for BPAD, what do each of the following do:

Asenapine (sublingual wafers)

Olanzapine (tablets, wafers)

Risperidone (liquid, tablets, consta)

Quetiapine (immediate release and XR tabs)

Zisprasidone

A
  • Asenapine (sublingual wafers)
    • Acute mania or mixed episode associated with bipolar I disorder, for up to 6 months tx
    • Maintenance treatment of bipolar I disorder as monotherapy
  • Olanzapine (tablets, wafers)
    • Maintenance treatment of bipolar I disorder
    • Injection not indicated
  • Risperidone (liquid, tablets, consta)
    • Adjunctive therapy to mood stabilisers for up to 6 months, of an episode of acute mania associated with bipolar I disorder (oral)
    • Maintenance treatment, in combination with lithium or sodium valproate, of treatment refractory bipolar I disorder (Constaâ)
  • Quetiapine (immediate release and XR tabs)
    • Monotherapy, for up to 6 months, of an episode of acute mania associated with bipolar I disorder
    • Maintenance treatment of bipolar I disorder
  • Zisprasidone
    • Monotherapy, for up to 6 months, of an episode of acute mania or mixed episodes associated with bipolar I disorder

AC- CNS lectures (28 decks)

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