Mania and Hypomania Flashcards
Antimanic drugs are used in ___________ to manage acute episodes of mania or hypomania, and to prevent recurrence
bipolar disorder
Are antidepressants used in the treatment of bipolar disorder?
Sometimes; An antidepressant drug may be required in addition to antimanic medication for the treatment of co-existing bipolar depression, but should be avoided in patients with rapid-cycling bipolar disorder, a recent history of mania or hypomania, or with rapid mood fluctuations.
An antidepressant drug may also be required for the treatment of co-existing bipolar depression, but should be avoided in patients with _____________, ________________, or with _____________.
rapid-cycling bipolar disorder
a recent history of mania or hypomania
rapid mood fluctuations
Consider stopping antidepressant drug if a patient with bipolar disorder develops __________ or ___________
mania
hypomania
Which drugs are used in the treatment of acute episodes of mania or hypomania?
Antipsychotics eg haloperidol, olanzapine, quietiapine, risperidone
Lithium or valproate may be added if inadequate response to other agents
A(n) ______________ drug may also be used concomitantly with lithium or valproate in the initial treatment of severe acute episodes of mania
antipsychotic
____________, a second-generation antipsychotic drug, is licensed for the treatment of moderate to severe manic episodes associated with bipolar disorder.
Asenapine
____________ can be used for the long-term management of bipolar disorder; it is licensed for the prevention of recurrence in patients whose manic episode has responded to ____________ therapy.
Olanzapine
olanzapine
When discontinuing antipsychotic drugs, the dose should be reduced gradually over at least ____________ to minimise the risk of recurrence
4 weeks
What is the role of benzodiazepines in the treatment of bipolar disorder?
May be helpful in the initial stages of treatment for behavioral disturbance or agitation BUT should not be used for long periods because of the risk of dependence
What is the role of lithium in the treatment of bipolar disorder?
- Treatment of acute episodes of mania or hypomania
- Long-term management to prevent recurrence of acute episodes (decision to give prophylactic lithium must be based on careful consideration of the likelihood of recurrence in the individual patient, and the benefit of treatment weighed against the risks)
In the treatment of bipolar disorder, the full prophylactic effect of lithium may not occur for _____________ after the initiation of therapy.
six to twelve months
What is the role of valproate in the management of bipolar disorder?
- Acute manic (but not hypomanic) episodes if lithium is not tolerated or contra-indicated
- Long-term management to prevent recurrence of acute episodes in combination with lithium if treatment with lithium alone is ineffective OR as monotherapy if lithium is contra-indicated or not tolerated
What is the role of carbamazepine in the treatment of bipolar disorder?
Long-term management to prevent recurrence of acute episodes in patients unresponsive to therapy
(Not used to treat acute episodes of mania or hypomania)
Which drugs can be used in the long-term management of bipolar disorder to prevent recurrence of acute episodes? (4)
First line:
- Lithium
Second line:
- Valproate
- Carbamazepine
- Olanzapine
Which drugs can be used in the treatment of acute episodes of mania associated with bipolar disorder? (4)
- Antipsychotics (haloperidol, olanzapine, quetiapine, and risperidone, asenapine)
- Benzodiazepines
- Lithium
- Valproate
What are the contraindications to using lithium? (7)
- Addison’s disease
- Cardiac disease associated with rhythm disorders
- Cardiac insufficiency
- Dehydration
- Family or personal history of Brugada syndrome
- Low salt diets
- Untreated hypothyroidism
Long-term use of lithium has been associated with __________ disorders and mild ___________ and ____________ impairment.
thyroid
cognitive
memory
How often is thyroid function assessed in patients taking long-term lithium therapy?
Every 6 months (more often if evidence of deterioration)
What are the side effects of lithium? (5)
- GI/GU: discomfort, decreased appetite, diarrhea, dry mouth, gastritis, hypersalivation, nausea/vomiting, polyuria, renal impairment, weight gain
- MSK/derm: alopecia, folliculitis, muscle weakness, rhabdomyolysis, skin reactions, ulcers,
- CV: angioedema, arrhythmias, AV block, cardiomyopathy, circulatory collapse, hypotension, peripheral edema, QT prolongation
- Neuropsych: cerebellar syndrome, coma, delirium, dizziness, encephalopathy, raised ICP, memory loss, MG, movement disorders, peripheral neuropathy, abnormal reflexes, seizures, sexual dysfunction, speech impairment, altered taste, vertigo, tremor, vision disorders
- Endo: electrolyte imbalance, hyperglycemia, hyperparathyroidism, hypothyroidis, thyrotoxicosis
What are the signs and symptoms of lithium overdose? (9)
- Increasing GI disturbances (vomiting, diarrhea) and incontinence
- Visual disturbances
- Polyuria
- Muscle weakness
- Fine tremor increasing to coarse tremor
- CNS disturbances (confusion and drowsiness increasing to lack of coordination, restlessness, stupor)
- Abnormal reflexes, myoclonus
- Hypernatremia
What are the consequences of severe lithium overdose? (5)
- Seizure
- Cardiac arrhytmias (sino-atrial block, bradycardia, first-degree heart block)
- BP changes, circulatory failure
- Renal failure
- Coma and sudden death
Is lithium safe during pregnancy?
Avoid if possible, particularly in the first trimester due to risk of teratogenicity including cardiac abnormalities (eg Epstein’s anomaly=RVOT obstruction)
**use effective contraception during treatment with lithium for women of childbearing potential
Lithium exposure in the first trimester of pregnancy is associated with which congenital abnormality?
Ebstein’s anomaly, a RVOT obstruction defect
Is lithium safe to use while breastfeeding?
No, present in milk and risk of toxicity to infant
Can lithium be prescribed to patients with renal and/or hepatic impairment?
Caution in mild to moderate renal impairment
Avoid in severe renal impairment
(Okay in liver disease)
Do serum lithium levels need to be monitored routinely?
Yes, due to their narrow therapeutic index
Serum-lithium samples should be taken _________ after the dose to achieve a serum-lithium concentration of __________ (lower end of the range for maintenance therapy and elderly patients).
12 hours
0.4–1 mmol/litre
Samples should be taken 12 hours after the dose to achieve a serum-lithium concentration of 0.4–1 mmol/litre (lower end of the range for ___________ therapy and ___________ patients).
maintenance
elderly
A target serum-lithium concentration of ________ mmol/litre is recommended for acute episodes of mania, and for patients who have previously relapsed or have sub-syndromal symptoms.
0.8–1
A target serum-lithium concentration of 0.8–1 mmol/litre is recommended for ___________, and for patients who have ___________, or have sub-syndromal symptoms.
acute episodes of mania
previously relapsed
Routine serum-lithium monitoring should be performed ___________ after initiation and after each dose change until concentrations are stable, then every __________ for the first year, and every ____________ thereafter
weekly
3 months
6 months
Patients who are 65 years and older, taking drugs that interact with lithium, at risk of impaired renal or thyroid function, raised calcium levels or other complications, have poor symptom control or poor adherence, or whose last serum-lithium concentration was 0.8 mmol/litre or higher, should be monitored every ___________
3 months
Additional serum-lithium measurements should be made if a patient develops significant ______________ or if there is a significant change in a patient’s __________ or __________
intercurrent disease
sodium
fluid intake
Manufacturer advises to assess __________, ___________, and ___________ function before treatment initiation with lithium
renal
cardiac
thyroid
In addition to assessment of renal, cardiac, and thyroid function, which investigations should be done before initiating treatment with lithium? (3)
- Body weight or BMI
- Serum electrolytes
- FBC
+ ECG in patients with CVD or risk factors for it
How often should body-weight or BMI, serum electrolytes, eGFR, and thyroid function be tested in patients receiving long-term lithium therapy?
Every 6 months; more often if there is evidence of impaired renal or thyroid function, or raised calcium levels.
Manufacturer also advises monitoring cardiac function ‘regularly’
Why is it important to withdraw lithium therapy gradually?
To minimize risk of relapse
NOT due to risk of withdrawal or rebound psychosis
If lithium is to be discontinued, the dose should be reduced gradually over a period of at least __________ (preferably over a period of up to __________)
4 weeks
3 months
If lithium is stopped or is to be discontinued abruptly, consider changing therapy to a(n) ____________ or __________
atypical antipsychotic
valproate
Patients taking lithium should be advised to report signs and symptoms of __________, ___________, __________, and ____________.
lithium toxicity (eg tremor, increased GI disturbance, etc)
hypothyroidism
renal dysfunction (including polyuria and polydipsia)
benign intracranial hypertension (persistent headache and visual disturbance)
What lifestyle advice should be given to patients and carers regarding lithium therapy?
Maintain adequate fluid intake and avoid dietary changes which reduce or increase sodium intake
Lithium should be prescribed with caution in which patients? (7)
- Cardiac disease, QT prolongation
- Concurrent ECT (may lower seizure threshold)
- Epilepsy ( “ ” )
- MG
- Psoriasis (risk of exacerbation)
- Diarrhea and intercurrent infection, especially if sweating profusely (review dose as necessary)
- Surgery
Concurrent use of _____________, _____/______, or __________ with lithium increases the risk of lithium toxicity
NSAIDs
ACE inhibitors/ARBs
Diuretics
*Increase monitoring
Drugs with which side effects should be avoided in patients taking lithium? (2)
- Drugs that prolong the QT interval eg amiodarone, macrolides, antimalarials
- Drugs that cause hypokalemia eg amphotericin B, beta blockers, corticosteroids, diuretics
What consideration should be taken when prescribing lithium alongside antidepressant medications?
Risk of serotonin syndrome
