Mania Medications

Question 1

Lithium-

Answer 1

1. The oldest treatment for bipolar
2. unknown MOA; may work by inhibition of 2nd messenger systems such as inositol monophosphates
3. affects glutamate reuptake, increases BDNF, inhibits glycogen synthase kinase-3 (GSK-3).
4. effective in mania and in maintenance.
5. dose: 300mg TID or less
6. titrate to serum concentrations
7. raise dose based on response and side effects
8. check lithium levels after each dose increase
9. acute mania levels 1.0-1.5 (UptoDate –> .8-1.2)
10. maintenance levels- .5 - 1.2 (APA guidelines)
11. Toxic levels 2.0 and above (very close to therapeutic level).
12. Life threatening side effects- renal impairment, nephrogenic diabetes insipidus, arrhythmias, cardiovascular changes, sick sinus syndrome, bradycardia, hypotension, T wave flattening & inversion, seizures
13. Ebstein’s anomaly (in pregnancy).

Question 2

Lithium

Answer 2

Before prescribing check:
kidney and thyroid function
electrolytes
weight and BMI
urinalysis
calcium, parathyroid, vitamin D (new recommendations)

**The only drug shown to decrease suicidality.
If lithium is discontinued about 60-90% chance of a recurrence in one year.
. poorer prognosis if discontinue abruptly.
. better prognosis if discontinue over 2-4 weeks.
. can start a mood stabilizer while on Lithium for three days, then slowly decrease every few days while increasing the mood stabilizer.

Question 3

Mania Treatment ala Stahl

Answer 3

1. 5HT/DA (atypical antipsychotic) plus lithium
2. 5HT/DA (atypical antipsychotic) plus valproate
3. Lithium plus valproate
4. Lamotrogine plus valproate
5. lamotrogine plus lithium
6. lamotrogine plus lithium plus valproate

Question 4

Mania Treatments ala Schwartz (monotherapy approach).

Answer 4

1. Lithium
2. divalproex
3. Carbemazepine (atypical antipsychotic)
4. atypical antipsychotic

For severe mania:
. high dose atypical antipsycotics or divalproex

Question 5

American Psychiatric Association treatment approach to mania

Answer 5

1. Lithium plus atypical antipsychotic or valproate (for severe mania).
2. Monotherapy Lithium or Valproate OR olanzapine for less severe mania.
3. May consider: carbamazepine or oxcarbamazepine or quetiapine in lieu of another atypical antipsychotic.

Question 6

Mania Algorith- Eminence Based (Puzantian and Carlat (2020).

Answer 6

1. Euphoric mania- Lithium or Lithium plus antipsychotic; or valproic acid alone; or valproic acid plus an antipsychotic.
2. Mixed mania-Antipsychotic, or antipsychotic plus valproic acid or lithium
3. Agitated/acute setting (not cooperating with providers)-
   a. IM forumulation of haloperidol (5mg), lorzepam (1mg), benztropine (1mg)/dephenhydramine (50mg).
   b. olanzapine (10mg)
   c. geodon/ziprasidone (20mg)
4. Treatment resistant
   a. Lithium plus valproic acid plus antipsychotic
   b. carbamazepine
   c. clozapine.
5. At the end of the rope:
   . allopurion (zyloprim); used to treat gout
   . tamoxifen- used to treat breast cancer.