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MPharm Y3S2 > Mental Health Clinical Bipolar > Flashcards

Mental Health Clinical Bipolar Flashcards

1
Q

What does euthymia mean?

A

Mood is stable

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2
Q

Describe the epidemiology of BPD:

A

1% of pop
Up to 5% on bipolar spectrum
Incidence is similar in both genders and all ages, races, ethnic groups and social classes
Can occur at any age, first diagnosed 18-24

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3
Q

Describe the aetiology of BPD:

A

70% of BPD patients have at least one close relative with it or unipolar depression
6th leading cause of disability in the world

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4
Q

What are the risk factors for BPD?

A

FHx- genetics, combo of many genes
Being male (only slightly increased)

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5
Q

What are the trigger factors of an episode of BPD?

A

Life events e.g trauma, abuse
Stopping a mood stabiliser suddenly esp lithium
Potentially being on an AD without mood stabiliser if bipolar
Goal attainment events
Disrupted circadian rhythm e.g shift working
Spring/ summer - mania/ hypomania

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6
Q

What is the physical health risk to an individual having BPD?

A

Obesity
Heart disease and HTN 5x increase
Dying from resp 3x increase
Dying from infection 2x
Poor memory more likely
Life expectant lowered by 10 yrs

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7
Q

What is the mental health risk to an individual having BPD?

A

Suicidal 4x increase
Substance misuse is common
1 in 2 dependent on alcohol and 2 in 5 dependent on other drugs

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8
Q

Name the most common symptoms of drug induced mania:

A

Increased activity
Rapid speech
Elevated mood
Insomnia

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9
Q

What are the drugs that can induce mania?

A

Hallucinogens e.g LSD
CNS stimulants e.g amphetamines, caffeine
Antidepressants- switch from depression to mania
Antipsychotics- newer gen rather than haloperidol

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10
Q

What are the general prescribing points for mania?

A
  1. discontinue any manicogenic agents, inc ADs and stimulants
  2. stabilise any medical conditions
  3. start non specific calming meds e.g benzos, antipsychotics
  4. start specific mood stabilisers or relapse prevention agents, preferable when pt is able to consent
  5. hypnotic/ sedative should be considered
  6. any co-morbid substance misuse must be tackled
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11
Q

Name the first line mood stabilisers/ relapse prevention agents for BPD:

A

Lithium
Quetiapine
Olanzapine
Aripiprazole
Lamotrigine
Valproate

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12
Q

Describe the licensing of quetiapine for BPD:

A

Licensed as monotherapy for acute mania and relapse prevention acute BPD (only one licensed) and relapse prevention
Also acute mania and relapse prevention in people who response in acute state over 2 years

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13
Q

Name the baseline monitoring for quetiapine:

A

Weight/ BMI
Pulse/ BP (HTN risk)
Lipid abnormality
ECG if at risk (as can increase QT)

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14
Q

Name the ongoing monitoring for quetiapine:

A

Pulse and BP after each dose change
Weight/ BMI weekly for 6 weeks, then at 12 weeks
BG or HBA1C
Blood lipid profile at 12 weeks
Response to treatment
SEs
Emergence of movement disorders
Adherence

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15
Q

Name the SEs of quetiapine:

A

Very common: sleepiness, dizziness, dry mouth (anticholinergic), weight gain, post hypo
Common: headache, akathisia, anticholinergic SEs

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16
Q

Describe the prescribing advice for quetiapine:

A

Initial dose titration must be slow due to risk of post hypotension an about 16% of pts
Although highly sedative at low doses (e,g 25mg) the sedation is not proportional to dose

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17
Q

Describe the licensing for olanzepine in BPD:

A

Licensed for mania and relapse prevention in people who have responded to it acutely and are lithium or valproate non responders
Widely used as an anti manic and as a mood stabilisers

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18
Q

Name the formulations of olanzapine:

A

Tabs
IM injection
Orodispersible tabs
Depot (restricted use)- rare but serious section and sudden cardiac death

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19
Q

Describe the monitoring requirements for olanzapine:

A

Same as quetiapine

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20
Q

What are the very common SEs of olanzapine?

A

Sedation- so take at night
Weight gain

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21
Q

What are the common SEs of olanzapine?

A

Post hypotension
Dry mouth, constipation
Peripheral oedema
Diabetes
Long term weight gain
Metabolic syndrome e.g diabetes, raised lipids and cholesterol

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22
Q

Describe the smoking interaction with olanzapine:

A

Smoking induces CYP1A2 enzyme that metabolised olanzapine
If stopping smoking can increase levels

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23
Q

What is the prescribing advice for olanzapine?

A

Starting dose in acute mania is 15mg/d as monotherpay or 10mg/d as adjunct
Don’t give benzo within an hour of short acting IM olanzapine as reports of death

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24
Q

Describe the licensing of aripiprazole in BPD:

A

Licensed for acute mania and main presentation in people who have responded acutely including in adolescents aged 13 years or older

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25
Q

What are the monitoring requirements of aripiprazole?

A

Same as quetiapine

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26
Q

What are the formulations of aripiprazole?

A

Tabs
Oridisperisble tabs
Liquid
Injection- long acting depot

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27
Q

What are the very common SEs of aripiprazole?

A

Akathisia
Insomnia- take in morning
Stomach upset
Constipation
Blurred vision

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28
Q

What are the common SEs of aripiprazole?

A

Movement disorders (extra-pyramidal SEs)
Post hypotension
Palpitations

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29
Q

What is the prescribing advice for aripiprazole?

A

For mania start at 15mg and increased to 30mg/d
Relapse prevention dose can be 15-30mg/d
Due to its partial agonism, start it at 5mg/d if patient has had another antipsychotic in their system

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30
Q

Describe the licensing of lamotrigine for BPD:

A

Licensed for prevention of relapse of BPD
No efficacy in mania, mixed, rapid-cycling or unipolar depression nor acute BPD (due to long titration)
Efficacy shown in severely depressed pts

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31
Q

Describe the prescribing points of lamotrigine:

A

Must be titrated ‘by the book’
Starting dose must be low and slowly titrated as per BNF
25mg/d for 2 weeks, 50mg/d for 2 weeks then increase by 50-100mg/d every 1-2 weeks
Half this if used with valproate (e.g 25mg alternative days for 2 weeks, taking 6 weeks to reach 200mg/d)

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32
Q

Why is the dosing of lamotrigine so specific?

A

Almost abolished the risk of potential fatal rashes

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33
Q

What are the most common SEs of lamotrigine?

A

Drowsiness, headache, dizziness, nausea, blurred vision

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34
Q

What are the rare but serious SEs of lamotrigine?

A

Oedema
Bone marrow suppression
Skin rashes

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35
Q

Describe the skin rash side effect of lamotrigine:

A

Stevens-Johnson syndrome (SJS) or Toxic Epidermal Necrolysis (TEN)
Red rashes across the face and body, blisters and inflammation in the nose, mouth and eyes, looks like serious sunburn

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36
Q

Describe the licensing of valproate for BPD:

A

For mania and relapse prevention
Depakote (semi sodium valproate) and Episenta are licensed for BPD
Epilim is available in tabs, MR and liquid

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37
Q

What is the baseline monitoring for valproate?

A

Height, weight, FBC, LFTs
Blood cell count, inc platelet count, bleeding time and anticoagulation before treatment starts then during first 6 months
LFTs then at 6 months

38
Q

What is the dosing of valproate?

A

Oral LD 20mg/kg/ day may give a rapid response often within 3 days
MD not full established

39
Q

What are the very common SEs of valproate?

A

Weight gain, increased appetite

40
Q

What are the common SEs of valproate?

A

Gastric irritation, diarrhoea, hair loss, nausea

41
Q

What are the uncommon SEs of valproate?

A

Sleepiness, impaired liver function

42
Q

What are the rare but serious SEs of valproate?

A

Thrombocytopenia and impaired platelet function
Hepatic dysfunction in first 6 months
Pancreatitis- abdominal pain, N&V
PCOS

43
Q

What are interactions with valproate?

A

Carbapenem antibiotics decrease valproate
Lamotrigine (variable effects):
-34% have more 25% increase in V levels
-14% have an increase of more 50% in V levels
-5% have a more 25% decrease in V levels

44
Q

What is the patient and carer advice for people on valproate?

A

PPP
Infertility and testicular toxicity for males
MRHA risk acknowledgement forms are mandatory for males and females below 55
Blood hepatic disorders- recognising
Pancreatitis- recognising

45
Q

What are the options for women already on valproate?

A

Stop valproate gradually
Switch to another medicine
Continue:
-two specialists must agree
-PPP

46
Q

What are the valproate risks in those of fathering potential?

A

Can cause infertility, this may be reversible upon withdrawl or reduction
Animal studies show testicular toxicity with decrease rate of testicular development
MHRA determine high risk in under 55

47
Q

What is the action in those of fathering potential taking valproate?

A

All males under 55 must have risk acknowledgement form complete when starting
Two specialists confirm
Pt must be informed of risk and provided with patient guide
No mandatory requirement in users over 55 but risk may still be present

48
Q

Name other second line treatments for BPD:

A

Carbamazepine
Haloperidol
Risperidone
Benzodiazepines
Antidepressants

49
Q

Describe carbamazepine as a treatment for BPD:

A

Acute mania, relapse prevention, lithium non responder
Limited efficacy, blood disorders, TCA interaction

50
Q

Describe haloperidol as a treatment for BPD:

A

Mania and hypomania
With benzodiazepine

51
Q

Describe risperidone as a treatment for BPD:

A

Monotherapy of bipolar mania- not widely used

52
Q

Describe benzodiazepines as a treatment for BPD:

A

Not licensed but calming

53
Q

Describe the use of antidepressants as a treatment for BPD:

A

Lacks evidence but use is common
Potential for switching to mania but can be safe if combined with a mood stabiliser (short term)
If someone is manic/hypomanic and on AD, must be stopped stepwise

54
Q

What is the combination therapy for bipolar mania?

A

Antipsychotic and/ or mood stabiliser+ benzo

55
Q

What is the combination therapy for bipolar depression?

A

Any combo of lithium, lamotrigine or valproate, quetiapine, risperidone or olanzepine

56
Q

What is the combination therapy for relapse prevention?

A

Mood stabilisers
Mood stabilisers plus ADs
Lamotrigine plus ADs

57
Q

Which mood stabilisers pose the greatest risk during pregnancy?

A

No safe mood stabiliser in pregnancy
Lithium, valproate and carbamazepine pose greatest risk

58
Q

What is the mood stabiliser used in hepatic impairment?

A

Amisulpride exception, everything else metabolised by liver

59
Q

What is the mood stabiliser used in renal impairment?

A

Avoid lithium and amisulpride

60
Q

Name some bipolar support groups?

A

Bipolar UK
Mind
SANE
Carers UK
Rethink
Samaritains

61
Q

What are the main diagnostic symptoms of mania/hypomania?

A

Abnormal elevation of mood
Inability to conc/ easily distracted
Flight of ideas
Obsessive preoccupation with some idea, activity or desire
May be over active and intrusive
Risk taking and disinhibition e.g spending money

62
Q

What are the main presenting symptoms of mania/hypomania?

A

Euphoric and labile mood
Bright or untidy appearance
Low sleep requirement
Increase drive/ energy
Reduced insight
Pressure of speech, intrusive manner

63
Q

What is the DSM V diagnosis of mania?

A

Duration of elevated and irritable mood needs to be for 7 days or more
Severe functional impairment
May have psychotic symptoms

64
Q

What are the DSM V diagnosis of hypomania?

A

Duration of elevated and irritable mood needs to be for 4 days or more
Decrease or increased function
Psychotic features absent

65
Q

What are the clinical features of bipolar depression?

A

Decreased energy and fatigue
Sleeping badly
Doing less
Poor sleep (increased or decreased)
Loss of interest in things that used to be enjoyable
Feelings of wanting to self harm

66
Q

Name the different categories of BPD?

A

Bipolar I (classic manic- depression)
Bipolar II
Bipolar III (pseudounipolar bipolar disorder)
Rapid-cycling

67
Q

Describe bipolar I:

A

Mania and severe depression, mania alone

68
Q

Describe bipolar II:

A

Depression with at least one hypomanic episode
May be genetically distinct from bipolar I

69
Q

Describe bipolar III:

A

Recurrent depression and mixed states (high and low symptoms at same time)
ADs may induce this

70
Q

Describe rapid-cycling:

A

4 or more mood episodes in a year

71
Q

What is the therapeutic indication of lithium?

A

Prophylaxis against bipolar disorders
In the management of acute manic or hypomanic episodes (must have previously responded to lithium and symptoms not severe)
Recurrent depression
Control of aggressive behaviour/self harm
Not often used for mania as takes 5-7 days to work and need high doses, testing blood levels are difficult
GOLD standard for relapse prevention

72
Q

Describe the MoA of lithium:

A

Is an alkali metal available for medical use as lithium carbonate (tabs) or lithium citrate (liquid)
MoA not fully understood, modifies the production and turnover of certain NTs, particularly serotonin and it may also block dopamine receptors

73
Q

Describe how preparations of lithium vary widely in bioavailability:

A

Need to always stay on same brand
Priadel MR tabs 200/400 and Priadel liquid 520mg/5ml
5ml of liquid is equal to ONE lithium carbonate 200mg tab

74
Q

What are the CI of lithium therapy?

A

Hypersensitivity to lithium
Cardiac disease/ insufficiency (QT)
Severe renal impairment
Untreated hypothyroidism, Addison’s
Breast feeding
Pt with low body Na e.g dehydrated or low Na diets
Brugada syndrome hereditary disease of the cardiac sodium channel

75
Q

What are the cautions of lithium therapy?

A

Pregnancy- AVOID unless exceptional circumstances esp in first trimester
Renal impairment (mild-moderate)
ECT and other meds that can decrease epileptic threshold
QT interval prolongation and other meds that do this

76
Q

What is the monitoring prior to initiating lithium theory?

A

ECG- QT interval increased
Renal function (eGFR)- excreted via kidneys
Thyroid function- hypo can be mistaken for depression
Weigh gain/BMI, Ca (hyper), U&E, FBC

77
Q

What are the dose monitoring requirements during lithium therapy?

A

Regular blood tests required to ensure therapeutic dose maintained as narrow window
Plasma levels must be taken weekly until stable conc maintained for 4 weeks
Plasma levels should 4-7 days after each dose change
NICE- take plasma every 3 months for 1st year then 6 monthly unless at risk

78
Q

What patients would be at risk and therefore need more frequent lithium dose monitoring?

A

Elderly- interactions at risk of impaired renal/ thyroid
Raised Ca levels, poor symptom control, poor adherence
Plasma levels 0.8mmol/L or higher

79
Q

When should blood tests be taken to measure lithium dose?

A

12 hours post dose so take it at night

80
Q

What should the blood test range be for lithium therapy?

A

0.4-1mmol/L (higher 0.8mmol in mania)
Lower in elderly

81
Q

What are additional ongoing monitoring requirements with lithium therapy?

A

Renal function
Thyroid (TSH, T4)
Every 6 months ^
Weight, BMI, Ca, U&E’s

82
Q

What is the dosage of lithium?

A

Individualised depending on serum lithium levels and clinical response
Usually staring dose 200mg in elderly and 400mg in adults- usual dose range 400-1.2g daily at night

83
Q

What are specific patient factors which would mean they have a reduced dose of lithium?

A

Renal impairment (avoid if possible)
Patients less than 50kg

84
Q

What are the SEs of lithium?

A

Upset stomach- esp at start
FINE tremor of hands
Metallic taste in mouth
Swelling of ankles- dose reduction
Increase thirst and urine output- renal impairment
Weight gain- up to 27kg

85
Q

Describe blood results which would indicate lithium toxicity:

A

Blood conc over 1.5mmol/L (overdose) and may be fatal and toxic effect
Blood conc over 2mmol/L (severe overdose) requires urgent medical attention- check compliance

86
Q

What are the signs and symptoms of lithium toxicity?

A

SEVERE hand tremor
Stomach ache with nausea and diarrhoea
Muscle weakness
Unsteady on feet
Slurring of words
Blurred vision
Confusion
Unusually sleepy
Muscle twitches

87
Q

What could severe lithium toxicity lead to?

A

Convulsions
Coma
Renal and circulatory failure
Hyperflexia- over active reflexes
Toxic psychoses

88
Q

Name drug interactions that can increase lithium levels:

A

ACEi/ ARBs (renal, increase Na+ loss)
NSAIDs
COX2i e.g ketorolac avoid
Metronidazole
SSRIs
Diuretics and aldosterone agonists (thiazides worst) e.g bumetanide/ furosemide (least risk)

89
Q

Name drug interactions that can decrease lithium levels:

A

Sodium bicarbonate containing products
Caffeine

90
Q

Name other drug interactions with lithium:

A

Ventricular arrythmia can be caused by concomitant use with amiodarone- avoid
Increase risk of neurotoxicity with methyldopa and some antipsychotics e.g clozapine

91
Q

What are other risk which can increase lithium levels?

A

Sodium depletion increases lithium concentration due to competitive reabsorption at the renal level
Pts should be monitored for:
-dehydration
-changes in salt levels
-infection
-V&D

92
Q

Describe the counselling points for lithium:

A

OD at night
Effectiveness takes 6/12 months to fully establish
Duration of treatment 2-3 years min
Stop stepwise over at least 4 weeks, preferably longer
Plasma levels monitoring (3 months)
Medical attention if d&v
May lose efficacy if stopped and restarted
No OTC NSAIDs

MPharm Y3S2 (22 decks)

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