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Year 3 Psych thats the wrong number > Mood stabilisers > Flashcards

Mood stabilisers Flashcards

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1
Q

What disorders can be treated using mood stabilisers?

A

Bipolar disorders

Cyclothymia (less severe bipolar*)

Schizoaffective disorder

*very simple definition - more to it than that

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2
Q

What are the classes of mood stabilisers?

A

Lithium

Anticonvulsants

Antipsychotics

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3
Q

What is lithium used to treat?

What factors predict a positive response to lithium treatment?

A

Bipolar disorder (mainly) - also cyclothymia

Only medication to reduce suicide rate in BAD patients

Factors predicting effectiveness:

  • prior long-term response by patient or by family member
  • classic pure mania
  • if mania happened first, and followed by depression
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4
Q

Before starting a patient on lithium - what investigations should be done?

A

U&Es - affects renal function

TSH - can cause hypothyroid

Pregnancy test - ebstein anomaly in 1st trimester*

*Can still prescribe to women of child bearing age but they should be on birth control

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5
Q

What monitoring must be done if a patient is started on lithium?

A

After 5 days, 12 hours after their last dose - check blood levels of lithium:

Goal = 0.6 - 1.2

Check lithium levels every 3 months

Check TSH & creatinine (U&Es) every 6 months

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6
Q

What are the side effects of lithium?

A

GI upset - reduced appetite, N&V, diarrhoea

Thyroid abnormalities (hence TSH checks)

Nonsignificant leukocytosis

Polyuria/polydypsia

Hair loss, acne

Reduced seizure threshold, tremor, cognitive slowing

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7
Q

Polyuria and polydypsia are both potential side effects of lithium

What causes this?

What serious complication involving the kidneys can arise?

A

Polyuria/polydypsia happen secondary to ADH (vasopressin) antagonism

Renal interstitial fibrosis can occur in a small number of patients - hence why renal function must be checked

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8
Q

How toxic is lithium?

What symptoms are seen at increasing levels of overdose?

A

Pretty darn toxic

Mild (1.5-2.0) - vomiting, diarrhoea, ataxia, dizziness, slurred speech, nystagmus

Moderate (2.0-2.5) - nausea, vomiting, anorexia, blurred vision, clonic limb movements, convulsions, delirium, syncope

Severe (>2.5) - generalised convulsions, oliguria, renal failure, death

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9
Q

What are the main anti-convulsants?

A

Valproic acid (Depakote)

Carbamezapine (Tegretol)

Lamotrigine (Lamictal)

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10
Q

How does Valproic acid compare to Lithium in the treatment of Bipolar disorder?

A

Valproic acid is as effective as lithium in prophylaxis of mania

But it is less effective in prophylaxis of depressive episodes of BAD

Valproic acid is also tolerated better than lithium

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11
Q

What factors predict a positive response to Valproic acid?

A

Rapid cycling patients* (females > males)

Comorbid substance abuse issues

Mixed patients (no idea)

Patients with comorbid anxiety disorders

*patients with frequent manic-depressive transitions

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12
Q

What tests must be done before starting a patient on valproic acid?

A

Liver function test (LFT)

Pregnancy test

FBC

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13
Q

What are contraindications to using Valproic acid?

A

Child bearing age - causes neural tube defects in pregnancy

Liver problems

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14
Q

How is Valproic acid monitored?

A

5 days for steady state so check 5/6 days after commencement - 12 hours after last dose

Goal = 50-125

Blood level not as significant as with Lithium though

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15
Q

What are the potential side effects of using valproic acid?

A

Nausea, vomiting, weight gain

Thrombocytopenia & platelet dysfunction

Sedation, tremor

Alopecia (hair loss)

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16
Q

What is Carbamazepine used for?

A

First line for acute mania and mania propylaxis

Indicated for rapid cyclers and mixed patients

17
Q

Before starting a patient on Carbamazepine, what tests must be done?

A

LFT

FBC

ECG

18
Q

How is the response to Carbemazepine monitored?

A

Again - 5 days to steady state

12 hours after last dose

Goal = 4-12 mcg/ml

Check level and adjust dosing after a month as it induces its own metabolism

19
Q

What are the potential side effects of Carbamazepine?

A

Rash

Nausea, vomiting, diarrhoea

Sedation, ataxia, dizziness, confusion

AV conduction delays

Aplastic anaemia & agranulocytosis

Water retention, hyponatraemia

Drug-drug interactions

20
Q

What are the benefits of Lamotrigine compared to other anti-convulsants?

A

Can be used in women of CBA

Can also be used for neuropathic/chronic pain

21
Q

What tests must be done before commencing treatment with Lamotrigine?

A

LFT

22
Q

How does the titration of Lamotrigine differ from that of the other anti-convulsants?

What happens if the patient stops taking Lamotrigine?

A

Slowly titrate dose up

Faster titration risks Steven johnson syndrome (very severe rash)

If stops for 5 or more days - then have to start at lowest dose (25mg) and titrate up again

23
Q

What are the potential side effects of Lamotrigine?

A

Nausea & vomiting

Sedation, dizziness, ataxia, confusion

Steven Johnson’s syndrome - if any rash develops then immediately stop

Blood dyscrasias

24
Q

What medications can interfere with Lamotrigine?

A

VPA (valproic acid) - doubles concentration so have to titrate up even more slowly

Sertraline

25
Q

Case copied from presentation

33 yo woman hospitalized with her first episode of mania. She has no previous history of a depressive episode. She has no drug or ETOH history and has no medical issues.

  1. What medication would you like to start?
  2. What investigations would you do first?
  3. What would you discuss with the patient?
A

Given her first presentation was a manic episode statistically she will do better on lithium

Pregnancy test, U&Es, TSH

Discuss with her what she will use for birth control and document this discussion

26
Q

Case from presentation

27 yo male is admitted secondary to a manic episode. In reviewing his history you find he has 5 to 6 manic or depressive episodes a year. He has also struggled on and off with ETOH abuse.

What medication would you start him on?

Why?

A

Valproic acid (Depakote)

Good for the patient because he is:

  • Rapid cycler (6 episodes per year)
  • comorbid substance abuse (alcohol)
27
Q

You start a patient on an anticonvulsant - and check their LFTs after you have titrated to the adequate dose

Their LFTs are elevated as follows:

  • ALT 48 –> 115
  • AST 62 –> 140
  • ALK phos 32 –> 80

Is this bad?

A

It is not unusual for patients on anticonvulsants to experience an increase in lfts.

As long as they do not more than triple no change in therapy is indicated

You would continue to monitor this however

28
Q
A

Year 3 Psych thats the wrong number (20 decks)

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