Mood Stabilizers Flashcards
What lab testing do you order initially when initiating valproate acid or carbamazepine?
Liver panel (ALT, AST, ALP, bilirubin, albumin, total protein)
CBC with WBC differential and platelet count
serum hCG, VPA level at baseline, monthly for the first few months, then every six to 24 months.
How would you dose Depakene?
60mg/kg/d in divided doses, serum trough level 12 hours from previous dose
What is the half life of valproic acid?
13 hours
What is the therapeutic level for valproate acid?
50 - 120
What are the most common hematologic symptoms of VA?
thrombocytopenia and neutropenia
What levels are expected to be elevated in a patient taking VA therapy?
elevated transaminases such as ALT/AST are expected and reported in 2-44% of patients, esp in the first six months of treatment.
In patients taking carbamazepine or being considered for this therapy, which ethnic group is at risk of an increased risk of Steven Johnsons syndrome?
Asian Ancestry- specifically South Asian Indians with the HLA-B*1502 allele.
genetic testing is encouraged
What levels of AST/ALT would prompt the NP to discontinue VA therapy?
elevations above 2-3 times the upper limit of normal ULN.
4 major monitoring key points in patients on VA therapy?
monitor for change in mental status ( assess for hyperammonemia)
CBC (thrombocytopenia), liver function ( transaminitis), pregnancy ( excreted in breast milk)
What is VA FDA approved for?
seizures in children
If child bearing age or hx of hepatic disease, avoid _________
VA
In a patient starting Lithium, the NP will order which labs/tests initially?
Creatine/BUN GFR TSH UA CBC 12 hours lith level Q4-8 weeks then every 6 to 12 months kidney function testing EKG- if over 50 Q 6-12 months lith levels should be 0.6-1.0 if on maintenance treatment and .8-1.2 for acute treatment
where is Lithium absorbed in the body and excreted?
GI tract
urine
NOT metabolized
When would Lithium be contraindicated?
severe dehydration
acute renal failure
sodium depletion
CAN be used in STABLE kidney disease, even kidney transplant patients
Patient has a GFR of 59 ml/min, and is on Lithium for Bipolar II. When is the NPs next intervention?
if GFR is less than 60ml/min or 1.00 mL/s the NP will monitor closer and reduce dose
3 major things Lithium is effected by?
sodium levels
renal function
hydration status
when do lithium toxicity signs develop?
level of 1.5
symptoms: lethargy fatigue clumsy weak muscle cramps nausea vomiting severe tremor blurred vision confusions
Signs: nystagmus ataxia increased deep tendon reflexes altered mental status cardiac arrhythmias
Educated patients on what if on Lithium?
hydration
blood monitoring
meds to avoid
s/s lith toxicity
What medications can INCREASE lithium level?
ACE ARB NSAIDS tetracycline, metronidazole potassium-sparing diuretics thiazide diuretics
What meds can DECREASE lithium ?
Theophylline
What meds can increase or decrease lithium? ( unpredictable)
loop diuretics
calcium channel blockers
Potential effects of lithium on the body system?
elevated TSH (23%) thyroid hypofunction, goiter cardiac conduction-very rare renal: polyuria, polydipsia neuro: fine hand tremor general: weight gain
the MAJOR lab to check for clozapine?
ANC above or equal to 1500 needed to start d/c if falls below 1000 beware of BEN monitor labs weekly X6 months, then Q2 weeks X 6 months, then monthly if ANC 1500
Biggest risk of Clozapine?
major risk of agranulocytosis (1-2%)
What program must the np navigate through to get a patient on clonzapine?
REMS The Clonazpine Risk Evaluation and Mitigation Strategy Program
Steven Johnsons Syndrome risk is increased in patient taking lamictal along with__________
valprioc acid
Half life of lamotrigine?
30 hours
half-life is DOUBLED when using VA with it
What reduces the half-life of lamotrigine?
smoking induces metabolism and reduces half-life by 50%
What trimester is Lithium contraindicated in?
1st trimester- risk of Ebstein’s Anomaly: Right Ventricular outflow tract obstruction in the fetus
Is lithium excreted in breast milk, true or false
TRUE
half life of Lithium?
20 hours
Avoid which drugs in the use of lamotrigine?
birth control pills or implant ( decreases their effectiveness)
Acetaminophen DC effects of Lamictal
VA increased Lamictal
st johns wort -DC lamo
folate inhibitors- methotrexate, sulfamethoxazole, trimethoprim
oxcarbazepine, phenobarbital, phenytoin, primidone -may dc LAMO
medroxyprogesterone acetate- may DC hormonal contraceptive levels
Where is lamotrigine metabolized?
liver CYP450
excrete in urine and poop
peak plasma, bioavailability, and half life of lamotrigine
half-life 14.5-70.25 hours
PP: 1-5 HRS
BIO: 98%
Precautions of patients on lamotrigine?
mod- severe renal impairment
older adults
