Mood Stabilizers

Question 1

What lab testing do you order initially when initiating valproate acid or carbamazepine?

Answer 1

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.

Question 2

How would you dose Depakene?

Answer 2

60mg/kg/d in divided doses, serum trough level 12 hours from previous dose

Question 3

What is the half life of valproic acid?

Answer 3

13 hours

Question 4

What is the therapeutic level for valproate acid?

Answer 4

50 - 120

Question 5

What are the most common hematologic symptoms of VA?

Answer 5

thrombocytopenia and neutropenia

Question 6

What levels are expected to be elevated in a patient taking VA therapy?

Answer 6

elevated transaminases such as ALT/AST are expected and reported in 2-44% of patients, esp in the first six months of treatment.

Question 7

In patients taking carbamazepine or being considered for this therapy, which ethnic group is at risk of an increased risk of Steven Johnsons syndrome?

Answer 7

Asian Ancestry- specifically South Asian Indians with the HLA-B*1502 allele.
genetic testing is encouraged

Question 8

What levels of AST/ALT would prompt the NP to discontinue VA therapy?

Answer 8

elevations above 2-3 times the upper limit of normal ULN.

Question 9

4 major monitoring key points in patients on VA therapy?

Answer 9

monitor for change in mental status ( assess for hyperammonemia)
CBC (thrombocytopenia), liver function ( transaminitis), pregnancy ( excreted in breast milk)

Question 10

What is VA FDA approved for?

Answer 10

seizures in children

Question 11

If child bearing age or hx of hepatic disease, avoid _________

Answer 11

VA

Question 12

In a patient starting Lithium, the NP will order which labs/tests initially?

Answer 12

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

Question 13

where is Lithium absorbed in the body and excreted?

Answer 13

GI tract
urine
NOT metabolized

Question 14

When would Lithium be contraindicated?

Answer 14

severe dehydration
acute renal failure
sodium depletion
CAN be used in STABLE kidney disease, even kidney transplant patients

Question 15

Patient has a GFR of 59 ml/min, and is on Lithium for Bipolar II. When is the NPs next intervention?

Answer 15

if GFR is less than 60ml/min or 1.00 mL/s the NP will monitor closer and reduce dose

Question 16

3 major things Lithium is effected by?

Answer 16

sodium levels
renal function
hydration status

Question 17

when do lithium toxicity signs develop?

Answer 17

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

Question 18

Educated patients on what if on Lithium?

Answer 18

hydration
blood monitoring
meds to avoid
s/s lith toxicity

Question 19

What medications can INCREASE lithium level?

Answer 19

ACE
ARB
NSAIDS
tetracycline, metronidazole 
potassium-sparing diuretics
thiazide diuretics

Question 20

What meds can DECREASE lithium ?

Answer 20

Theophylline

Question 21

What meds can increase or decrease lithium? ( unpredictable)

Answer 21

loop diuretics

calcium channel blockers

Question 22

Potential effects of lithium on the body system?

Answer 22

elevated TSH (23%) thyroid hypofunction, goiter 
cardiac conduction-very rare 
renal: polyuria, polydipsia
neuro: fine hand tremor 
general: weight gain

Question 23

the MAJOR lab to check for clozapine?

Answer 23

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

Question 24

Biggest risk of Clozapine?

Answer 24

major risk of agranulocytosis (1-2%)

Question 25

What program must the np navigate through to get a patient on clonzapine?

Answer 25

REMS The Clonazpine Risk Evaluation and Mitigation Strategy Program

Question 26

Steven Johnsons Syndrome risk is increased in patient taking lamictal along with__________

Answer 26

valprioc acid

Question 27

Half life of lamotrigine?

Answer 27

30 hours

half-life is DOUBLED when using VA with it

Question 28

What reduces the half-life of lamotrigine?

Answer 28

smoking induces metabolism and reduces half-life by 50%

Question 29

What trimester is Lithium contraindicated in?

Answer 29

1st trimester- risk of Ebstein’s Anomaly: Right Ventricular outflow tract obstruction in the fetus

Question 30

Is lithium excreted in breast milk, true or false

Answer 30

TRUE

Question 31

half life of Lithium?

Answer 31

20 hours

Question 32

Avoid which drugs in the use of lamotrigine?

Answer 32

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

Question 33

Where is lamotrigine metabolized?

Answer 33

liver CYP450

excrete in urine and poop

Question 34

peak plasma, bioavailability, and half life of lamotrigine

Answer 34

half-life 14.5-70.25 hours
PP: 1-5 HRS
BIO: 98%

Question 35

Precautions of patients on lamotrigine?

Answer 35

mod- severe renal impairment

older adults