Mood Stabilizers Flashcards
symptoms of bipolar seen in childhood
and puberty and adolescence
- sleep, anxiety, mild depressive symptoms
- sensitivity to stress, irritability, lability
- recurrent MDD, hypomanic/manic symptoms
definition of mania
a state of abnormally
elevated arousal, affect,
and energy level,
heightened overall
activation with enhanced
affective expression
together with lability of
affect
manifestations of mania
Agitation
Excessive talking
Elevated mood
Grandiose thoughts
Flight of ideas
Impulsive behavior
Inflated self esteem
Racing thoughts
Poor sleep
Sexuality
Poor attention span
Suicide
symptoms of mild-moderate lithium toxicity
Diarrhea
Vomiting
Fatigue
Tremors
Increased drowsiness
Uncontrollable movement
Blurred vision
primary goal of treatment of Acute Bipolar Mania
the control of symptoms ot allow a return to normal levels of psychosocial functioning. The rapid control of agitation, aggression, and impulsivity is important to ensure the safety of patients and those around them.
how many pts with acute bipolar mania will respond to mono therapy
50%
medication most associated with Steven Johnson syndrome
lamotrigine
indication for neuropathic pain
Carbamazepine
what type of antidepressants are most likely to cause manic cycling in pts
TCAs and MAO-I antidepressants
target Lithium levels for acute mania phase
0.8-1.2 mmol/L
target maintenance levels of lithium
0.6-1 mEq/L
maintenance level of lithium for elderly
Elderly 0.4-0.6 mEq/L
why would a pt taking lithium also be on calcium and vitamin D supplements
Lithium = decreased bone density
mania can be induced by?
- antidepressant
- stimulants (cocaine, amphetamines, diet-aids)
- hormones: thyroid hormone, corticosteroids, testosterone
- herbals: st johns wart, ginseng, ma-huang
- levodopa and other antiparkinsons,
dementia drug
order of 1st line treatment for Bipolar Disorder 1
- lithium
- quetiapine
- divalproex
- lamotrigine
- aripiprazole
what is a trough level
lowest point of the medication in steady state = just before their last dose (e.g. taking lithium levels just before they take their 8am - medication after sleeping/not taking meds for 12 hours prior to levels being drawn)
1st line tx for acute mania
Adults: Lithium
valproates, SGAs: risperidone,
aripiprazole, quetiapine, asenapine OR Combination
treatment
1st line tx for depression
1st line: Adults: lamotrigine
quetiapine, lithium, OR
combination.
2nd line tx for acute mania
olanzapine, ECT
2nd line tx for depression
Adults: divalproex (Epival), adjunctive SSRIs,
bupropion (NDRI), ECT
1st line tx for BD2 depression
2nd line tx
- quetiapine
- lithium, lamotrigine
lithium ______ GABA
increases
lithium works in _____% of pts
70-80%
when do symptoms start to decrease after starting lithium
4-14 days
when will pts notice a maximum therapeutic response from lithium
10-21 days
where is lithium excreted
kidneys
half life of lithium
18-20 hours
36 hours in the elderly
which mood stabilizer causes alopecia?
valproic acid
low serum sodium _______ lithium levels
increases
hypernatremia leads to _______ lithium levels
decreased
Caffeine, Metamucil and bronchial dilators _____ lithium levels
decrease
Nausea, vomiting, diarrhea, sweating, diuretics, ACE Inhibitors/ARB, Carbamazepine,
Calcium Channel Blockers, NSAIDS, fluoxetine (Prozac)
= things that promote water loss
________ lithium levels
increase
true or false: lithium provides a suicidal protective factor?
true
those not on Lithium commit suicide 20 times more often
lithium prevents relapse 25-50% in both ____ & ______ episodes
manic and depressive
contraindications of lithium
Severe cardiovascular disease
Severe renal disease
Severe sodium depletion
Dehydration (Exercise Diuretics Hot environment Diarrhea/vomiting)
Concurrent use of diuretics
Substance use
Pregnancy/ Lactation
Use of OTC ( NSAIDs Ibuprofen, Naproxen)
Consider Developmental Variable
excess fluid intake ____ lithium
dilutes
what would indicate someone should be on a lower dose of lithium?
renal disease, older age, interacting medications
SE of lithium
- GI: nausea, vomiting (usually resolve in a few days), metallic taste, polyuria,
polydipsia - muscle weakness, fine hand tremor, fatigue
- headache poor concentration and memory
- weight gain
- Acne, psoriasis, hair loss
- Decreased bone density
- Hypothyroidism
- Leukocytosis
- Assess for Metabolic Syndrome
how long does it take for lithium to reach a steady state
up to 5 days to reach steady
state (i.e. 5 1/2 half lives)
what levels indicate mild-moderate lithium toxicity
1-2 mEq/L
symptoms of mild-moderate lithium toxicity
- Diarrhea
Vomiting
Fatigue
Tremors
*** Increased drowsiness
Uncontrollable movement
Blurred vision
what levels indicate severe lithium toxicity
> 2 mEq/L
symptoms of severe lithium toxicity
Delirium
Slurred Speech
Seizures
Rapid Heart Rate
Hyperthermia
Nystagmus
Confusion
Kidney failure
Coma
ideal dose of lithium
once daily to decreases risk of
toxicity or long term kidney damage.
true or false - there are physical withdrawal symptoms when you abruptly stop lithium
false - but rapid cycling may occur
pt teaching for lithium
- Eat a regular diet with adequate salt and fluids (avoid excessive salt and fluids).
- Never double up on missed doses.
- Ensure all physicians involved in care aware on Lithium.
- Report signs of toxicity to physician at once.
- Ensure patients do not take Lithium 12 hours prior to levels being drawn.
What is a commonly used analgesic that can increase lithium
levels and risk of nephrotoxicity?
IBprofin (advil) is hard on the kidneys (so take Tylenol) – both use the kidneys so it can cause lithium increase which can cause toxicity
true or false all anticonvulsants can be used as mood stabilizers
false
Mechanism of Action: lamotrigine
- Increases inhibitory (GABA) neurotransmission
- Inhibits excitatory (glutamate) neurotransmission
indications for lamotrigine
Epilepsy
Bipolar depression acute treatment and maintenance
Off Label use- Borderline Personality
lamotrigine should be used with caution in pts with?
renal or hepatic impairment
SE of lamotrigine
- Dizziness
- Somnolence
- Diplopia
- Headache
- Nausea, vomiting, diarrhea
- Non serious rash
- Rare serious: fever, swelling lips and tongue and lymph nodes. Can be life
threatening (Steven-Johnson syndrome- black box warning re: life threatening skin
rash)
valproic acid & divalproex indications
Prophylaxis and treatment of BD in those who fail to respond to Lithium
Better for mixed mania or rapid cycles.
Effective in treating mania secondary to a general/other medical condition
More rapid response than Lithium
Treatment of many focal and generalized seizure types
Migraine prophylaxis
valproic acid & divalproex contraindications
Blood dyscrasias (eg hemophilia,
leukemia)
Renal or hepatic impairment
Organic brain disease
what precautions should be considered when a pt starts taking valproic acid or divalproex
- Avoid in Pregnancy (category D) /breast feeding
- Hepatic dysfunction
- Dental work
half life of valproic acid/ divalproex
6-16 hours
how long for valproic acid/ divalproex to reach a steady state
2-5 days
typical serum level valproic/divalproex
level range is 350-835 umol/L [50-100 mcg antiepileptic]
valproic/divalproex interactions
- Phenytoin, aspirin, ETOH,
antipsychotics, carbamazepine,
clonazepam, antidepressants. - These interactions can increase
or decrease absorption leading
to greater risk of toxicity, or lack
of therapeutic effect. They can
also be used to boost the
therapeutic effect (eg
antipsychotics)
valproic/divalproex SE
Transient hair loss, weight gain/loss, tremors, GI upset, somnolence (sleepiness or drowsiness), dizziness, headache, sleep disturbance, metabolic syndrome, thrombocytopenia, and on rare occasions hepatotoxicity, pancreatitis,
thrombocytopenia.
What is one of the most serious adverse effects of valproic acid?
hepatotoxicity
pt teaching for valproic/divalproex
- its an acid - take with food
pt teaching for carbamazepine
- take with food/avoid grapefruit
Therapeutic serum levels: carbamazepine
4- 12 mmol/L
mechanism of action carbamazepine
increases GABA
why is carbamazepine less commonly used
because of erratic absorption
carbamazepine indications
Effective antimanic agent (does not treat depression)
Effective prophylactic agent but not as good as Lithium
Epilepsy
Neuropathic pain
carbamazepine SE
- Common: sedation, fatigue, dizziness, headache, GI upset (nausea and vomiting),
blurred vision, slurred speech. - Rare but serious: skin rash, leukopenia, hyponatremia, agranulocytosis
Seizures definition
excessive stimulation of neurons in the brain involving sensory or motor activity
convulsion definition
more severe seizure caused by involuntary spasmodic contractions, involving any or all muscles in the body
epilepsy definition
chronic recurrent pattern of seizures
status epilepticus
ongoing seizures that you can’t stop *medical emergency
Barbiturate (phenobarbital, pyrimidine) mostly used for
Mainly used for ER , status epilepticus
Barbiturate (phenobarbital, pyrimidine) Plasma levels
15-20 mcg/L
Barbiturate (phenobarbital, pyrimidine) SE
Dizziness, drowsiness, sedation, lethargy, paradoxical restlessness
First line for seizure maintenance
Phenytoin
- inexpensive, well tolerated, highly effective
Phenytoin plasma levels
10-20 mcg/L
phenytoin SE
Drowsiness, dizziness, lethargy, abnormal movements (ataxia) , mental confusion and cognitive changes, measles like rash*
longterm phenytoin use can cause
gingival hyperplasia, dilantin facies (subcutaneous tissue of face becomes swollen and thick, causing dysmorphia of face)
and osteoporosis
phenytoin IV use cautions
- dose slowly in NS solution only - Irritating to vein; will cause phlebitis if you don’t dilute it with NS
- safety measures to prevent falls
- daily oral care and frequent dental visits
signs of phenytoin toxicity
nystagmus, ataxia, dysarthria and
encephalopathy
indications for topiramate
epilepsy, mania and rapid cycling, adjunct therapy
nursing actions for topiramate
Assess and monitor vital signs and mental sensorium; level of
alertness or consciousness or mental depression
topiramate SE
weight loss, word finding difficulties, agitation, fatigue.
gabapentin indications
epilepsy, rapid cycling BD II, or as adjunct for neuropathic pain or migraines.
gabapentin SE
sedation, tremor, hypotension, ataxia, uncoordination,
GI upset, including appetite and weight gain
first line tx for severe convulsions
benzodiazepines (diazepam, lorazepam, clonazepam, clorazepate)
first line tx for status epileptics
diazepam - and severe convulsions
- used as a muscle relaxant and for decreasing anxiety
- lorazepam can also be used for status epilepticus.
second line tx for epilepsy
benzodiazepines (diazepam, lorazepam, clonazepam, clorazepate)
indications for clonazepam
Used to treat absence seizures and also for treating manic/panic disorders
SE clonazepam
drowsiness, ataxia, and behavioral
(hyperactivity, irritability), moodiness, aggressive behavior changes and personality change
- tolerance
clorazepate
- Long acting benzodiazepine used as an adjunct for partial seizures
and for anxiety and alcohol withdrawal - half life is 48 hours
benzodiazepine SE
- CNS depression, most common; H/A, dizziness, lethargy, cognitive impairment
- palpitations, dry mouth
- Because of the effect on normal sleep many experience a hangover effect
- Physical dependency and withdrawal symptoms
- GI upset therefore take with food
- Grapefruit juice alters absorption
benzodiazepine SE that alert nurse to notify doctor
Notify doctor if seizures occur, or if develop vomiting, weakness,
what level of lithium will cause mild-moderate toxicity
Levels 1-2 mEq/L
what level of lithium will cause severe toxicity
> 2 mEq/L
S&S of severe lithium toxicity
Delirium
Slurred Speech
Seizures
Rapid Heart Rate
Hyperthermia
Nystagmus
Confusion
Kidney failure
Coma
Gingival hyperplasia
Overgrowth of gum tissue; often an adverse effect of phenytoin.
Status epilepticus
A medical emergency of prolonged seizure activity, that lasts for 5 minutes or longer, of continuous clinical or electrographic seizure activity or recurrent seizure activity without recovery (returning to baseline) between seizures.
Mechanism of Action of anti epileptic drugs
the overall effect is that antiepileptics stabilize neurons and keep them from becoming hyperexcited and generating excessive nerve impulses to adjacent neurons.
anti epileptic drugs effective for focal onset (partial) seizures
phenobarbital, phenytoin, primidone, car- bamazepine, and valproic acid
anti epileptic drugs used as adjunct therapy for refractory (not responsive to other therapy) focal onset (partial) seizures
Lamotrigine, topiramate, gabapentin, and levetiracetam
which patients are at high risk for aquiring a seizure disorder who receive AED therapy
Patients who undergo brain surgery or who have suffered severe head injuries receiving prophylactic AED therapy
what is the only contraindication to anti epileptics
- known drug allergy
- Pregnancy is also a common contraindication; however, the prescriber must consider the risks of untreated maternal epilepsy to the mother and fetus and the increased risks for sei- zure activity.
For patients taking AEDs, nursing interventions are aimed at?
monitoring the patient while providing safety measures and securing the airway, breathing, and circulation.
if a pt misses one or more doses of AED medication
the prescriber needs to be contacted immediately due to the increased risk of seizure activity.
which AED can be taken without regard to meals
Gabapentin
Oral dosage forms of this drug are not to be taken with carbonated beverages. It is recommended that this drug be taken with food or at least 180–240 mL of water to minimize GI upset.
Valproic acid
how long must a pt wait before they can drive after starting an AED
Educate the patient about the sedating effects of drug ther- apy so that appropriate steps can be taken to ensure patient safety until a steady state is achieved (usually after four or five drug half-lives). The patient is not to drive, operate heavy machinery, or make major decisions until a steady state is achieved.
common and modifiable risk factors that may influence the risk of seizures or epilepsy and are to be avoided
Alcohol, caffeine intake, and smoking
The adverse effects most commonly associated with AEDs
drowsiness, GI upset, and CNS-depressing effects. Remind the patient that these adverse effects often decrease after the drug has been taken for several weeks. Taking the AED with food or 180–240 mL of fluids, unless otherwise noted, will help to minimize GI upset.
a recurrence of seizure activity is usually due to
- a lack of adherence with the drug regimen
- *treatment of epilepsy is lifelong
and that adherence with the treatment regimen is important
for effective therapy
important ways to improve safety in day-to-day activities while taking AEDs
- In the kitchen: Use an electric stove with no open flame, wear oven mitts, and cook only on rear burners. Cook in the microwave—it is thesafest option. Have a plumber install a heat-control device on faucets to avoid burns. Cover floors in carpet to help cush- ion falls and use plastic dishes and containers instead of glass when possible
- In the bathroom: Use heat-control devices on faucets. Cover floors in carpet instead of using tile. Do not put a lock on the bathroom door so that help can be obtained if needed. Bathe with only a few inches of water in the tub, and if seizure activity has not been fully controlled, bathe while someone else is present in the home.
- During activi- ties: Always have someone along when engaging in sports, and make sure the person is knowledgeable about the man- agement of airway and seizures. Bike riding with a helmet, swimming, and water sports are okay if an accompanying adult is present who knows how to manage seizure activity and its consequences.
A patient is experiencing temporary lapses in consciousness that last only a few seconds. Her teachers have said that she “daydreams too much.” What type of seizure can this be classified as?
generalized
Which condition is a life-threatening emergency in which patients typically do not regain consciousness?
a. Status epilepticus
b. Tonic clonic convulsions
C. Epilepsy
d. Primary epilepsy
Status epilepticus
Which of the following is true about the intravenous infusion of phenytoin (Dilantin)?
(Select all that apply.)
i. Phenytoin is injected quickly. ii. Phenytoin is injected slowly.
ili. The injection of phenytoin is followed by an
injection of sterile saline.
iv. Phenytoin must not be infused continuously.
v. Phenytoin is mixed with D, W 5% dextrose and water) for the infusion.
a. 1, ii, ili
b. i, ii, iv
c. ii, ili, iv
d. ii, ili, v
c. ii, ili, iv
The nurse administers phenobarbital to a patient.
What priority clinical manifestation should the nurse monitor as a possible adverse effect of this therapy?
Drowsiness
A patient with a history of epilepsy experiences status epilepticus. What medication can the nurse expect to prepare for this condition?
diazepam (valium)
A patient who is experiencing neuropathic pain tells the nurse that the health provider is going to start him on a new medication that is generally used to treat seizures. The nurse anticipates that which drug will be ordered?
Gabapentin
Phenytoin (Dilantin) is prescribed for a patient.
The nurse checks the patient’s current list of medications and notes that interactions may occur with which drugs or drug classes?
phenobarbital
phenytoin
gabapentin
A patient is unable to take oral medications and has received a loading dose of phenytoin (Dilantin) intravenously. The orders call for him to receive phenytoin 5 mg/kg per day in three divided doses. The medication comes in a vial containing 50 mg/mL. The patient weighs 90 kg.
a. How many milligrams will the patient receive each day? For each dose?
b. How many millilitres of medication will be drawn up for each dose?
a. 450 mg/d; 150mg per dose
b. 3 mL per dose
true or false: Half of manic episodes are characterized by the presence of psychosis. Antipsychotics may be used as an adjunctive treatment of acute psychotic symptoms fi not already being administered
true
Rapid Cycling
- Includes four or more episodes a year, effecting 1/3 of those with Bipolar Disorder.
- Hypothyroidism, antidepressant use, and substance abuse are often associated with rapid cycling; thus assessing thyroid function and discontinuation of antidepressants, stimulants, and other psychotropic agents that are contributors to cycling are important.
which disorders are contraindicated with lithium
- CV disease / cardiac impairment
- brain damage
- conditions requiring reduced sodium intake
- renal impairment
what can cause severe lithium toxicity
lithium accumulation due to dosage, dehydration, sodium depletion, or renal dysfunction
why is it unsafe for clients to take carbamazepine with grapefruit or grapefruit juice
I can significantly increase serum levels.
serious SE related to carbamazepine
Agranulocytosis /Aplastic
anemia: monitor for signs of unusual bleeding or bruising, mouth sores, infections, fever or sore
carbamazepine half-life
Initial half-life values range from 25-65 hours, decreasing to 12-17 hours on repeated doses.
