mood stabilizers Flashcards
what are the 5 main mood stabilizers
carbamazepine
lamotrigine
lithium
oxcarbazepine
valproate
brand name of carbamazepine
tegretol
brand name of lamotrigine
lamictal
brand name of lithium
eskalith
brand name of oxcarbazepine
trileptal
brand name of valproate
depakote
carbamazepine upward titration
start 200mg BID w/ food
increase by 200mg qd divided doses at weekly intervals
dosage range for carbamazepine
400-1200mg for bipolar
FDA approved uses for carbamazepine
acute/mixed mania
off label uses for carbamazepine
bipolar depression and maintenance
what two meds are particularly useful for rapid cycling
carbamazepine and lamotrigine
labs prior to starting carbamazepine
CBC
CMP
TSH
LFT
labs to monitor with carbamazepine
CBC
LFT
renal panel
TSH
pregnancy risk of carbamazepine
avoid
give all child bearing age women folate
sedation considerations with carbamazepine
very sedating
ER can decrease sedation
contraindications for carbamazepine
bone marrow suppression
what is unique about carbamazepine
it is a subtrate and an inducer of CYP450 3A4 so dosage must be increased after long term use
which meds are decreased by carbamazepine
birth control
caffeine
olanzapine
clozapine
duloxetine
mirtazapine
luvox
severe side effects of carbamazepine
stevens johnson syndrome
aplastic anemia
agranulocytosis
how long should you try lamotrigine before abandoning
10-12 weeks
upwards titration of lamotrigine
25mg x2wks
50mg x2 wks
100mg x1 wk
200mg on wk 6
titration of lamotrigine when given with valproate
25mg qod x2 wks
25mg qd x2 wks
50mg x1 wk
100mg wk6
interaction between lamotrigine and valproate
valproate doubles the concentration of lamotrigine
FDA approved uses for lamotrigine
Bipolar 1
off label uses for lamotrigine
MDD adjunct
effect of lamotrigine on UDS
can cause false positive for PCP
pregnancy risk of lamotrigine
avoid
dc taper for lamotrigine
taper over at leat 2 weeks unless rash develops then taper over 2 days
severe side effects of lamotrigine
stevens johnson syndrome
blood dyscrasias
aseptic meningitis
lamotrigine and oral contraceptives
birth control decreases effectivenss of lamotrigine
when should you be cautious with lamotrigine
renal, hepatic, and cardiac impairment
initial dose for lithium
300mg BID or TID then titrate based on serum levels
therapeutic lithium levels for mania
1-1.5
therapeutic lithium levels for depression
0.6-1
therapeutic lithium levels for bipolar
0.7-1
FDA approved uses for lithium
acute/mixed bipolar mania and bipolar maintenance
off label uses for lithium
bipolar depression
adjunct for treatment resistant depression
serum lithium level in the elderly
<0.6 is usually still effective
labs to monitor with lithium
CBC w/ diff
BMP
TSH
calcium
fasting glucose
what should you monitor if a patient is over 50 and taking lithium
ECG
how often should you draw lithium levels
every 1-2 weeks until therapeutic
q2-3 months x6 months
q6-12 months thereafter
what is important about the blood sample for lithium levels
must be trough
pregnancy risk with lithium
avoid
what if a patient on lithium is going to have ECT
hold lithium x2 day d/t increased risk of delirium
signs of lithium toxicity
tremor
slurred speech
poor coordination
vomiting
diarrhea
excessive sedation
which medications can increase lithium toxicity
carbamazepine
methyldopa
phenytoin
metronidazole
NSAIDs
what can help with a lithium tremor
low dose propranolol
dc taper for lithium
taper slowly over 3 months
lithium and SSRIs
can exacerbate tremor and increase risk of serotonin syndrome
contraindications for lithium
GFR <50
severe cardiac impairment
intial dose for oxcarbazepine
600mg in divided doses
upwards taper of oxcarbazepine
increase by 300mg daily q3 days to a max of 2400mg
dosage range for oxcarbazepine
1200-2400mg qd
Only FDA approved use for oxcarbazepine
partial seizures
off label use for oxcarbazepine
bipolar
geriatric considerations with oxcarbazepine
lower doses d/t reduced creatinine clearance
pregnancy risk with oxcarbazepine
avoid
dose of oxcarbazepine with renal disease
decrease initial dose by 1/2
how to dc oxcarbazepine
taper slowly
what is different about oxcarbazepine’s side effects compared to other mood stabilizers
less sedation and weight gain than other mood stabilizers
may cause life threatening hyponatremia
oxcarbazepine and oral contraceptives
oxcarbazepine decreases effectiveness of birth control
initial dosage of valproate if mania is NOT acute
500mg qd
initial dose of valproate for acute mania
15mg/kg in 2 divided doses
FDA approved uses for valproate
acute/mixed mania
off label uses for valproate
seizures
migraine prophylaxis
bipolar depression
geriatric considerations for valproate
reduce starting dose and titrate slowly
monitor fluid/nutritional intake
initial labs for valproate
CBC
coagulation tests
LFTs
pregnancy test
BMI
labs to monitor with valproate
LFTs and platelets for first few months then q6-12 months
pregnancy risk for valproate
avoid
when should you change from valproate
if weight gain exceeds 5% of starting weight
dc valproate
must taper slowly
contraindications for valproate
pancreatitis
liver disease
urea cycle DO
valproate and birth control
birth control decreases effectiveness of valproate
