Mood Stabilizers

Question 1

Drug of choice in acute mania

Answer 1

Lithium

*also used for maintenance of both manic and depressive episodes in bipolar and schizoaffective disorder. Also used in cyclothymia and unipolar depression

Question 2

Prior to starting lithium what tests should be ordered? (5)

Answer 2

1. EKG
2. BMP - for kidney function (Li cleared renally!)
3. Thyroid function tests
4. CBC
5. Pregnancy test

*need to regularly monitor blood levels of Li, thyroid function, and kidney function, monitor carefully if renal dysfunction

Question 3

When should blood levels of lithium be checked (first two times after starting)?

Answer 3

1st after 5 days, then q2-3 days until therapeutic

Question 4

What is a therapeutic range for lithium

Answer 4

0.6 to 1.2

Question 5

At what level does lithium become toxic? Lethal?

Answer 5

> 1.5; lethal above 2

Question 6

What are 3 signs of Li toxicity?

Answer 6

1. Altered mental status
2. coarse tremors
3. Convulsions

Eventually death if not treated

Question 7

What are four factors that can cause Li levels to rise?

Answer 7

1. Renal impairment
2. Dehydration
3. Sweating (salt loss)
4. Salt deprivation

Question 8

What common drug causes Li levels to decrease? What other two classes of drugs affect Li levels?

Answer 8

NSAIDs decrease levels

*Diuretics (thiazides esp) and ASA both alter levels as well

Question 9

What are 5 side effects of Li?

Answer 9

1. Nephrogenic diabetes insipidus
2. Weight gain
3. Thyroid enlargement/ hypothyroidism
4. EKG changes
5. Benign leukocytosis

Question 10

What two conditions is carbamazepine useful in treating?

Answer 10

Mixed episodes and rapid cycling bipolar d/o

• less effective for the depressed phase
• also used for treatment of trigeminal neuralgia

Question 11

What two tests must be ordered and monitored in patients taking carbamazepine?

Answer 11

1. CBC

2. LFTs

Question 12

What are th most common side effects of carbamazepine?

Answer 12

GI and CNS (drowsiness, ataxia, sedation, confusion)

Question 13

What are 6 serious side effects that can be seen with carbamazepine?

Answer 13

1. SJS
2. Agranulocytosis (so leukopenia)
3. aplastic anemia
4. hyponatremia
5. Elevation of liver enzymes - hepatitis
6. thrombocytopenia

Question 14

What is a teratogenic effect that can be seen with carbamazepine?

Answer 14

Neural tube defects

Question 15

What effects does carbamazepine have on CYP enzymes?

Answer 15

Is an inducer - even of its own metabolism, so may require increasing doses to achieve therapeutic range

Question 16

What are symptoms of carbamazepine toxicity?

Answer 16

1. nystagmus
2. tremor
3. confusion
4. ataxia
5. confusion
6. vomiting

Question 17

MOA of carbamazepine

Answer 17

Na channel blocker - inhibits APs

Question 18

When are valproic acid levels checked after initiation? Therapeutic levels are?

Answer 18

After 3-5 days; levels are 50-150 microgram/mL

*used for mixed episodes and rapid cycling, like carbamazepine

Question 19

What two tests to monitor with valproic acid?

Answer 19

LFTs and CBC

Question 20

what is lamotrigine used for? What is it not as helpful for?

Answer 20

Used for bipolar depression, not as useful for acute mania or prevention of acute mania

Question 21

What is most serious side effect of lamotrigine?

Answer 21

SJS - most likely in first 4-6 weeks, start low dose and increase slowly
*other side effects include dizziness, sedation, HA, ataxia

Question 22

What relationship do valproic acid and lamotrigine have on each other if given at same time?

Answer 22

Valproate will increase lamotrigine levels and lamotrigine will decrease valproic acid levels

Question 23

What drug is as effective as carbamazepine in mood disorder, but is better tolerated and has less risk of rash and hepatic toxicity?

Answer 23

Oxcarbazepine (trileptal)

Question 24

What drug is useful for impulse control disorder and anxiety?

Answer 24

Topiramate

*but can cause hypochloremic, non-anion gap metabolic acidosis and kidney stones