Mood Stabilizers Flashcards
Which class of over the counter drug can decrease lithium excretion and thereby increase lithium concentrations?
NSAIDS (except sulindac and aspirin)
What are the indications for lithium?
- Acute mania
- Bipolar maintenance
What mood stabilizer is demonstrated to reduce suicidality?
Li+
What mood stabilizer has proven to be effective prophylaxis in majority of bipolar patients?
Li+
What is Li+ less effective in treating?
Less effective in rapid cycling or mixed bipolar states
What baseline labs need to be done before starting Li+?
Get baseline Creatinine, BUN, TSH, and CBC ( every 6 months)
What teratogenic effect may Li+ have?
First trimester associated with Ebstein’s anomaly (RV hypoplasia & Tricuspid insufficiency)
What are the major side effects of Li+?
- Diarrhea, irritability, fine tremor, weight gain, nausea, hair loss, acne
- Nephrogenic DI (polyuria/polydipsia) secondary to ADH antagonism
- Coarse tremor, gait instability, vomiting, diarrhea, confusion, cognitive slowing, seizures, oliguria, and renal failure
- Alopecia
- Metallic taste
- Women are at greater risk of thyroid dysfunction secondary to Li+
What conditions can increase the risk of Li+ toxicity?
Increased risk of toxicity with:
- Fluid or salt restriction
- Hot weather/sweating
- Use of anti-inflammatory drugs (except Aspirin)
- ACE-I/ARBs
- Thiazide diuretics
In what ways is valproic acid more effective than Li+?
- More effective than lithium in rapid cycling & mixed states
- Can treat aggression and impulsivity in other psychiatric disorders
In what ways is valproic acid not as effective as Li+?
- As effective as Lithium in mania prophylaxis but is not as effective in depression prophylaxis.
What baseline tests should be taken before starting valproic acid?
Before med is started: baseline liver function tests (LFT), pregnancy test, and CBC
When is steady state achieved for Li+ , Carbamazepine, and Valproic acid and what should be done after it is achieved?
- Steady state achieved after 4-5 days
- Valproic Acid => check 12 hours after last dose and repeat CBC and LFTs
- Lithium => check TSH and Creatinine
- Carbamazepine => CBC and LFTs
What are the target blood levels for Li+, Carbamazepine, and Valproic acid?
Lithium : 0.8-1.2
Carbamazepine: 8-12
Valproic Acid: 80-120
What are the major side effects of Valproic Acid?
- Nausea, weight gain, sedation, unsteadiness (ataxia), hair loss, tremor
- Liver dysfunction/hepatic failure, decreased platelets (thrombocytopenia)
- Acute pancreatitis
- Hyperammonemia
- Neural tube defects
What is the use of Carbamazepine as a mood stabilizer?
Utility falls somewhere between Li+ and Valproic Acid
What tests should be done before Carbamazepine is started?
Baseline liver function tests (LFTs), CBC, and EKG
What are the major side effects of Carbamazepine?
- Agranulocytosis (also with clozapine)
- Aplastic anemia
- SIADH
What are the GI effects of Carbamazepine?
GI: nausea, constipation, diarrhea, appetite loss
What are the CNS effects of Carbamazepine?
CNS: sedation, dizziness, unsteadiness, confusion
What are the dermatological effects of Carbamazepine?
Dermatology - benign rashes common, catastrophic rashes (TEN, SJS) rare
What are the cardiac effects of carbamazepine?
AV conduction delays
What is special about the metabolism of carbamazepine?
- p450 inducer
- induces its own metabolism
What is lamotrigine/lamictal particularly good at treating?
Appears to be especially effective in tx of bipolar depression and maintenance treatment of bipolar; unproven to treat mania
Why must lamotrigine be increased slowly?
Slow increase in dosage will decrease risk of steven johnson’s syndrome
What effect does valproic acid and carbamazepine have on lamotrigine?
Valproic acid - increases lamotrigine levels
Carbamazepine - decreases lamotrigine levels
Why are antidepressants discouraged as monotherapy for bipolar disorder?
Concerns of activating mania or hypomania
When is ECT indicated in the treatment of bipolar disorder?
ECT works well in the treatment of manic episodes (usually requires more treatments than depression)
How should a patient with a history of postpartum mania be treated?
- Antidepressants and Li+ in subsequent pregnancies as prophylaxis
- HOWEVER, these are contraindications to breast feeding
