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Pharm III - Exam 4 > Mood Stabilizers > Flashcards

Mood Stabilizers Flashcards

1
Q

Neurochemical theories of BD

A
  • Catecholamine hypothesis
  • Permissive theory
  • GABA and glutamate involvement
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2
Q

Catecholamine hypothesis of BD

A
  • Mania may be related to excess NE and DA

- Depression may be related to deficits in NE, 5HT, DA

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3
Q

Permissive theory of BD

A
  • Underlying decrease in 5HT with increased NE resulting in mania
  • Decreased NE resulting in depression
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4
Q

What is necessary to rule out in evaluation of BD?

A
  • Medical or drug induced causes

- Other psych diagnoses

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5
Q

Complete work-up prior to diagnosing BD?

A
  • PE
  • Basic labs (CBC, thyroid, electrolytes)
  • Toxicology screen
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6
Q

Treatment goals for BD

A
  1. Resolve acute symptoms
  2. Facilitate pt’s return to pre-morbid functioning
  3. Prevent further episodes
  4. Pharm is cornerstone of treatment
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7
Q

Pharm treatment of BD

A
  • Mood stabilizers

- Other agents (adjunctive anxiolytic or short term antipsychotic)

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8
Q

How long does it take mood stabilizers to elicit a response in BD?

A

7-10 days

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9
Q

How long does it take anxiolytic or short term antipsychotics to elicit a response in BD?

A

3-5 days

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10
Q

What are mood stabilizer agents used in BD?

A
  • Lithium
  • Valproic acid/divalproex sodium
  • Lamotrigine
  • Carbamazepine
  • Oxcarbazepine
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11
Q

Drug of choice for “classic” mania?

A

Lithium

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12
Q

Lithium is FDA approved for:

A
  • Acute mania

- Maintenance of BPD 1

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13
Q

What is shown to reduce risk of suicide in patients with depressive episodes in BD?

A

Lithium

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14
Q

Lithium MOA

A
  • Unclear

- May involve 5HT, DA, GABA

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15
Q

Lithium metabolism

A

Excreted unchanged in the urine

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16
Q

Early ADEs of Lithium

A

Dose related and worse at peak serum concentrations

  • GI
  • Muscle weakness/lethargy
  • Polydipsia w/polyuria (70%)
  • HA, memory impairments, confusion (40%)
  • Fine hand tremor (50%)
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17
Q

ADEs of Lithium later in treatment

A
  • Nephrogenic DI
  • Morphological renal changes
  • Hypothyroidism (30%)
  • Cardiac effects (30%)
  • Wt gain
  • Decreased libido
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18
Q

Monitoring parameters of Lithium

A
  • Plasma concentration taken 8-12 hrs after last dose (trough)
  • Renal function
  • Thyroid function
  • ECG
  • CBC
  • Serum electrolytes
  • Pregnancy test
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19
Q

Lithium toxicity

A
  • Plasma concentrations over 1.5: GI, decrease in coordination
  • Plasma concentrations over 2: seizures, cardiac arrhythmias, neuro impairment, kidney damage, coma, death
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20
Q

What situations predispose a patient to Lithium toxicity?

A
  • Na restriction (aka DASH diet)
  • Dehydration
  • Vomiting, diarrhea
  • Drug interactions that lower Li clearance
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21
Q

How to treat Lithium toxicity?

A

Dialysis

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22
Q

What drugs cause decreased Lithium clearance?

A

FANTS

  • Fluoxetine
  • ACE inhibitors
  • NSAIDs
  • Thiazides
  • Salt restricted diets
23
Q

What drugs cause increased Lithium clearance?

A
  • Caffeine

- Theophylline

24
Q

Lithium in pregnant/lactating patients

A
  • Category D
  • Crosses placenta
  • May cause floppy infant syndrome
  • Present in breast milk
25
Q

What is Valproic acid FDA approved for?

A
  • Acute mania in BPD 1

- NOT approved for maintenance, but commonly used as monotherapy or in combo w/other agents

26
Q

How does Valproic acid compare to Lithium?

A

Better efficacy for mixed states and rapid cycling

27
Q

Valproic acid MOA

A

Proposed mechanisms:

  • Increases GABA in CNS
  • Antikindling properties (may decrease rapid cycling/mixed states)
28
Q

Valproic acid drug interactions

A

Inhibits Lamotrigine and Carbamazepine metabolism (competes with hepatic glucuronidation site)

29
Q

Valproic acid use in pregnant/lactating pts

A
  • Category D (neural tube defects during 1st trimester)

- Considered compatible with breast feeding

30
Q

Valproic acid monitoring

A
  • Therapeutic plasma concentrations
  • CBC w/diff
  • Chem panel w/electrolytes
  • LFTs
31
Q

What is Lamotrigine FDA approved for?

A

Maintenance of BPD 1

  • Has both antidepressant and mood stabilizing effects
  • May prevent bipolar depression
32
Q

Lamotrigine MOA

A

Proposed mechanisms:

  • Modulates or decreases glutamate release
  • Antikindling properties
33
Q

Which mood stabilizers may cause a rash leading to SJS?

A
  • Valproic acid

- Lamotrigine

34
Q

How does lamotrigine affect weight?

A

It doesn’t (Li and VA do)

35
Q

Lamotrigine use in pregnant/lactating

A
  • Category C

- NOT recommended in breast feeding

36
Q

Lamotrigine monitoring

A

Derm (assess for rash)

37
Q

Carbamazepine MOA

A

Proposed mechanisms:

  • Modulates or decreases glutamate release
  • Antikindling properties
38
Q

Use of Carbamazepine in BPD

A

Monotherapy or in combo for acute and maintenance (NOT 1st line)

39
Q

What is unique regarding Carbamazepine?

A

Pan-inducer: induces its own metabolism (and others)

40
Q

Carbamazepine ADEs

A
  • CNS toxicity (up to 60% pts)
  • GI
  • Hyponatremia
  • Wt gain
  • Agranulocytosis
  • Derm reactions
41
Q

Carbamazepine toxicity

A
  • At over 15 mcg/mL

- Ataxia, choreiform movements, diplopia, nystagmus, etc.

42
Q

Carbamazepine use in pregnant/lactating

A
  • Category D (craniofacial deformities, spina bifida, low birth wt)
  • Considered ok w/breast feeding
43
Q

Carbamazepine serum levels monitoring

A
  • Every 1-2 wks during first 2 mos then every 3-6 mos

- 10-12 hrs post-dose and at least 5-7 days after a dosage change

44
Q

Carbamazepine monitoring

A
  • CBC w/diff
  • LFTs
  • Serum electrolytes
  • Derm monitoring
45
Q

Describe oxcarbazepine

A
  • Analog of CBZ
  • May have fewer ADEs
  • NOT FDA approved for BPD so not 1st line
  • Preg Cat C, not recommended in breast feeding
46
Q

Which meds are FDA approved for acute mania BPD?

A

Lithium
Divalproex (Depakote)
Carbamazepine

47
Q

Which meds are FDA approved for acute mixed BPD?

A

Divalproex (Depakote)

Carbamazepine

48
Q

Which meds are FDA approved for BPD maintenance?

A

Lithium

Lamotrigine

49
Q

Which meds are FDA approved for depressive episodes in BPD?

A

Lamotrigine

50
Q

How are antipsychotics used in BPD?

A
  • Acute mania (monotherapy or adjunctive)

- Bipolar depression

51
Q

Which antipsychotics are used to treat acute mania in BPD?

A
  • Aripiprazole
  • Olanzapine
  • Risperidone
  • Haloperidol
  • Quetiapine
  • Ziprasidone
  • Lithium or VA plus antipsychotic has better efficacy than any of these alone
52
Q

Which antipsychotics are used for treatment of bipolar depression?

A
  • Quetiapine XR
  • Lurasidone
  • Fluoxetine/Olanzapine
53
Q

How are BZDs used in BPD?

A
  • Can be used as an alternative or in combo w/antipsychotics for acute mania
  • Alternative to mood stabilizers in 1st trimester of pregnancy
54
Q

Antidepressant use in BPD

A
  • Concern of mood switching in pts w/BP depression
  • Can precipitate a manic episode
  • Higher w/TCAs or Venlafaxine
  • No better than placebo

Pharm III - Exam 4 (5 decks)

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