Mood Stabilizers Flashcards
Indications of mood stabilisers
Bipolar, cyclothymia, schizoaffective,
Classes of mood stabilisers
Lithium, anticonvulsants, antipsychotics
What is the only medication to reduce suicide rate
Lithium
Lithium is effective in
Long-term prophylaxis of both mania and depressive episodes in 70% of bipolar affective disorder
Factors predicted + response to lithium
Prior long-term response or family member with good response
Classic pure mania
Mania is followed by depression
How should lithium be used (before starting)
Get baseline U+E and TSH.
In women check a pregnancy test- during the first trimester is associated with Ebstein’s anomaly 1/1000
Monitoring of lithium treatment
Steady state achieved after 5 days- check 12 hours after last dose. Once stable check level 3 months and TSH and creatinine 6 months.
Blood level goal of lithium
0.6-1.0
Side effects of lithium
Most common are GI distress including reduced appetite, nausea/vomiting, diarrhea
Thyroid abnormalities
Nonsignificant leukocytosis
Polyuria/polydypsia secondary to ADH antagonism. In a small number of patients can cause interstitial renal fibrosis.
Hair loss, acne
Reduces seizure threshold, cognitive slowing, intention tremor
Mild lithium toxicity
1-5-2 presents with vomiting, diarrhea, ataxia, dizziness, slurred speech, nystagmus
Moderate lithium toxicity
2-2.5 nausea, vomiting, anorexia, blurred vision, clonic limb movements, convulsions, delirium, syncope
Severe lithium toxicity
> 2.5 generalised convulsions, oliguria and renal failure
Valproic acid
Is as effective as lithium in mania prophylaxis but is not as effective in depression prophylaxis
Factors predicting a positive response in valproic acid
rapid cycling patients (females>males)
comorbid substance issues
mixed patients
Patients with comorbid anxiety disorders
Before Valproic acid is started
baseline liver function tests (lfts), pregnancy test and FBC
Avoid Valproic acid in
Women of child bearing age
Monitoring of Valproic acid
Steady state achieved after 4-5 days -check 12 hours after last dose and repeat CBC and lfts
target level is between 50-125
Side effects of valproic acid
Thrombocytopenia and platelet dysfunction
Nausea, vomiting, weight gain
Sedation, tremor
Increased risk of neural tube defect 1-2% vs 0.14-0.2% in general population secondary to reduction in folic acid
Hair loss
Carbamazepine
First line agent for acute mania and mania prophylaxis. Indicated for rapid cyclers ad mixed patients.
Before carbamazepine started
baseline liver function tests, FBC and an ECG
Monitoring of carbamazepine
Steady state achieved after 5 days -check 12 hours after last dose and repeat CBC and lfts
Goal: Target levels 4-12mcg/ml
Side effects of carbamazepine
Rash- most common SE seen
Nausea, vomiting, diarrhea
Sedation, dizziness, ataxia, confusion
AV conduction delays
Aplastic anemia and agranulocytosis (<0.002%)
Water retention due to vasopressin-like effect which can result in hyponatremia
Drug-drug interactions!
Lamotrigine (lamictal) indications
Similar to other anti-convulsants and neuropathic/chronic pain
Before lamotrigine started
baseline liver function tests
Initiation/titration of lamotrigine
start with 25 mg daily X 2 weeks then increase to 50mg X 2 weeks then increase to 100mg- faster titration has a higher incidence of serious rash
Side effects of lamotrigine
Nausea/vomiting
Sedation, dizziness, ataxia and confusion
The most severe are toxic epidermal necrolysis and Stevens Johnson’s Syndrome. The character/severity of the rash is not a good predictor of severity of reaction. Therefore, if ANY rash develops, discontinue use immediately.
Blood dyscrasias have been seen in rare cases.
Drugs that increase lamotrigine levels: VPA (doubles concentration, so use slower dose titration), sertraline.
