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Psychiatry > Mood Stabilizers > Flashcards

Mood Stabilizers Flashcards

1
Q

What are the classes of antipsychotics?

A
  • Lithium
  • anticonvulsants
  • antipsychotics
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2
Q

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

What are the key points of lithium?

A
  • Only medication to reduce suicide rate.
  • Rate of completed suicide in BAD ~15%
  • Effective in long-term prophylaxis of both mania and depressive episodes in 70+% of BAD I pts
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3
Q

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

What factors predict a positive response to lithium?

A

Factors predicting positive response to lithium

  • Prior long-term response or family member with good response
  • Classic pure mania
  • Mania is followed by depression
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4
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

How should you use lithium?

A

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 (20X greater risk than the general population)

Monitoring: Steady state achieved after 5 days- check 12 hours after last dose. Once stable check level 3 months and TSH and creatinine 6 months.

Goal: blood level between 0.6-1

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5
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

How should you use lithium?

A

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 (20X greater risk than the general population)

Monitoring: Steady state achieved after 5 days- check 12 hours after last dose. Once stable check level 3 months and TSH and creatinine 6 months.

Goal: blood level between 0.6-1

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6
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

What are the side-effects of lithium use?

A
  • 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
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7
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

What levels can cause mild lithium toxicity? What are the effects?

A

Mild- levels 1.5-2.0

  • vomiting
  • diarrhea
  • ataxia
  • dizziness
  • slurred speech
  • nystagmus.
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8
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

What levels can cause moderate lithium toxicity? What are the effects?

A

Moderate-2.0-2.5

  • nausea
  • vomiting
  • anorexia
  • blurred vision
  • clonic limb movements
  • convulsions
  • delirium
  • syncope
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9
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

What levels can cause severe lithium toxicity? What are the effects?

A

Severe- >2.5

  • generalized convulsions
  • oliguria and renal failure
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10
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Valporic acid (Depakote) is a type of anticonvulsant.

How does it compare with lithium?

A

Valproic acid is as effective as Lithium in mania prophylaxis but is not as effective in depression prophylaxis.

Better tolerated than Lithium

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11
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Valporic acid (Depakote) is a type of anticonvulsant.

What factors predict a positive response?

A
  • rapid cycling patients (females>males)
  • comorbid substance issues
  • mixed patients
  • Patients with comorbid anxiety disorders
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12
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Valporic acid (Depakote) is a type of anticonvulsant.

Before valporic acid is started what must you do?

A
  • baseline liver function tests (lfts)
  • pregnancy test
  • FBC
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13
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Valporic acid (Depakote) is a type of anticonvulsant.

Which patients should not be given this? Why?

A

Avoid in woman of child bearing age due to neural tube defects.

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14
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Valporic acid (Depakote) is a type of anticonvulsant.

How should you monitor this medication?

A

Steady state achieved after 4-5 days

-check 12 hours after last dose and repeat CBC and lfts

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15
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Valporic acid (Depakote) is a type of anticonvulsant.

How should you monitor this medication?

A

Steady state achieved after 4-5 days

-check 12 hours after last dose and repeat CBC and lfts

How well did you know this?
1
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16
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Valporic acid (Depakote) is a type of anticonvulsant.

What it the target level of medication?

A

Goal = target level is between 50-125

17
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Valporic acid (Depakote) is a type of anticonvulsant.

What are the side-effects?

A
  • 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
18
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Carbamazepine is a type of anticonvulsant.

What is it used as a first line in the acute phase?

A

Mania

19
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Carbamazepine is a type of anticonvulsant.

What is it used as a prophylactic treatment?

A

Mania

20
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Carbamazepine is a type of anticonvulsant.

What is the indication for use?

A

Indicated for rapid cyclers and mixed patients

21
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Carbamazepine is a type of anticonvulsant.

Before this medication is started, what must you do?

A
  • baseline liver function tests
  • FBC
  • ECG
22
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Carbamazepine is a type of anticonvulsant.

How should you monitor the drug?

A

Steady state achieved after 5 days

-check 12 hours after last dose and repeat CBC and lfts

23
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Carbamazepine is a type of anticonvulsant.

What is the target level of the medication?

A

Target levels 4-12mcg/ml​

24
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Carbamazepine is a type of anticonvulsant.

What must you do at around a month?

A

Need to check level and adjust dosing after around a month because induces own metabolism.

25
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Carbamazepine is a type of anticonvulsant.

What are the side-effects?

A
  • 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!
26
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Lamotrigine (Lamictal) is a type of anticonvulsant.

What must you do before starting the medication?

A

baseline liver function tests

27
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Lamotrigine (Lamictal) is a type of anticonvulsant.

This medication must be titrated to avoid a serious rash (Steven-Johnsons Syndrome).

How do you titrate this medication?

A

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
28
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Lamotrigine (Lamictal) is a type of anticonvulsant.

This medication must be titrated to avoid a serious rash (Steven-Johnsons Syndrome).

What must happen if the patient stops taking the medication for 5 days or more?

A

If the patient stops the med for 5 days or more have to start at 25mg again!

29
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Lamotrigine (Lamictal) is a type of anticonvulsant.

This medication must be titrated to avoid a serious rash (Steven-Johnsons Syndrome).

What are the side-effects?

A
  • 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.
30
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Lamotrigine (Lamictal) is a type of anticonvulsant.

This medication must be titrated to avoid a serious rash (Steven-Johnsons Syndrome).

What are the side-effects?

A
  • 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.
31
Q

Case 3

33 yo woman hospitalized with her first episode of mania. She has no previous history of a depressive episode. She has no drug or ETOH history and has no medical issues. What medication would you like to start?

A
  • Given her first presentation was a manic episode statistically she will do better on lithium.
  • Make sure to check a pregnancy test, serum creatinine and TSH prior to initiation of treatment.
  • Discuss with her what she will use for birth control and document this discussion.
32
Q

Case 3

33 yo woman hospitalized with her first episode of mania. She has no previous history of a depressive episode. She has no drug or ETOH history and has no medical issues.

  • Given her first presentation was a manic episode statistically she will do better on lithium.
  • Make sure to check a pregnancy test, serum creatinine and TSH prior to initiation of treatment.
  • Discuss with her what she will use for birth control and document this discussion.

You start her at 800mg nocte (average starting dose) and when she comes to see you in one week she is complaining about stomach irritation and some diarrhoea. What do you think is going on and what should you do?

A

GI irritation including diarrhoea is common particularly early in treatment.

Encourage pt to drink adequate fluid, leave at current dose and see if side effects resolve.

33
Q

Case 4

27 yo male is admitted secondary to a manic episode. In reviewing his history you find he has 5 to 6 manic or depressive episodes a year. He has also struggled on and off with ETOH abuse. What medication would you like to start?​

A

Depakote would be a good choice because pt is a rapid cycler (4 or more depressive or manic episodes/year) and because of comorbid ETOH abuse.

34
Q

Case 4

27 yo male is admitted secondary to a manic episode. In reviewing his history you find he has 5 to 6 manic or depressive episodes a year. He has also struggled on and off with ETOH abuse.

You start 250mg BD and titrate to 500mg BD. His depakote level is 70. You check his lfts and compared to baseline they have increased as follows:

ALT 48 => 115

AST 62 => 140

ALK PHOS 32 => 80

What happened and what do you want to do??

A
  • It is not unusual for patients on anticonvulsants to experience an increase in lfts and as long as they do not more than triple no change in therapy is indicated.
  • Continue to monitor over time
35
Q

Case 4

27 yo male is admitted secondary to a manic episode. In reviewing his history you find he has 5 to 6 manic or depressive episodes a year. He has also struggled on and off with ETOH abuse.

You start 250mg BD and titrate to 500mg BD. His depakote level is 70. You check his lfts and compared to baseline they have increased as follows:

ALT 48 => 115

AST 62 => 140

ALK PHOS 32 => 80

What happened and what do you want to do??

A
  • It is not unusual for patients on anticonvulsants to experience an increase in lfts and as long as they do not more than triple no change in therapy is indicated.
  • Continue to monitor over time
36
Q

Antipsychotics are used to treat bipolar, cyclothymia and schizoaffective disorders.

The following classes of drugs are used;

  • Lithium
  • anticonvulsants
  • antipsychotics

Lamotrigine (Lamictal) is a type of anticonvulsant.

This medication must be titrated to avoid a serious rash (Steven-Johnsons Syndrome).

How do you titrate this medication?

A

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

Psychiatry (21 decks)

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