Mood Stabilizers and Anticonvulsants

Question 1

what are mood stabilizers most frequently used for?

Answer 1

treating acute mania and to help prevent relapse episodes of mania in bipolar and schizoaffective disorders

Question 2

What are the “mood stabilizers?”

Answer 2

they include lithium, and anticonvulsants (valproic acid, lamotrigine, and carbamazepine)

Question 3

What is important about lithium metabolism?

Answer 3

it is metabolized by the kidney; so you may have to adjust the dose based on renal function

Question 4

Which tests should be ordered on a patient prior to starting lithium? (5)

Answer 4

1) CBC
2) Thyroid
3) basic chemistries (kidney function)
4) ECG baseline
5) pregnancy test (if female)

Question 5

Do blood levels of always correlate with efficacy?

Answer 5

NO… as in SSRIs…

BUT…

clozapine, lithium, valproic acid, and carbamazepine levels DO correlate with efficacy and they should be monitored (as some like lithium) have a very narrow therapeutic window

Question 6

What is the therapeutic range of lithium? toxic? lethal?

Answer 6

therapeutic: 0.6-1.2
toxic: >1.5
lethal: > 2

Question 7

Who should get lithium?

Answer 7

It should be cautiously started/monitored for at least 1 year following an acute manic episode and if asymptomatic start to taper them off…

Question 8

Is it safe for a patient on lithium to be taking ibuprofen?

Answer 8

it should be carefully watched… NSAIDs block lithium excretion and cause levels to build up

Question 9

why should a patient not stop taking lithium cold turkey?

Answer 9

lithium has been proven to decrease suicide… BUT if stopped suddenly… there is an increased risk of relapse and suicide

Question 10

Name some medications/conditions that would effect lithium levels… and what would it do to the levels of lithium?

Answer 10

NSAIDs
dehydration
salt deprivation
sweating (salt loss)
thiazide diuretics
impaired renal function

ALL cause an increase in lithium levels!

Question 11

What is one weird side effect of lithium that can be advantageous when combined with clozapine? (an atypical antipsychotic)

Answer 11

Lithium can cause leukocytosis… which balances out clozapines tendency to cause agranulocytosis

Question 12

What is carbamazepine useful for treating? (3)

Answer 12

1) mixed episodes
2) rapid cycling bipolar
3) DOC for trigeminal neuralgia

Question 13

What is the MOA of carbamazepine?

Answer 13

blocks sodium channels thus inhibiting action potentials

Question 14

What should you monitor on pts on carbamazepine?

Answer 14

CBC (can cause leukopenia, hyponatremia, agranulocytosis etc) and LFTs (both before and while on med)… recall it tends to induce CYP450 so watch out for the female girl on birth control with a history of seizures (recall the “autoinduction of metabolism”)

Question 15

What is a potentially dangerous side effect of both carbamazepine and valproic acid that starts as a skin rash?

Answer 15

Stevens-Johnson Syndrome!

Question 16

Why would you do a pregnancy test on a young female before starting lithium or carbamazepine?

Answer 16

Lithium –> ebsteins anomaly

Carbamazapine –> neural tube defects

Question 17

What is Valproic Acid useful in treating? (2)

Answer 17

1) mixed episodes of bipolar
2) rapid cycling bipolar
* just like carbamazepine

Question 18

What is the normal therapeutic range for valproic acid?

Recall: valproic acid, lithium, carbamazepine, and clozapine all have specific levels that should be monitired and correlate with efficacy

Answer 18

50-150 mg/mL

Question 19

which drug is unique in that it actually helps treat bipolar depression?

Answer 19

Lamotrigine!!! (although its not very useful for acute mania or preventing mania)

Question 20

What is the MOA of lamotrigine?

Answer 20

works on sodium channels that modulate glutamate and aspartate

Question 21

What is a serious side effect that actually effects 10% of those taking lamotrigine? and when is it most likely to occur?

Answer 21

Stevens Johnson Syndrome! most likely to occur within the first 4-6 weeks… risk is minimized by starting really low and increasing slow…

dizziness, sedation, headaches and ataxia are also common

Question 22

What is the interplay between valproic acid and lamotrigine if taken at the same time?

Answer 22

Valproate will increase lamotrigine levels

and

lamotrigine will decrease valproate levels

V increases L… increasing L will decrease V… V down, L up is the bottom line

Question 23

Random Drug: Topiramate… what is it useful for?

Answer 23

helps with impulse control disorder and anxiety

often used as a weight loss drug

most limiting side effect is cognitive slowing