mood stabilizers & seizures

Question 1

mood stabilizers: use (2)

Answer 1

• prevent, relieve symptoms during manic, depressive episodes (bipolar affective disorder)
• relieve, prevent recurrence of labile mood in non-bipolar

Question 2

lithium mnemonic

Answer 2

” when sodium is displaced, lithium takes its placed, and kidneys go to waste! “

Question 3

lithium

Answer 3

mood stabilizer

Question 4

gold standard for treating bipolar affective disorder

Answer 4

lithium

+ more recently, divalproex (depakote)

Question 5

lithium: moa

Answer 5

alters distribution of neuron ions
– interchangeable with Na

modulates synaptic transmissions
– stabilizes neuron electrical activity

• influences excitatory second messenger systems
• decreases neuronal activity
• depends on renal function: RAPID RENAL EXCRETION

Question 6

lithium: toxicity

Answer 6

usually involves kidneys (RAPID RENAL EXCRETION)

• sodium depletion causes accumulation
• dehydration causes retention

Question 7

lithium: plasma levels (3)

Answer 7

0.8 - 1.4 mEq/L initial treatment (during acute phase)
0.4 - 1.0 mEq/L maintenance (during stable phase)
> 1.5 mEq/L toxic

Question 8

lithium: dosing

Answer 8

individualized to plasma levels

• 300 mg TID/QID, max = 1200 mg
• ER form = BID

Question 9

lithium: monitoring

Answer 9

annual: CBC, electrolytes, renal and thyroid function, hepatic function if indicated

Question 10

lithium: interactions (list)

Answer 10

diuretics
anticholinergic meds
NSAIDs 
theophylline
muscle relaxants used during anesthesia
SSRIs

Question 11

lithium: interaction with thiazide, loop

Answer 11

DIURETIC. may increase Li levels

Question 12

lithium: interaction with osmotic, K-sparing

Answer 12

DIURETIC. may decrease Li levels

Question 13

lithium + SSRI = ?

Answer 13

interaction: serotonin syndrome

Question 14

lithium: adverse effects

Answer 14

• early: transient (HA, GI, muscle weakness, fatigue, confusion)
• general (tremor, goiter/hypothyroidism, renal toxicity, fetal effects)
• persistent (polyuria, polydypsia)
• other effects @ therapeutic levels: weight gain, decrease in WBC, cardiac (EKG changes)

Question 15

pregnancy or breastfeeding + lithium = ?

Answer 15

DON’T DO IT

Question 16

lithium: toxicity - most common s/s

Answer 16

n, v, d

Question 17

lithium: toxicity - early s/s

Answer 17

thirst, polyruria
lethargy, slurred speech
muscle twitching, fine tremor

Question 18

lithium: toxicity - progressive s/s

Answer 18

progressive s/s
oliguria, anuria
confusion, impaired consciousness
poor coordination, frank twitching, seizures
blurred vision, tinnitus
coma -> death

Question 19

lithium: mild-moderate toxicity treatment

Answer 19

mild-moderate (1.5 - 2)

HOLD med, check levels, re-evaluate dosage

Question 20

lithium: severe toxicity treatment

Answer 20

> 2

STOP med, increase excretion (emetic, lavage, meds), renal dialysis

Question 21

lithium: assess these before beginning

Answer 21

health status
renal, thyroid function
CBC
electrolytes
baseline EKG

Question 22

lithium: key educational points

Answer 22

dietary sodium
illness associated with n, v, fever
abrupt changes in activity

Question 23

seizure vs convulsion

Answer 23

“seizure” is often used interchangeably with “convulsion”

seizure: physical findings, changes in behavior after episode of abnormal electrical activity in brain
convulsion: body shakes rapidly, uncontrollably; muscles contract and relax repeatedly

can have seizure without convulsion

Question 24

seizure pathophysiology

Answer 24

remember: uncontrollable, excessive electrical discharge of neurons

extracellular calcium =
long-lasting depolarization =
opens sodium channels =
high frequency bursts of action potentials

propagates through multiple synchronized neurons

Question 25

antiseizure meds: moa* (4)

Answer 25

• suppression of Na channel activation
• inhibition of T-type calcium channels
• antagonism of glutamate (not in book)
• GABA potentiation (GABA CALMS)

Question 26

antiseizure meds effect on OTHER meds

Answer 26

can increase metabolism

Question 27

OTHER meds effect on antiseizure

Answer 27

can decrease plasma levels

Question 28

antiseizure meds + hepatic metabolism enzymes =

Answer 28

some INDUCE hepatic metabolism enzymes

- can speed their own metabolism (meaning half-life decreases as therapy progresses)

Question 29

antiseizure meds: goal

Answer 29

get seizures under control to the point that pt can function in everyday life

Question 30

antiseizure meds: MUST check serum levels (2)

Answer 30

cabamazepine (tegretol)
valproic acid (depakote)

Question 31

antiseizure meds: adjunct use with mood stabilizers (3)

Answer 31

gabapentin (neurontin)
lamotrigine (lamictal)
topiramate (topamax)

Question 32

first choice for seizure treatment

Answer 32

valproic acid (depakote)

unofficially first choice for bipolar

Question 33

valproic acid vs divalproex

Answer 33

divalproex is a derivative of valproic acid

Question 34

lamotrigine (lamictal)

Answer 34

mood stabilizer, antiepilepsy; ok to use adjunct with antiseizure meds

Question 35

topiramate (topamax)

Answer 35

anticonsulsant; ok to use adjunct with antiseizure meds

Question 36

phenytoin (dilantin)*

Answer 36

moa: suppresses action potential of hyperactive neurons by delayed recovery of select Na channels

administration notes:

• small dosing changes can result in considerable changes in therapeutic levels
• rapid IV administration can result in cardiac collapse

ae: gingival hyperplasia!

therapeutic dosage range: 10-20 mcg/ml NARROW!

Question 37

valproic acid (depakote)*

Answer 37

first choice for seizure treatment, unofficially first choice for bipolar

moa:

• suppresses Na channels
• suppresses Ca influx
• augments GABA

adverse effects: can be hepatotoxic

dosage range: 50-150mcg/ml