Mood Stablizers Flashcards
pregabalin (Lyrica)
Indication: Peripheral Neuropathy; Partial Sz; Fibromyalgia
Dose: 75mg daily – up to 300mg BID. Lower in renal impairment
Mechanism: alpha-2 delta of Ca channels; reduces NT release
Advantages: no monitoring; negligible metabolism (excreted unchanged)
Disadvantages: Class V controlled; more abuse with it than gabapentin; caution with ACE Inhibitors
ADEs: edema, sedation, dizziness, hypersensitivity, CPK increase
Off-Label: GAD, Benzo/Alcohol Withdrawal, Alcohol Dependence
carbamazepine (Equetro, Tegretol)
Indication: Bipolar Disorder (Equetro specifically for acute mania); seizures, trigeminal neuralgia
Dose: 200mg BID, increase by 200mg 3-4d to 600mg BID (based on clinical response); max = 800mg BID
Monitoring: CBZ Levels (4-12 mcg/mL); CBC; Sodium; LFT; pregnancy test; HLA-B*1502 in Asians (baseline; 6 weeks; q3mos)
Mechanism: Sodium channel blocker
Advantages: none particularly; not first line
Disadvantages: powerful interactions; lowers OCPs; more agranulocytosis with Clozapine
ADEs: dizziness; nausea; headache; aplastic anemia, agranulocytosis; pancytopenia; hepatic dysfunction (LFTs); SIADH; hyponatremia; exfoliative rash; SJS; epidermal necrolysis (esp. in Asian populations)
Off-Label: Impulse control disorders; aggression; Bipolar Disorder maintenance
gabapentin (Neurontin)
Indication: partial seizures; post-herpetic neuralgia; restless leg syndrome
Dose: 100mg at bedtime, increasing to 300mg TID; Max=3600mg/d. Lower doses with renal impairment; restless leg: 600mg at bedtime
Monitoring: None
Mechanism: blocks voltage-dependent calcium channels and modulates excitatory NT release; structurally related to GABA (but does not bind GABA receptors)
Advantages: not metabolized; excreted unchanged by kidney
Disadvantages: potential for recreative use; scheduled medication in some states (Schedule V)
ADEs: dizziness, somnolence, ataxia, DRESS (drug reaction with eosinophilia – fatal multiorgan hypersensitivity)
Off-Label: pain; anxiety; alcohol/benzo withdrawal; alcohol dependence; (NOT Bipolar)
lamotrigine (Lamictal)
Indication: Bipolar Disorder (adults); seizures (adults and children)
Dose: 25mg QD x 2wks; 50mg QD x 2wks; then 100mg QD; Max=200mg daily
(on VPA): 25mg QOD x 2wks; then as above; Max=100mg QD
Monitoring: HLA-B*1502 in Asians (baseline; 6 weeks; q3mos)
Mechanism: sodium channel blocker
Advantages: best efficacy in prophylaxis of depressive episodes in Bipolar
Disadvantages: caution with enzyme inducing agents; OCPs decrease levels by half (and OCPs are decreased with it (estrogen>progest.)); missed doses require restart; levels continue to increase, even in dose-free days; VPA doubles lamotrigine levels
ADEs: dizziness; headache; nausea; benign rash; SJS and necrolysis (esp. with VPA and CAPS populations)
Off-Label: Bipolar Depression; neuropathic pain; MDD
lithium (Eskalith; Lithobid)
Indication: Acute mania; Bipolar Disorder (maintenance) – adults and CAPS
Dose: 300mg at bedtime; increase by 300mg weekly (to BID) to level of 0.8-1.2 mEq/mL; MAX=2400mg/d; Dose increase of 300mg increases levels by @0.25; Toxic>1.5 mEQ/mL
Monitoring: Lithium level; TSH; BUN/Cr; pregnancy test; EKG
Mechanism: unknown; alters neuronal sodium transport
Advantages: gold standard; more useful for euphoric mania; anti-suicide effects
Disadvantages: monitoring; No ACE in Hole (NSAIDs, ACE, HCTZ increase levels); caffeine and osmotic diuretics decrease levels
ADEs: nausea; fine tremor; polyuria/thirst; memory problems; hypothyroidism (more common in women); increases in WBC; nephrogenic DI; flattened T-waves; bradycardia; sinus node dysfunction
Off-Label: Bipolar Depression; TRD; vascular HA; neutropenia
oxcarbazepine (Trileptil)
Indication: Seizure Disorders (adults and CAPS)
Dose: 300mg BID; increase by 300mg daily q3d to 1200mg BID; MAX=2400mg/d
Monitoring: Sodium; HLA-B*1502 in Asians (baseline; 6 weeks; q3mos)
Mechanism: sodium channel blocker and neuronal membrane stabilizer; 10-keto analogue of CBZ
Advantages: no auto-induction interactions
Disadvantages: Need elevated dose than with CBZ (30% more); gentler, but not as efficacious for Bipolar
ADEs: hyponatremia (first 3mos); dizziness, somnolence; ataxia; nausea, SJS; epidermal necrolysis (esp. in Asian populations); angioedema (rare)
Off-Label: Bipolar Disorder
topiramate (Topamax)
Indication: Seizure Disorders (ages 2+); migraine prophylaxis
Dose: 25mg QHS; increase by 50mg/d in divided doses weekly; dosage 50-300mg/d
Monitoring: Bicarbonate
Mechanism: sodium channel blocker
Advantages: may have some efficacy in obesity (not usual)
Disadvantages: dose-related cognitive effects (“Dopa-max”)
ADEs: somnolence; dizziness; ataxia; nervousness; speech problems; memory problems; confusion; significant decreases in bicarbonate (metabolic acidosis); osteomalacia; kidney stones; risk of hyperammonemia with VPA; decreases OCPs
Off-Label: alcohol dependence (best evidence); Bipolar Disorder; PTSD; binge-eating disorder; obesity
Bipolar Algorithms
Classic Euphoric: Lithium; Lithium + Antipsychotic; VPA; VPA + Antipsychotic
Mixed Manic: Antipsychotic; Antipsychotic + VPA; Antipsychotic + Lithium
Treatment-Resistant: Lithium + VPA; CBZ; Clozapine
“Kitchen Sink” Alternatives: Allopurinol; Tamoxifen
Not Likely Effective: lamotrigine; gabapentin; oxcarbazepine
Lithium Remedies
Polyuria: dose all at bedtime
Nausea: dose with meals; consider CR form; ginger 1-2k/d – 1° before meal, eat meal, then take Li); Zofran BID; promethazine 25-50mg q8°
Tremor: decrease caffeine; lower dose and keep levels at 0.6-0.8; use propranolol (10mg BID to 120mg/d); B6 at 900-1200mg/d, but watch for neuropathies; nimodipine at 120mg daily (also helpful for anxiety in bipolar)
Nephrogenic DI: discontinue or HCTZ 25-50mg per day or amiloride 5-10mg BID
valproic acid (Depakote/Depakene)
Indication: Bipolar Disorder (acute mania); Migraine Prophylaxis; Seizures
Dose: 250-500mg QHS; increase rapidly to target 1000mg-1500mg/d (to symptom control); MAX = 4000mg/d (60mg/kg); ER form gets 20% less VPA (need higher doses)
Co-administer: Folate 3mg daily with this, BUT at separate times than Depakote (increases hair loss risk); consider Zinc (15mg/d) and selenium (20mcg/d) if hair loss a concern (also separate from VPA dose)
Monitoring: VPA Level (50-125 mcg/mL); LFTs, CBC (platelets); ammonia (tx elevations with L-carnitine); pregnancy test; folate
Mechanism: sodium channel blocker
Advantages: faster onset than lithium; fewer interactions; efficacy for rapid cycling/relapse prevention; can sprinkle in DR (“this end up” label)
Disadvantages: co-administration with lamotrigine increases risk of rash; topiramate to encephalopathy
ADEs: sedation/fatigue; nausea; hair loss; elevations in LFTs; reversable, dose-related thrombocytopenia (1/4 of patients); hepatotoxicity (in first 3mos); pancreatitis; PCOS (10% of women); hyperammonemia; encephalopathy (sometimes fatal; even with normal liver enzymes)
Off-Label: Bipolar Disorder maintenance; impulse control disorders; aggression/violence
