Pharm - Bipolar

Question 1

Primary goal of bipolar therapy

Answer 1

Primary goal: remission - resolution of mood symptoms/improvement to only 1-2 sx

• if psychotic features: resolution of psychosis required for remission
• if subsyndromal symptoms of mania: increased risk of relapse

Question 2

If remission is not achieved in bipolar therapy, what is the goal?

Answer 2

• reasonable goal = response
• stabilize patient’s safety, improve number/intensity/frequency of mood/psychotic symptoms
• resolve acute manic/hypomanic/depressive episode
• prevent further episodes
• maintain good functioning
• promote treatment adherence
• minimize adverse effects

Question 3

List the drug or drug classes used to treat acute mania or hypomania

Answer 3

First line monotherapy = second generation antipsychotic: risperidone, olanzapine

• Alternative second-generation antipsychotics: aripiprazole, asenapine, cariprazine, paliperidone, quetiapine, ziprasidone
• Anticonvulsants: valproate (MC), carbamazepine
• Lithium, haloperidol
• Benzodiazepine if pt can’t tolerate lithium, anticonvulsants or antipsychotics

Question 4

What is the general approach to treatment for a patient with acute mania?

Answer 4

• initial psychiatric history/mental status exam, risk of suicide
• they will tell you if something worked in the past, if they have other illnesses you should know, etc.
• look at secondary causes of mania, like ETOH/drugs
• get general medical history/PE/labs to see if mood is due to physiologic effect of general medical condition to rule out contraindications of treatment

Question 5

What should you do it acute manic episode happened while taking currently prescribed maintenance therapy?

Answer 5

• assess adherence
• get serum concentration

Note: acute on chronic is common if pt has good adherence

Question 6

How should you alter the drug list for pt with acute mania?

Answer 6

• optimize therapy: titrate doses to get to therapeutic concentrations or increase dose within range
• discontinue antidepressants
• discontinue abuse drugs/eliminate ETOH
• taper off stimulants, caffeine, nicotine

Question 7

Lifestyle modifications for pt with acute mania

Answer 7

encourage good nutrition (good protein and essential fatty acid intake), adequate sleep, stress reduction, psychosocial

Question 8

Next step for pt with acute mania after all tx mentioned…

Answer 8

first line therapy: optimize current mood stabilizer or initiate mood stabilizer
–Lithium, valproate, second generation antipsychotic

add on/switch therapy - alternate first-line therapy

add on/switch therapy - second/third line therapy

Question 9

What medications are used to treat severe manic episodes?

Answer 9

First line = medication combinations:

1. Lithium + second generation antipsychotic
2. Valproate + second generation antipsychotic

Antipsychotics to use: aripiprazole, haloperidol (first generation) olanzapine, quetiapine, risperidone

Question 10

What are the 2nd line meds for maintenance therapy of an acute manic episode?

Answer 10

• Lithium: reduces risk of relapse by 30%, more widely studied, lowers suicide risk
• Valproate: reduces risk of relapse by 30%, discontinuation from intolerance/nonadherence lower than with lithium, very teratogenic, increase PCOS risk
• Quetiapine: increased time to recurrence compared to those without treatment or those treated with lithium, discontinuation from ADR <10%, can be combined with lithium
• Lamotrigine: reduces risk of relapse by 16%, better tolerated by lithium

Question 11

What are the 3rd line meds for maintenance therapy of an acute manic episode?

Answer 11

• Olanzapine: comparable efficacy to 2nd line drugs but poorly tolerated: causes weight gain/increased risk of DM2
• Aripiprazole, risperidone, olanzapine: available as oral formulations or long-acting depot injections every 2-4 weeks

Question 12

What is the preferred treatment for mania in pt who relapses?

Answer 12

• treat acute with medication combo: continue to maintenance
• usual combo: lithium/valproate + second generation antipsychotic
• -2nd gen antipsychotics as adjunctive therapy evaluated:
  1. Quetiapine: fewer recurrence
  2. Long-acting injectable risperidone: fewer recurrence
  3. Ziprasidone: longer time to relapse
  4. Aripiprazole: fewer recurrence

Question 13

Given a patient with an acute depressive bipolar episode, select the appropriate treatment
-9 steps

Answer 13

1. clinical assessment for risk of suicide, aggressiveness and violence to others
2. assess secondary causes (ETOH/drugs)
3. address psychosocial problems if amenable
4. assess treatment adherence, optimize current meds
5. taper off antipsychotics, benzodiazepines, sedative-hypnotic agents
6. treat substance abuse
7. encourage good nutrition, exercise, adequate sleep, stress reduction and psychosocial therapy
8. pharmacologic therapy:
   - antidepressants
   - Lithium
   - Anticonvulsants
   - 2nd gen antipsychotics
9. use combo if no response to one drug

Question 14

Antidepressants for acute depressive bipolar disorder

-efficacy/safety

Answer 14

fluoxetine + olanzapine
–efficacy/safety of antidepressants controversial because of concerns that drugs not effective and harm patients by causing switches from depression to mania and rapid cycling

Question 15

Lithium for acute depressive bipolar disorder

Answer 15

very efficient but slow for antidepressant effects

Question 16

Anticonvulsants for acute depressive bipolar disorder

Answer 16

lamotrigine, lamotrigine + lithium, valproate, carbamazepine

Question 17

2nd gen antipsychotics for acute depressive bipolar disorder

Answer 17

quetiapine, lurasidone, olanzapine

Question 18

Combo drugs for acute depressive bipolar disorder

Answer 18

consider quetiapine, divalproex, olanzapine