Pharmacology for Bipolar Disorder Flashcards
What are the CANMAT 2018 bipolar guidelines – for the treatment of acute mania? (Monotherapy)
Lithium
Quetiapine
Divalproex
Asenapine
Aripiprazole
Paliperidone (> 6mg/day) Risperidone
What are the CANMAT 2018 bipolar guidelines – for the treatment of acute mania? (Combination therapy)
Quetiapine + lithium/divalproex
Aripiprazole + lithium/divalproex
Risperidone + lithium/divalproex
Asenapine + lithium/divalproex
Compare the effectiveness of monotherapy vs combination therapy for Bipolar?
First-line monotherapy (50% significant improvement in 3-4 weeks)
First-line combination therapy (70% significant improvement in 3-4 weeks but greater side effect burden)
What are the CANMAT 2018 bipolar guidelines – for the treatment of acute bipolar I depression FIRST LINE
Quetiapine
Lithium
Lurasidone + lithium/divalproex
Lamotrigine
Lurasidone
Lamotrigine (adjunct)
What are the CANMAT 2018 bipolar guidelines – for the treatment of acute bipolar I depression SECOND LINE
Divalproex
SSRIs/bupropion (adjunct) ECT
Olanzapine + fluoxetine
What are the CANMAT 2018 bipolar guidelines – for the prevention of any mood episode? FIRST LINE
Lithium
Quetiapine
Divalproex
Lamotrigine
Asenapine
Quetiapine + lithium/divalproex Aripiprazole + lithium/divalproex Aripiprazole
What psychoeducation would you provide for mood stabilizers
- Patients should be reminded that mood stabilizers only prevent extremes in mood, not the highs and lows of everyday life i.e. mood stabilizers do not make people emotionless
- To a patient who is hypomanic or manic (and hypersexual), mood
stabilizer-induced euthymia may feel like depression (with severe sexual dysfunction)
What are things to consider when prescribing an antidepressant for bipolar 1 depression
- Mood stabilizer must always be co-prescribed (if the mood stabilizer is lithium, divalproex, or carbamazepine, ensure that plasma level is therapeutic)
- Dual-action antidepressants such as venlafaxine and MAOIs are more likely to cause switch to hypomania or mania than SSRIs or bupropion
- Duration of antidepressant treatment for bipolar depression may be shorter than for unipolar depression (3 months vs. 6-12 months)
- Ensure that depression due to medical causes has been ruled out
- Ensure that depression due to substance abuse has been ruled out
Lithium
first line in BD all stages
anti-suicidal
can manage aggression and behavioural disturbances in BPD
can augment antidepressants
renally excreted
amount is inversely proportional to sodium levels
many drug interactions, be careful when prescribing
Lithium side effects
-ECG changes (use cautiously in patients with pre-existing cardiac
disease)
-Fine tremor (treat with propranolol and/or change to long-acting
preparation)
-Hypothyroidism
-Leukocytosis
-Loose stools (change to short-acting preparation or oral liquid)
-Metallic taste in the mouth
-Nausea (take with food and change to long-acting preparation)
-Polyuria (change to long-acting preparation)
-Polydipsia
-Renal toxicity
-Skin disorders and hairloss
-Weight gain
-major malformations and epsteins anomaly
Signs of moderate vs severe lithium toxicity
moderate: ataxia, course tremor, confusion, twitching, nausea, vomiting, diarrhea, slurred speech
severe: cardiovascular collapse, coma, convulsions, death
Divalproic acid side effects
metabolized by liver
fine tremor
liver dysfunction
menstrual changes
PCOS
osteoporosis
thrombocytopenia
weight gain
hair loss
drowsiness
carbemazepine
caution in asian people because of increased risk of SJS due to HLA subtype
report all rashes and mouth sores
side effects: agranulocytosis, rashes including SJS, anticholinergic, dizziness, hyponatremia, weight gain, sedation
lamotrigine
Ineffective treatment for mania, first-line treatment for bipolar depression, first-line treatment for prevention of new episodes (but only if manias are mild)
SJS risk with titration
patient to report skin rashes
