pharmacotherapy of BPD Flashcards by Brianna Lent

What is the typical age at onset for bipolar disorder?

Late adolescence/early adulthood

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What type of disorders are common comorbidities with bipolar disorder?

Anxiety disorders

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True or False: Depression is the most frequently experienced mood pole in bipolar disorder.

True

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What is mania?

Abnormally and persistently elevated, expansive, or irritable mood

Mania includes symptoms like grandiosity, flight of ideas, distractibility, and agitation.

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List symptoms commonly associated with mania.

Grandiosity
Flight of ideas
Distractibility
Pressured speech
Decreased need for sleep
Agitation
Excessive involvement in pleasurable activities

These symptoms can significantly impact daily functioning.

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What often initiates a manic episode?

Change in sleep pattern

Sleep disturbances can trigger the onset of mania.

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What is hypomania?

Less severe form of mania where hospitalization is NOT often required

Hypomania includes elevated mood symptoms but lacks psychotic features.

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List symptoms associated with hypomania.

Elevated mood
Inflated self-esteem
Decreased need for sleep
Distractibility
no psychotic features

Hypomania is characterized by less extreme symptoms compared to mania.

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What characterizes rapid-cycling in mood episodes?

Four or more mood episodes in 1 year

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What is required for a diagnosis of Bipolar I Disorder?

≥ 1 manic episodes; depressive or hypomanic episode may have occurred

Manic episodes generally last ≥ 1 week.

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What characterizes Bipolar II Disorder?

Major depressive and hypomanic episodes; hypomanic episodes generally last ≥ 4 days

Unlike Bipolar I, there are no full manic episodes.

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What are the symptoms of a manic or hypomanic episode with mixed features?

Include ≥ 3 of the following: prominent dysphoria or depressed mood, diminished interest or pleasure in activities, psychomotor retardation, fatigue or loss of energy, feelings of worthlessness or guilt, recurrent thoughts of death.

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What are the symptoms of a depressive episode with mixed features?

Include ≥ 3 of the following: elevated, expansive mood, inflated self-esteem or grandiosity, more talkative than usual or pressure to keep talking, flight of ideas or racing thoughts, increased involvement in activities with high potential for consequences, increased energy/goal-directed activities, decreased need for sleep.

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What somatic therapy can contribute to secondary mania?

Sleep deprivation.

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What does DIG FAST stand for

Distractibility
* Indiscretion
* Grandiosity
* Flight of ideas
* Activity increased
* Sleep deficit
* Talkative

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what does the acronym Giddiness stand for

Grandiosity
* Increased goal directed activity
* Decreased judgment
* Distractibility
* Irritability
* Need for sleep decreased
* Euphoria
* Speedy thoughts
* Speedy talk

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what are non-pharm treatments

Pyschoeducation
ECT – most data supporting
Bright light therapy
Repetitive transcranial magnetic stimulation
diet exercise and sleep

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What medications are the foundation of acute and maintenance treatment

mood stabilizers

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what are first line drugs

lithium or valproic acid
atypical antipsychotics can also be used 1st line, as monotherapy or in combination with lithium or valproic acid

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list the mood stabilizers

Lithium
Valproic acid
Carbamazepine
Oxcarbazepine
Lamotrigine
Topiramate

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What is Lithium used for?

Decreases number and severity of episodes in bipolar disorder. associated with decrease in suicidality

Lithium is effective in managing mood swings in bipolar disorder.

T or F: some difference in lithium content in dosage forms but use 1:1 conversion

True or False: Lithium has a wide therapeutic index.

False Narrow therapeutic index (NTI) medication

Lithium is classified as a narrow therapeutic index medication.

What are some symptoms of lithium toxicity?

GI issues
Ataxia
Coarse hand tremor
Altered mental status
Seizure
Lethargy
Confusion
Agitation

These symptoms indicate a potential overdose or adverse reaction to the medication.

What are common SE associated with lithium?

* Fine hand tremor * Hypothyroidism * Polyuria * Polydipsia * Acne * Dry mouth * Weight gain * ECG changes ## Footnote Monitoring for these toxicities is important for patient safety.

What is a potential cardiac side effect of lithium?

Cardiac structural abnormality (Ebstein’s anomaly) ## Footnote This condition can have serious implications for heart function.

During which trimester should lithium be avoided?

1st trimester can use in 2nd or 3rd ## Footnote Use with caution in the 2nd and 3rd trimester as well.

What is the classification of Valproate (valproic acid, divalproex)?

Common 1st line agent

How does the bioavailability of the extended release (ER) dosage form compare to the delayed release (DR) dosage form?

ER is ~ 10-15% less bioavailable than DR 1:1 conversion expect lower serum concentration with ER not clinically significant

What is the risk associated with Valproic acid syrup (IR) and capsule sprinkle form?

Higher risk for GI ulcerations (usually esophageal)

What serum levels of Valproate are associated with most efficacy in mania?

80 – 125 mcg/ml

When should serum levels of Valproate be obtained after the first dose or dose increase?

At least 96 hours (4 days) after

Valproic acid Adverse effects

Unsafe in any trimester of pregnancy Polycystic ovarian syndrome occurs in up to 50% of women GI – anorexia, N/V/D, dyspepsia, ulceration Increased appetite – weight gain (~6-8 kg) Thrombocytopenia, platelet dysfunction Teratogenic – neural tube defects, enduring negative effects on IQ of offspring Hyperammonemia

Carbamazepine (Tegretol)

considered 2nd or 3rd line mood stabilizer * Known teratogen Induces nearly all CYP450 enzymes, auto-induction of metabolism (steady state at ~14 days) *Associated with thrombocytopenia/ hematologic effects

Oxcarbazepine (Trileptal)

* Considered 2nd or 3rd line mood stabilizer * May be used as adjunctive therapy CYP450 3A4 inducer * Associated with hyponatremia,

Lamotrigine (Lamictal)

1st line treatment for DEPRESSIVE symptoms in bipolar disorder NOT useful for acute treatment or for manic episodes * MUST know dose titration and dosing schedule – see seizure lecture notes/drug table

Topiramate (Topamax)

Clinically used as adjunctive treatment May cause weight loss Heat intolerance/ oligohidrosis Metabolic acidosis and kidney stones Possible teratogen – cardiac structural defects

True or False: Clozapine, brexpiprazole iloperidone and paliperidone are all included among the atypical antipsychotics that are FDA-approved for acute and/or maintenance treatment.

False

List the Atypical antipsychotics approved for maintenance tx (manic and mixed episodes with and without psychosis

quetiapine aripiprazole olanzapine/fluoxetine lurasidone

What are atypical antipsychotics used for in bipolar disorder?

Atypical antipsychotics may be used as monotherapy or in combination with other mood stabilizers (usually valproate or lithium) ## Footnote Atypical antipsychotics are preferred for their efficacy and side effect profiles.

What monitoring parameters apply when using antipsychotics for bipolar disorder?

All monitoring parameters for metabolic syndrome and movement side effects apply ## Footnote This includes weight gain, glucose levels, and extrapyramidal symptoms.

what are tx considerations

Mood stabilizer treatment is long-term and considered to be maintenance treatment to reduce time to subsequent mood episodes Suicide attempt risk is high in both poles of bipolar disorder – monitor closely, use lithium cautiously

Which medications are known or possible teratogens during pregnancy?

Lithium, valproic acid, carbamazepine, and topiramate ## Footnote These medications have been linked to various developmental risks for the fetus.

What is a potential risk associated with the use of antidepressants in bipolar disorder?

Use of antidepressants is linked with a switch to mania ## Footnote This highlights the risk that antidepressants may trigger manic episodes in patients with bipolar disorder.

What type of therapy should be combined with antidepressant therapy in bipolar disorder?

Need to have maintenance mood stabilizer therapy in combination with antidepressant therapy ## Footnote This emphasizes the importance of mood stabilizers to prevent mood swings.

What are common comorbidities in bipolar disorder?

Anxiety disorders are a common comorbidity in bipolar disorder ## Footnote This indicates that individuals with bipolar disorder often also experience anxiety disorders.

What type of antidepressants is preferred for treating anxiety in bipolar disorder?

Will use serotonergic antidepressants to treat anxiety ## Footnote This refers to antidepressants that influence serotonin levels, which can help alleviate anxiety.

What is preferred for targeting the depressive pole in bipolar disorder?

Prefer to use mood stabilizers that target the depressive pole ## Footnote This indicates a strategy to focus on stabilizing mood during depressive episodes.

Name some mood stabilizers that can be used in bipolar disorder to target the depressive pole

Lamotrigine, lithium, lurasidone, quetiapine ## Footnote These medications are commonly used to manage mood in bipolar disorder.

Valproate monitoring

Baseline – Pregnancy test, LFTs, CBC w/differential & platelets, serum concentration Serum ammonia – if suspect hyperammonemia;

valproate drug interaction

Significant concern with combination use with lamotrigine – increased lamotrigine serum concentrations ↑ risk of Stevens-Johnson syndrome