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Mental Health > Treatment for Bipolar > Flashcards

Treatment for Bipolar Flashcards

1
Q

What are some of the psychological interventions for bipolar?

A

This can include psychotherapy, CBT and family therapy for patients early on with treatment or hard to treat symptoms.

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2
Q

Are psychological interventions helpful?

A

Ultimately they do not stop the highs and lows associated with bipolar, but interventions like psychosocial support and talk therapies alongside medication can help to reduce relapse and stress management which mania is susceptible to.

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3
Q

What are the three categories for pharmacotherapy for bipolar?

A

Treatments aimed at:
- Mood stabilisation and relapse prevention
- Acute hypomania/mania
- Bipolar depression

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4
Q

Which medications should be stopped if mania occurs?

A

Discontinue any manicogenic agents such as anti-depressants and psychostimulants

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5
Q

What are some important considerations about prescribing in bipolar regarding anti-depressants?

A

Medications for bipolar should be adjusted specific to the patient and the symptoms which they are experiencing.
For example if they are suffering with severe bipolar depression they must be on a mood stabiliser that either has cover for bipolar depression (Quetiapine) or used a combination of a mood stabiliser such as Olanzapine alongside an antipsychotic.
Also there will be people believed to have unipolar depression that have just never experienced a psychotic episode before.
Additionally if a person develops mania or hypomania and is taking an antidepressant (as defined by the BNF) in combination with a mood stabiliser, consider stopping the antidepressant.

Antidepressants should always be stopped within a stepwise manner and not suddenly.

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6
Q

Which medications should be started in mania?

A

Begin with non-specific calming medications such as benzodiazepines
Start a specific mood stabiliser or relapse prevention agent
Consider hypnotics/sedatives

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7
Q

What other considerations should be made if a patient is in acute mania?

A

Tackle any underlying/stabilise medical conditions and co-morbid substance misuse as recovery is poorer in people with a history of substance misuse.

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8
Q

What are the first line medications used for bipolar?

A

Lithium
Valproate
Olanzapine
Quetiapine
Aripiprazole

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9
Q

Which drug is often used first line for bipolar?

A

Usually Quetiapine as it is the only drug licensed for acute bipolar (mania/hypomania) and relapse prevention in addition to bipolar depression acute and relapse prevention.

It states Lithium is as well but I think is only used as an add on/failure of multiple mood stabilisers.

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10
Q

What are the second line medications for bipolar?

A

Carbamazepine
Risperidone
Asenapine
Benzodiazepines (although can be used acutely? not for long term)
Haloperidol
Lurasidone
Anti-depressants

Apart from Carbamazepine most of these medications have no licensing for bipolar depression and only a few have licensing for acute bipolar so they are used less frequently.

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11
Q

When may you consider a combination of fluoxetine and olanzapine?

A

If a person develops moderate or severe bipolar depression and is not taking a drug to treat their bipolar disorder. However the patient may be able to, if they prefer take Olanzapine on its own. Symbax is licensed within the US but not in the UK.

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12
Q

What is the baseline monitoring for Quetiapine?

A

As a second generation anti-psychotic due to the link with metabolic syndrome the following monitoring is required:

Weight
Pulse
Blood pressure
HbA1c
Lipids
ECG risk (QT prolongation)

Plasma levels of Quetiapine are not required for bipolar

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13
Q

What is the ongoing monitoring required for Quetiapine?

A

After each dose change:
Pulse and Blood pressure after each dose change

Weekly for the first six weeks and then every 12 weeks:
Weight, BMI

At 12 weeks:
Blood glucose, HbA1c
Side effects, emergence of movement disorders - Parkinsonism
Adherence

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14
Q

What is an example of dose titrations for Quetiapine?

A

Quetiapine XL for mania
Day 1: 300mg
Day 2: 600mg
Then 800mg the day thereafter

For depression:
Day 1: 50mg at bedtime
Day 2: 100mg at bedtime
Day 3: 200mg at bedtime
Day 4 onwards: 300mg at bedtime

If used standard release the dosing will be twice daily.

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15
Q

What are two key side effects to take into consideration regarding Quetiapine therapy?

A

The initial dose titration must be slow due to risk of postural hypotension which occurs within 10% of patients.
Furthermore sedation is not proportional to dose.

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16
Q

When is Olanzapine used?

A

In the treatment of mania and relapse prevention (again doesn’t have the bipolar depression cover) for patients who have responded to it acutely and for Valproate and Lithium non-responders.

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17
Q

What are the monitoring requirements/side effects of Olanzapine?

A

As a second generation antipsychotic the monitoring is the same as Quetiapine and similar side effect profile - antagonist at 5-HT, anticholinergic, metabolic disorders etc.

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18
Q

What are some key interactions with Olanzapine?

A

Smoking induces the CYP1A2 enzyme, leading to reduced levels of olanzapine, clozapine, and other drugs metabolized by CYP1A2, if stopped this can lead to toxic levels of Olanzapine accumulating.
Also don’t give a benzodiazepine within one hour of a short acting intramuscular injection as there is an increased risk of death.

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19
Q

When is Aripiprazole used?

A

In acute mania and relapse prevention in people who have responded to it acutely including adolescents aged over 13 years.

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20
Q

What is a key side effect associated with Aripiprazole which limits its use in mania/hypomania?

A

A very common side effect associated with Aripiprazole is akathisia (inability to remain still) which occurs at the beginning and is counter productive within acute mania.

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21
Q

Why is it important to take Aripiprazole in the morning?

A

As it is associated with insomnia and therefore important to take in the morning, as poor sleep can precipitate mania.

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22
Q

What are the most common side effects associated with Aripiprazole?

A

Very common:
Akathisia
Insomnia
GI - constipation, blurred vision, stomach upset

Common:
Movement disorders
Postural hypotension
Palpitations

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23
Q

What is an important consideration regarding Aripiprazole if switching anti-psychotic?

A

Aripiprazole has partial agonism at dopamine receptors so if the patient has just been discontinued on another antipsychotic begin Aripiprazole dose at 5mg/day rather than 15mg as if dopamine is decreased to only 5% of the usual activity, Arirpipirazole will increase this to 30% by displacing other anti-psychotics.

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24
Q

What is Lamotrigine licensed for?

A

Only for the prevention of relapse of bipolar depression, it has no efficacy for other indications within bipolar.

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25
Q

What are the most common side effects associated with Lamotrigine?

A

Drowsiness/Dizziness
Headache
Nausea
Blurred vision

Rare but serious side effects:
Oedema
Bone marrow suppression
Steven Johnson syndrome/Toxic epidermal necrolysis
Red rash/blisters across the face

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26
Q

How is the risk associated with fatal skin rashes mitigated with use of Lamotrigine?

A

Dosing regimen should be: start low, go slow
25mg/day for two weeks followed by 50mg/day for two weeks then increase by 50-100mg/day every 1-2 weeks

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27
Q

If used alongside Valproate how does this change the dosing requirements?

A

The dosing regimen should be halved - slower and lower dose should be used such as six weeks to reach 600mg/day

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28
Q

When is Valproate licensed?

A

Valproate is only licensed for mania and relapse prevention.

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29
Q

What is an important consideration regarding the brands of Valproate?

A

Only Depakote and Episenta is licensed for bipolar disorder.
Depakote which is semi-sodium valproate is only licensed for bipolar and not for epilepsy.

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30
Q

What is the baseline monitoring for Valproate?

A

Height and weights
FBC
LFTs
Clotting screening · including bleeding time and coagulation tests
Pregnancy test

31
Q

What is the ongoing monitoring required for Valproate?

A

LFTs should be continued until stable. Raised liver enzymes are usually transient- lasting only a short time but should be monitored closely

At 6 months, then annually
Body mass index
Full blood count
Liver function tests

If toxicity is suspected request plasma levels of valproate

32
Q

What is the dosing regimen for Valproate?

A

Oral loading doses of Valproate is more recommended in mania which is usually 20mg/kg a day with rapid onset, often within 3 days

33
Q

What are some of the very common/common side effects of Valproate?

A

Weight gain
Gastric irritation
Diarrhoea
Nausea
Sleepiness although not very common

34
Q

What are some of the rare but serious side effects associated with Valproate?

A

Thrombocytopenia, impaired platelet function
Hepatic dysfunction which usually occurs within the first six weeks
Pancreatitis which presents as abdominal pain, nausea, vomiting
PCOS

35
Q

What are the key interactions with Valproate?

A

Lamotrigine affects Valproate levels and Carbapenems (antibiotics) reduces Valproate levels.

36
Q

What are some of the key counselling advice for Valproate?

A

Advise on the signs and symptoms of liver toxicity, blood disorders and pancreatitis.

Valproate, like with its indication for epilepsy cannot be initiated without being signed by two independent specialist for both men and women under the age of 55 where there is no other effective or tolerated treatment.
If of child bearing potential patients should be initiated onto the pregnancy prevention programme- involving highly effective contraception which is either:
Copper or Levonorgestrel IUD
Progesterone implant
Male/female sterilisation

Or CHC patch, pill, vaginal ring or medroxyprogesterone injection used alongside a barrier method.

A risk acknowledgement form must be signed annually and patients should receive a guide/warning card

37
Q

What is the risks of Valproate use in men?

A

Infertility, which is reversible upon reduction/withdrawal
Testicular toxicity which is greater in males under 55

38
Q

When is Carbamazepine used?

A

Second line treatment for acute mania and relapse prevention and for bipolar depression in Lithium non-responders but has limited efficacy

39
Q

What are some of the key interactions with Carbamazepine?

A

It is a CYP 3A4 inducer and therefore has key interactions associated with COC, TCA and Anthramycin

Again can cause Steven Johnson syndrome and therefore plasma levels may need to be checked

40
Q

When is Haloperidol often used?

A

In acute mania or hypomania, frequently used alongside benzodiazepines as it comes in the IM formulation (rapid tranquilisation)

41
Q

When is Risperidone used?

A

As monotherapy of bipolar mania 1-6mg to be used daily
Lack of sedation and slow titration

42
Q

Golden three medications for acute mania?

A

Anti-psychotics and/or mood stabiliser and benzodiazepines for quicker onset and are more effective short term.

43
Q

Which antipsychotics are mood stabilisers?

A

Haloperidol FGA
Quetiapine SGA
Risperidone SGA
Olanzapine SGA

44
Q

What is the importance of mood stabilisers?

A

Reduce the risk of mood switching from depression to mania. They do what their name says they stabilise mood.
Think mood stabilisers have the cover of both - cover mania and depression.
Anti-depressants only cover depression and therefore there is a risk of mania.

45
Q

Which medications can be used for bipolar depression?

A

Either:
Mood stabilisers alone, Mood stabilisers with anti-depressant or Lamotrigine and anti-depressant

Lamotrigine
Sodium Valproate
Lithium
Quetiapine
Risperidone
Olanzapine

Any combination can be used for relapse prevention

46
Q

What is the appropriate amendments for bipolar prescribing in pregnancy?

A

Mood stabiliser is discontinued, risk of relapse is higher
There no mood stabilisers totally safe in pregnancy and therefore there is a risk to the mother, baby or neonate
Choice is between the patient and prescriber but Lithium and AEDs have the greatest risk

47
Q

What is the appropriate amendments for prescribing in hepatic impairment?

A

Majority of anti-psychotics are metabolised by the liver except amasolphadride/solphadride
AEDs must be taken into consideration/dose adjustments made

48
Q

What is the appropriate amendments for prescribing in renal impairment?

A

Avoid Lithium
Avoid amasolphadride/solphadride
Take care with Lamotrigine

49
Q

When is Lithium indicated?

A

Prophylaxis against bipolar disorder
Management of acute mania/hypomania episodes must have previously responded and symptoms are not too severe
Recurrent depression
Control of aggressive behaviour/intentional self-harm

50
Q

What are some of the disadvantages associated with Lithium therapy?

A

Whilst Lithium is actually the most effective treatment option it is not used as frequently due to the extensive blood monitoring which is required.
Furthermore in mania there is delayed onset of 5-7 days for the medication and higher levels are required- it is difficult to conduct blood monitoring when the patient is disturbed.

51
Q

What is the mechanism of Lithium?

A

Although not fully understood it is believed to modify the production and turnover of certain neurotransmitters particularly serotonin, may also block dopamine receptors.

52
Q

Why is it important to maintain the same brand of Lithium?

A

Different brands and formulations of lithium are not bioequivalent and care must be taken to make sure that the patient receives the same preparation each time a prescription is supplied.

53
Q

What is the Priadel MR tablets and Priadel liquid dose conversion?

A

Not bioequivalent:
For Priadel® liquid: Lithium citrate tetrahydrate 520 mg is equivalent to lithium carbonate 204 mg.

54
Q

What are some of the contraindications to Lithium therapy?

A

Hypersensivity to Lithium
Cardiac disease
Cardiac insufficiency (both due to QT prolongation)
Severe renal impairment - excretion
Untreated hypothyroidism
Breastfeeding
Patient with low body sodium dehydrated or on a sodium restricted diet)
Addison’s disease
Brugada syndrome which is a hereditary disease or the cardiac sodium channels

55
Q

When is use of Lithium cautioned?

A

Avoid in pregnancy unless there are exceptional circumstances
Renal impairment
ECT or other medications that lower epileptic threshold
QT prolongation or a patient taking concomitant medications causing QT prolongation

56
Q

Why is use of Lithium advised to be avoided in pregnancy?

A

Should be avoided particularly within the first trimester due to causing heart defects.
Dose requirements increased during the second and third trimesters (but on delivery return abruptly to normal).

57
Q

What is the baseline monitoring for Lithium?

A

Body weight or Body mass index
Cardiac function · especially in patients with cardiovascular disease or at risk who may require ECG.
Estimated glomerular filtration rate
Full blood count
Serum calcium )predispose Lithium toxicty)
Thyroid function tests · patients should be euthyroid before initiation
Urea and electrolytes

58
Q

What is the ongoing monitoring requirements for Lithium?

A

At one week; then weekly until levels stable; then every 3 months for first year
Lithium levels · take sample just prior to time of next dose (i.e. trough level 12 hours following last dose)

Ongoing once stable: Every 3 - 6 months
Lithium levels

6 monthly:
Body weight or Body mass index
Estimated glomerular filtration rate
Serum calcium
Thyroid function tests
Urea and electrolytes

59
Q

Which patient groups are considered high risk that require ongoing 3 monthly monitoring?

A

Age 65 years and older
Taking drugs that interact with lithium
Risk of impaired renal function: e.g. eGFR declines over two or more tests; or urea and creatinine elevated
At risk of impaired thyroid function
Raised calcium levels or other complications
Significant change in a patient’s sodium or fluid intake
Have poor symptom control or poor adherence
The last serum-lithium concentration was 0.8 mmol/litre or higher (Norfolk Lithium database this is 1 Lithium level above 1mmol/L)

60
Q

What is the ideal Lithium range?

A

Between 0.4 to 1 mmol/L with the aim of 0.8 mmol/L for mania

61
Q

What is the dosing for Lithium?

A

It is individualised based upon the clinical response and titrated according to serum levels however usual starting dose is:
200mg in the elderly and 40mmg in adults

Maintenance is usually 400-1.2 grams daily with dose reduction with those with hepatic impairment and patients under 50kg.

62
Q

What are some of the side effects associated with Lithium therapy?

A

Upset stomach usually at the start of treatment
Fine tremor of the hands
Metallic taste within the mouth
Swelling of the ankles which requires dose reduction
Increased thirst and urine output, can cause renal impairment
Weight gain of up to 27kg

63
Q

At what levels does Lithium toxicity occur?

A

Blood concentration over 1.5 mmol/L might be fatal
Over 2.0 mmol/L requires urgent medical attention

64
Q

What are some of the symptoms associated with Lithium toxicity?

A

Severe hand tremor
Muscle weakness
Stomach ache with nausea and diarrhoea
Unsteady on feet
Slurring of words
Blurred vision
Confusion
Unusually sleepy
Muscle twitches

65
Q

What are some of the signs of severe Lithium toxicity?

A

Convulsions
Coma
Renal/circulatory failure
Hyperreflexia
Toxic psychosis

66
Q

What are some of the key drug interactions that increase Lithium levels?

A

ACE inhibitors and ARBs
NSAIDs
COX-2 inhibitors
Metronidazole
SSRIs
Diuretics and aldosterone antagonists

67
Q

If diuretics need to be used which are the best to use?

A

Bumetanide/Furosemide are the least risky whereas thiazide diuretics have the highest risk

68
Q

Which drugs decrease Lithium levels?

A

Sodium bicarbonate
Caffeine

69
Q

What are some of the other key interactions regarding Lithium therapy?

A

When used with Amiodarone ventricular arrhythmias can occur
Increased risk of neurotoxicity when used alongside Methyldopa and some antipsychotics

70
Q

How does sodium depletion influence Lithium levels?

A

Causes increased Lithium levels due to competitive reabsorption renally.

Monitor patients for:
Dehydration
Changes in salt level in the diet
Infection
Vomiting and diarrhoea

71
Q

How long does Lithium therapy take to work?

A

Usually takes six months for patients to be fully established on Lithium and the minimum duration is between 2-3 years

72
Q

What happens if the patient stops taking Lithium suddenly?

A

Increased risk of suicide, if it is agreed between a healthcare professional and the patient that Lithium will be stopped it is normally done over 4 weeks but can be up to six months.

73
Q

What are the key counselling points regarding Lithium for patients?

A

Lithium should be taken once daily at night in order to minimalise the renal damage
Do not stop taking the medication suddenly
Seek medical attention if you have vomiting/diarrhoea
Do not take OTC NSAIDs
Must attend regular monitoring of Lithium level
Warn of signs of Lithium toxicity
Ensure fluid intake is maintained

74
Q

What must patients taking Lithium present with in the community pharmacy before the medication can be dispensed?

A

Their Lithium therapy record book which details information regarding the brand, dose and most recent Lithium level in addition to their thyroid, renal function and weight chart.

Mental Health (5 decks)

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