Week 8- treatment of bipolar disorder + lithium Flashcards
what is the non-pharmacotherpay for bipolar?
Psychological Therapies • Psychological treatments i.e. talking therapies such as psychotherapy, CBT and family therapy can be useful for some people, especially early on in treatment, when used with medicines and
perhaps in people with difficult-to-treat symptoms
• Overall CBT doesn’t seem to help to stop highs or lows in Bipolar Disorder
• Psychosocial interventions may have an important part to play. Reduces stress and helps manage
symptoms
• Psychotherapy and CBT are recommended by NICE, which takes the view that because these may help Unipolar Depression they must help Bipolar Depression too
Self-help:
• Mania is susceptible to stresses e.g. changes in time zone, irregular sleep, substance misuse
what are some types of pharmacotherapy for bipolar, acute mania and mood stabilisation?
-Mood stabilisation and relapse prevention= aims for Reduction in the frequency and/or severity of manic, depressive and/or mixed episodes. -Acute hypomania/mania= aims for Management and harm-reduction in manic or hypomanic episodes -bipolar depression= Management of acute bipolar depression.
what are the general prescribing princles for mania?
- discountiue any manigenics e.g. antidepressants and stimulants
- stablise any medical conditions
- start non-specific calming medications e.g. benzodiazepines, antipsychotics
- start specific mood-stabiliser or relapse prevenation agents
- hypnotic/sedative use should be consdiered appropriate as a nigh of sleep derivation is likely to escalate any manic patient to a higher degree of mania
- substance misuse should managed
what is quetiapine? status
-only drug licenced for acute bipolar depression. Licensed as monotherapy for acute mania and relapse prevention, acute bipolar depression and relapse prevention Also acute mania and relapse prevention in people who respond in acute state over 2 years Doses and titration varies for different indications.
what are some base-line monitoring for quetiapine?
Weight/BMI Pulse BP HbA1c Lipids ECG if at risk
what are the ongoing monitoring of quetiapine?
Pulse & BP after each dose change Weight/BMI weekly for first 6 weeks, then at 12 weeks Blood glucose or HbA1c Blood lipid profile at 12 weeks Response to treatment Side effects Emergence of movement disorders Adherence
what are the examples of dosing for quetiapine?
•Mania: •Quetiapine XL: •300 mg on day one •600 mg on day two •800 mg/d thereafter, effective at 400–800 mg/d from day four
•Depression: •Quetiapine XL in in bipolar depression: •Day 1: 50mg at bedtime •Day 2: 100mg at bedtime •Day 3: 200mg at bedtime •Day 4 onwards 300mg at bedtime •Onset of action is within one week
what are side effects of quetiapine?
•Very common: oSleepiness oDizziness oDry mouth oWeight gain oPostural hypotension •Common: oHeadache oAkathisia oAnticholinergic side effects
what prescribing advice for quetiapine?
Initial dose titration must be slow due to the risk of postural hypotension in about 10% people •Although highly sedative at low doses (e.g. 25mg) the sedation is not proportional to dose •Quetiapine XL vs Plain tabletsDependent on Trust and Patient
whats the status for olanzapine?
Licensed for mania and relapse prevention in people who have responded to it acutely and are lithium or valproate non-responders • Widely used as an antimanic and as a mood stabiliser
what is the monitoring for olazapine?
Weight/BMI Pulse BP HbA1c Lipids ECG if at risk
what is the formulation olanzapine comes in?
Available as tablets, shortacting IM injection and orodispersible tablet and Depot (restricted use). • In USA olanzapine is available as a combination product with fluoxetine (Symbyax®) for bipolar depression but not for UK
what are the adverse effectof olanzapine?
• Very common: Sedation (antihistaminic effect) Weight gain
• Common: Postural hypotension Dry mouth Constipation Peripheral oedema Diabetes Long-term effects may include
weight gain, metabolic
syndrome (e.g. diabetes, plus
raised lipids and cholesterol)
what are some interactions of olanzapine?
• Smoking
what are some prescribing advice for olanzapine?
Starting dose in acute mania is 15 mg/d as monotherapy or 10 mg/d as an adjunct Do not give benzodiazepines within an hour of short-acting IM olanzapine use (reports of deaths)
hat is it the status of ariprprazole?
Licensed for acute mania and manic relapse prevention in people who have responded acutely including in adolescents aged 13 years or older
whats the monitoring for aripiprazole?
Pulse & BP after each dose change Weight/BMI weekly for first 6 weeks, then at 12 weeks Blood glucose or HbA1c Blood lipid profile at 12 weeks Response to treatment Side effects Emergence of movement disorders Adherence
what formulations does aripiprazoe come in?
Available as tablets, orodispersible, liquid and injection (plus long-acting depot injection)
what are some adverse effects of arpiprazole?
•Very common: Akathisia (which can be counter-productive in
mania/hypomania) Insomnia
Stomach upset Constipation
Blurred vision •Common: Movement disorders (extra-pyramidal side effects) Postural hypotension Palpitations
what are some prescribing advice for aripiprazole?
For mania can start at 15mg, and increase to 30mg/d
•Relapse prevention dose can be 15-30mg/d•Due to aripiprazole’s partial agonism, start aripiprazole at 5mg/d if the person has had another antipsychotic in the
system
what is the status of lamotrigine?
Licensed for prevention of relapse of
bipolar depression
No efficacy in mania, mixed, rapidcycling or unipolar depression nor acute
bipolar depression (long titration)
what are the adverse effects of lamotrigine?
•Most common: Drowsiness and dizziness Headache Nausea Blurred vision •Rare but serious side effects: Oedema Bone marrow suppression
Symptoms of unexpected bruising,
infections, and anaemia Skin rashes- LIFE THREATENING
Stevens-Johnson syndrome (SJS) or
Toxic Epidermal Necrolysis (TEN). Red rashes across the face and body,
blisters and inflammation in the nose,
mouth and eyes - looks a bit like
serious burning or sunburn
what are some prescribing points for lamotrigine?
Lamotrigine titration must be“by the
book”
•Starting dose must be low and slowly
titrated as per BNF
•25mg/d for 2/52,50mg/d for 2/52 ,then increase by 50-100mg/d every 1-2 weeks
•Half this if used with valproate (e.g.
25mg alternate days for 2/52, taking 6/52 to reach 200mg/d)
•This almost abolishes the risk of the
potentially rapidly fatal Stevens-Johnson Syndrome and Toxic Epidermal
Necrolysis
what is the status for valproate?
Licensed for mania and relapse prevention Depakote® and Episenta® are licensed for bipolar disorder Epilim is available in tablets, Prolonged release tablets and liquid
what are the monitoring for valproate?
• Baseline: Height, weight, FBCs, LFTs Blood cell count,
including platelet count,
bleeding time and
coagulation before
treatment starts then
during first 6 months LFTs before starting,
then over next 6/12 • On-going Monitoring: LFTs and FBCs at 6
months
what are the formulations and dosing of valproate?
Oral loading doses are of valproate are more rapidly effective in mania, e.g. 20 mg/kg/d may give a rapid response, often within three days Maintenance dose not established Epilim is available in tablets, Prolonged release tablets and liquid
what are the adverse effects of valproate?
• Very common: Increase in appetite and weight gain
• Common
Gastric irritation, diarrhoea
Hair loss –
Nausea • Uncommon Sleepiness Impaired liver function
• Rare but serious: Thrombocytopenia and impaired
platelet function
Hepatic dysfunction – in first 6/12 Pancreatitis - abdominal pain, nausea,
vomiting PCOS
what are some interactions of valproate?
Carbapenem antibiotics (reduced valproate levels)
Lamotrigine (variable effect):
34% have a > 25% increase in valproate levels
14% have an increase of > 50% in valproate levels.
5% have a > 25% decrease in valproate levels
what are some patient and carer advice for valproate?
• Valproate use by women and girls
• Pregnancy Protection Programme ( next
slide)
• The MHRA advises women and girls should not stop taking valproate without first
discussing it with their doctor.
• Blood or hepatic disorders
• Recognise signs and symptoms of blood or
liver disorders and advised to seek
immediate medical attention • Pancreatitis
• recognise signs and symptoms of
pancreatitis and advised to seek immediate
medical attention
what is the main caution for valporate use?
-The UK has now imposed a ban on prescribing valproate for any female of
childbearing potential UNLESS there is no alternative and the woman is on
the UK “Pregnancy Protection Programme” (PPP)
what are the consequences if valproate is prescribed to someone of childbearing age?
If Valproate is taken during Pregnancy
• up to 4 in 10 babies are at risk of developmental disorders
• approximately 1 in 10 babies are at risk of birth defects
• An increased risk of autistic spectrum disorder (approximately three-fold) and childhood autism (approximately five-fold)
• Delayed development, such as talking and walking, low intellectual abilities, poor language skills, and memory problems.
what are the options for managment for Women Of Childbearing Potential
and Prescribed Valproate?
1.Stop valproate, gradually
2.Switch to another medicine
3.Continue valproate and become part of
the “Valproate Pregnancy Prevention
Programme”, but only if valproate is for
epilepsy, and there is no alternative
what must women Prescribed Valproate do?
Discuss with a doctor or family planning
clinic to get professional information
and advice on effective contraception• Rapidly consult Dr if a pregnancy is
planned or is confirmed Have a Valproate Annual Risk
Acknowledgement Form, where
everything should be explained, with a
signed document.
• Get a Patient Guide from the prescriber• Carry a Patient warning card
what are some treatments that can be used ?
• The use of antidepressants in bipolar depression is common and logical (based on the symptoms) but lacks an evidence base: • There is a potential for switching to mania • If used, antidepressants can be safeif combined with a mood stabiliser • Accelerated episode frequency is considered possible
- Carbamazepine
- Haloperidol
- Risperidone
- Benzodiazepines
