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PHA333 > Bpolar Disorder (PB) > Flashcards

Bpolar Disorder (PB) Flashcards

1
Q

What is bipolar?

A

the occurrence of one or more manic episodes usually followed by episodes of major depressive disorder

it is a cyclical mood disorder

abnormally elevated mood or irritability alternates with depressed mood

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2
Q

bipolar I

A

at least one manic or mixed episode

-> typical form of BP

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3
Q

bipolar II

A

at least one major depressive episode plus one milder manic syndrone called hypomanic episode

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4
Q

cyclothymic disorder

A

alternation in mood between hypomania and mild depression

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5
Q

2 criteria for diagnosis of BP

A
  1. elevated or irritable mood for > 1 week
  2. impairment/incapcitation and at least 4 of:
    - distractibility
    - racing thoughts
    - grandiosity
    - inc activity
    - inc talking
    - dec need to sleep
    - inappropriate/reckless behaviour
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6
Q

features of bipolar disorder

A 
mania
hypomania
depression
rapid cycling
mixed states
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7
Q

mania vs hypomania

A

mania - elevated/expansive/irritable mood, w/wo psychotic symptoms, marked impairment in functioning

hypomania - elevated/expansive/irritable mood, no psychotic symptoms, less impairment of functioning

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8
Q

key features of depression in BP

A

mild/mod/severe

w/wo psychotic symptoms

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9
Q

typical age of onset of BP

A

15 - 19 years

1st episode usually before 30yrs

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10
Q

women: men BP

A

both equally at risk

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11
Q

reasons for BP presentng later in life

A

family history of psychiatric disorder and medical comorbidities

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12
Q

ethnic groups and BP

A

higher in black and other minority ethnic groups than white population

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13
Q

comorbidities and BP

A

anxiety

substance misuse disorders (drugs/alcohol)

personality disorders esp. borderline personality disorder

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14
Q

What is pharmacological therapy dependent on for BP?

A
  • whether the patient has mania or depressed
  • severity of symptoms
  • patient prefernece
  • balance of benefit vs risk of adverse effects
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15
Q

drugs used in BP

A 
lithium
semisodium valporate
carbamazepine
lamotrigine (antiepileptic)
olanzapine
risperidone
quetiapine
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16
Q

What does seisodium valporate contain?

A

equal amounts of sodium valporate and valporic acid

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17
Q

treatment for acute mania

A

1st line

  • lithium
  • atypical antipsychotics (olanzapine, risperidone, quetiapine)
  • semisodium valporate

2nd line

  • benzodiazepines
  • carbamazepine
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18
Q

maintenance treatment of BP

A

lithium
carbammazepine
semisodium valporate
atypical antipsychotics

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19
Q

What NTs does lithium inhibit release of?

A

DA
NAD

(not 5-HT)

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20
Q

What antiepeleptic drugs NOT to give for BP?

A

gabapentin (dec Ca)

topiramate (inc GABA, blocks Na and Ca channels)

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21
Q

important factors for antipsychotic treatment

A
  • weight/BMI
  • pulse
  • BP
  • fasting blood glucose/HbA1c
  • blood lipid profile
  • ECG
  • > if physical exam has ID specific CV risk
  • > FHx of CVD/Hx of sudden collapse
  • > CV RF (arrhythmia)
  • > admitted as an inpatinet
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22
Q

What to monitor during titration and then regularly throughout treatment?

A
  • pulse and BP after each dose change
  • weight/BMI weekly for 1st 6 weeks, then at 12 weeks
  • blood glucose/HbA1c and blood lipid profie at 12 weeks, inc changes in symptoms/behaviour
  • s/e and their impact on physical health and functioning
  • emergence of movement disorders
  • adherence
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23
Q

What does secondary care need to monitor for 1st 12mths or until condition stabilised?

A

efficacy and tolerability of antisychotic medication

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24
Q

Can you start regular combined antipsychotic medication?

A

no expect for short periods eg. when changing medication

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25
Q

How to stop an antipsychotic drug and why?

A

reduce dose gradually over at least 4 weeks

minimise the risk of relapse

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26
Q

How does lithium work?

A

it is a monovalent cation

minics role of Na in the excitable tissues

penetrates the voltage gated Na channels responsible for AP generation

not pumped out by Na/K ATPase pump

Li might interfere with phosphatidyl-inositol pathway and negativelly affect hormone induced cAMP production

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27
Q

Lithium’s affect on inositol monophosphatase

A

Li inhibition leads to depletion of substrate for IP3 production

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28
Q

Lithium’s affect on inositol phosphophate-1-phosphatase

A

Li inhibition leads to depletion of substrate for IP3 production

29
Q

Lithium’s affect on bisphosphate nucelotidase

A

may be target that results in Li induced nephrogenic diabetes insipidus

30
Q

Lithium’s affect on fructose 1,6-bisphosphatase (glucogenesis) and phosphoglucomutase (glucogenolysis)

A

Li inhibition of unknown relevance

31
Q

Lithium’s affect on glycogen synthase kinase 3

A

inhibition by Li

32
Q

How is lithium administered?

A

oral administration

33
Q

therapeutic index of Li

A

narrow

0.5-1.5 mmol/L

34
Q

When should Li samples be taken?

A

12hrs after dose to achieve a serum-Li conc of 0.4-1 mmol/L

-> low end of the range for maintenance and elderly

35
Q

When are peak Li levels reached?

A

3-5hrs

36
Q

What does Li half life vary with?

A

age

37
Q

When does Li reach strady state?

A

days

38
Q

How is Li eleminated?

A

renally

39
Q

measurement of Li -> when/how to check serum Li levels

A
  • serum levels checked after 5-7 days of initial dose
  • once safe dose establised check every 4 weeks then every 3mths
  • 5ml of blood required
  • timing is important for accurate monitoring
  • blood sampled 12hrs after last dose
  • no patient perparation
40
Q

GI s/e of lithium

A

dyspepsia -> minor and reversible (0.4-1)

anorexia, n&v, diarrhoea -> early signs of toxicity (1.5-2.5)

41
Q

CV s/e of lithium

A

benign ECG changes (0.4-1)

hypotension, arrhythmias (1.5-2.5)

circulatory failure -> toxicity (>2.5)

42
Q

renal s/e with lithium

A

polyuria, polydipsia, oedema (0.4-1)

persistent polyuria (1.5-2.5)

renal danage, renal failure

43
Q

CNS and neuromuscular s/e of lithium

A

fine tremor, incoordination, muscle weakness

coarse tremor, muscle weakness/twitch, lethargy, dysarthria, ataxia

convulsions, coma, permanent neurological damage, death

44
Q

other s/e of lithium

A

non-myxodemic goitre, neurtophilia, exacerbation of psoriasis

hypothyroidism

45
Q

counselling points for lithium

A
  • maintain adequate fluid intake
  • avoid dietary changes relating to Na intake
  • don’t exceed alcohol limits
  • brand prescribing
  • don’t take NSAIDs
  • symptoms of hypothyroidism (lethargy, feeling cold, weight gain) referral, women > men
  • fluid loss due to diarrhoea/vomiting can lead to discontinuation of treatment (contact prescriber)
  • aware of signs of toxicity and report them urgently
46
Q

brand Rx and lithium

A

2 forms: lithium carbonate tabs and lithium liquid

  • tabs and liquid aren’t equivalent
  • doses are not interchangeable between preparations
  • need to Rx by brand
  • bioavailability differences
47
Q

signs of lithium toxicity

A 
excessive thirst
excessive urination
tremor
lack of coordination
n&v
48
Q

c/i with lithium

A

dehydration
untreated hypothyroidism

-> sample taken 12hrs after dose

49
Q

monitoring for lithium

A

renal function

thyroid function on initiation and every 6mths

50
Q

How long does it take to see effects of lithium?

A

3-4 weeks

51
Q

predisposing factors for lithium toxicity

A

dehydration
reduced renal perfusion
infections

52
Q

drugs that can cause lithium toxicity

A

diuretics
ACEIs
ARBs

53
Q

NSAIDs and lithium

A

reduced lithium excretion

54
Q

lithium and amiodarone

A

increases risk of ventricular arrhythmias

55
Q

What to check before initiation of lithium?

A

U&Es
LFTs
TFTs

56
Q

How often does Li conc need to be measured?

A

every 3 months

57
Q

How often to monitor U&Es and TFTs when taking lithium?

A

every 6-12 months on stable regimens

58
Q

What needs to be done before starting valporate (antiepeleptic)?

A

weight/BMI

FBC

LFTs

59
Q

Who can valporate not be prescribed to?

A

women of childbearing age without pregnancy prevention programme

60
Q

interactions with valporate

A

other anticonvulsants (carbamazepine, lamotrigine)
olanzipine
smoking

61
Q

When to monitor valporate levels?

A

not routinely unless evidence of ineffectiveness, poor adherence or toxicity

62
Q

monitoring for valporate

A

weight/BMI
LFTs
FBC

-> after 6mths and then annually

63
Q

What to monitor carefully in older people with valporate?

A

monitor sedation, tremor and gait disturbance

64
Q

How to stop valporate?

A

reduce dose gradually over at least 4 weeks to minimise risk of relapse

65
Q

What to monitor before starting lamotrigine?

A

FBC
urea and electrolytes
LFTs

66
Q

What does lamotrigine interact with?

A

valporate

67
Q

s/e when lamotrigine dose being increased

A

rash

-> contact doctor

68
Q

When to monitor plasma levels of lamotrigine?

A

not routinely unless evidence of ineffectiveness, poor adherence or toxicity

69
Q

How to stop lamotrigin?

A

reduce dose gradually over at least 4 weeks to minimise risk of relapse

PHA333 (27 decks)

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