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PHA333 > bipolar disorder in practice > Flashcards

bipolar disorder in practice Flashcards

1
Q

What is bipolar disorder?

A

a chronic relapsing and remitting disorder

abnormally elevated mood/irritability alternates with depresssed mood

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2
Q

What is bipolar affective disorder associated with?

A

poor physical health

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3
Q

physical health check for BP

A

annually

weight/BMI
diet
nutritional status
level of physical activity
CV status (pulse, BP)
metabolic status (fasting blood glucose, HbA1c, prolactin, blood lipid profile, liver fxn)
if Rx Li - renal fxn, TFTs, Ca levels
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4
Q

suspected BPAD (bipolar affetive disorder)

A

referred to specialist mental health services

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5
Q

choice of drug depends on what factors

A 
age
s/e
interactions and cautions
child bearing potential
previous Hx
medical comorbidities
individial prefernences
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6
Q

treatment for acute mania/hypomania

A

withdraw any antidepressants/stimulants

if not Rx any antipsychotics/mood stabilisers start

  • haloperidol, olanzapine, quetiapine, risperidone
  • poorly tol/inieffective alternative
  • not sufficient add lithium or valporate (Li not suitable)

taking Li

  • check plasma levels
  • consider adding antipsychotic

severe agitation
- ST BDZs

psychotherapy

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7
Q

When to discuss LT Tx after acute tx for mania?

A

within 4 weeks of resolution of symptoms

can continue tx for 3-6mths then review

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8
Q

drugs NOT recommended for mania

A 
antidepressants (induce mania)
lamotrigine
gabapentin
topiramate
carbamazepine + antipsychotics metabolised by CYP3A4 (interaction)
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9
Q

treatment of bipolar depression

A

psychological

antidepressant monotherapy NOT recommended

  • fluoxetine + olanzapine
  • atypical antipsychotic
  • lamotrigine (no response)
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10
Q

What to avoid for tx of bipolar depression?

A

antidepressant monotherapy

TCAs

venlafaxine

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11
Q

LT bipolar management

A

1st line

  • Lithium
  • valporate
  • olanzapine

2nd line

  • lamotrigine (adjunct)
  • carbamazepine
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12
Q

When to start LT management for bipolar?

A
  • after manic episode with significant risk
  • 2+ acute episodes bipolar 1 disorder
  • significant functional impairment/suicide risk
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13
Q

How long is LT treatment continued for?

A

at leat 2yrs after episode

reduce gradually on withdrawal

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14
Q

How to Rx lithium?

A

by brand

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15
Q

how long to see efficacy of lithium

A

at least 6mths

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16
Q

therapeutic effects of lithium

A

acute mania

prophylactic agent for mania and depression

antidepressant properties

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17
Q

therapeutic effects of lithium

A

acute mania

prophylactic agent for mania and depression

antidepressant properties

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18
Q

What is lithium 1st line for?

A

LT pharmacological tx to prevent relapse

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19
Q

when to monitor other things on lithium

A

at least every 6mths during treatment

more frequently at start

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20
Q

monitoring for lithium

A 
serum electrolytes (Na)
eGFR (declines, levels inc, toxicity)
body weight/BMI/waist circumference
lipids
thyroid function
calcium levels
FBC/ECG on initiation
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21
Q

When to monitor lithium levels?

A

initially weekly

additional tests if concerns (signs of toxicity)

additional test 5-7 days sfter every dose change or start/stop interacting drugs

22
Q

How to measure lithium levels?

A

take levels 12hrs after dose

23
Q

lithium levels for initial treatment

A
  1. 6 - 0.8 mmol/L
  2. 6 - 1 mmol/L

-> higher range for pts who relapsed previously

24
Q

toxic lithium levels

A

> 1.5 mmol/L

25
Q

side effects of lithium

A 
fine tremor
sedation
impaired co-ordination
GI disturbances
polyuria, polydipsia
QT prolongation
LT effects
- weight changes
- thyroid disorders
- hyperparathyroidism
- renal impairment
26
Q

signs of lithium toxicity >1.5mmol/L

A 
lack of appetite
diarrhoea
vomiting
blurred vision
marked tremor
unsteadiness
slurred speech
drowsiness, confusion
27
Q

signs of lithium toxicity >2mmol/L

A

muscle twitches
more severe drowsiness/confusion
convulsions
unconsciousness

28
Q

interactions with lithium

A 
drugs impacting on renal fxn
- diuretics
- NSAIDs
- ACEIs
- antidepressants (serotonin syndrome
(monitor kidney fxn if co-Rx)

carbamazepine

haloperidol

29
Q

lithium bioavailability

A

narrow therapeutic index

liquid/tabs not interchangeable

30
Q

tabs/liquid forms of lithium

A

lithium carbonate = tabs

lithium citrate = liquid

31
Q

counselling for lithium

A
  • take every day, don’t miss a dose
  • carry lithium card
  • same brand
  • tell pharmacist when buying OTC (NSAIDs)
  • adequate fluid intake
  • avoid dietary changes that inc/dec Na intake
  • regular blood tests
  • reliable contraception
  • common s/e
  • recognise toxicity symptoms
  • med advice if dehydrated/sickness/diarrhoea for >2 days
32
Q

common s/e of lithium

A 
dry mouth
metallic taste in mouth
thirsty
weight gain
fluid retention
33
Q

Why to have adequate fluid intake with lithium?

A

renal fxn important to maintain steady serum levels
-> fxn declines serum levels will increase

dehydration/diarrhoea/stomach bug will dec renal function
-> risk of lithium toxicity

34
Q

When is lithium given?

A

at night

-> trough serum lithium levels taken in morning 12hrs after dose

35
Q

What is valporate prescribed for?

A

acute mania

prophylactic agent

36
Q

3 forms of valproate

A

sodium valproate

valproic acid

semi-sodium valproate

37
Q

Which form of valproate is active?

A

valproic acid

-> semisodium valporate and sodium valporate are metabolised to valproic acid

38
Q

valproate risk

A

major human teratogen

39
Q

valoroate and pregnancy

A

not used in women/girls of childbearing potential unless pregnancy prevention programme in place

  • patient cards every time dispensed
  • dispensed with copy of PIL and warning on container if repackaged
  • remind of risks in pregnancy and need for effective contraception
  • annual specialist review
40
Q

s/e with valproate

A 
weight gain
GI irritation
blood disorders
impaired liver function
panreatitis
fatigue
nausea
sedation
hair loss
suicidal thoughts
teratogenic
41
Q

What to measure before starting valproate?

A

weight/BMI

FBC

LFTs

42
Q

valproate interactions

A

highly protein bound (94%) and can be displaced from albumin precipitating toxicity

other protein bound drugs can be displaced by valproate - higher free levels, inc therapeutic effect/toxicity of the other drug

metabolised in liver, drugs that inhibit CYP450 can inc valproate levels

43
Q

atypical antipsychotics used for bipolar

A

olanzapine

quetiapine

aripiprazole

44
Q

When are atypical antipsychotics used?

A

preferred tx for acute mania

improved s/e profile in ST use

45
Q

LT s/e with atypical antipsychotics

A 
weight gain
dyslipidaemia
hyperprolactinaemia
hypertension
reduced seizure threshold
impaired glucose tolerance
QT prolongation
stroke risk
VTE
46
Q

Why is hypertension s/e with atypical antipsychotics?

A

small steady inc in BP over time (may be associated with weight gain)
OR
unpredictable sharp inc in BP starting new drug

47
Q

What is lamotrigine used for?

A

prevention of depressive disorders in bipolar I disorder

-> NOT for acute mainc/depressive episodes

48
Q

s/e with lamotrigine

A 
skin rashes
headache
dizziness
nausea
drowsiness
insomnia
blood disorders (rare)
small risk of suicidal thoughts/behaviours
49
Q

lamotrigine interactions

A

phenytoin, primidone, carbamazepine, oestrogens, progestogens (dec plasms conc of lamotrigine)
-> inc lamotrigine dose

valproate (inc lamotrigine plasma conc)

50
Q

non-pharmacological inteventions for bipolar

A

patient education
- regular routine, sleep hygiene, detecting early warning symptoms

CBT
- individual/group

psychosocial support

ECT therapy

PHA333 (27 decks)

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