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Pamela - Naplex 2023 > Chapter 65 - Bipolar Disease > Flashcards

Chapter 65 - Bipolar Disease Flashcards

1
Q

Bipolar disorder is classified as bipolar I or bipolar II, which differ primarily by

A

the severity of mania experienced

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2
Q

BIPOLAR 1

A
  • At least one episode of mania, and usually, bouts of intense depression (a depressive episode is not required for diagnosis).
  • Mania is associated with at least one of the following:
    1) significant impairment in social/work functioning,
    2) psychosis/delusions or
    3) requires hospitalization.
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3
Q

BIPOLAR II

A
  • At least one episode of hypomania (lasting >= 4 consecutive days) and
  • At least one depressive episode (lasting >= 2 weeks).
  • Hypomania does not affect social/work functioning, does not cause psychosis nor require hospitalization.
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4
Q

BIPOLAR DEPRESSION

A

Predominant symptoms of a depressive episode include
- Feelings of sadness or depressed mood and/or
- Loss of interest in previously enjoyed activities.

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5
Q

PSYCHOSIS

A

Severe mental condition where there is a loss of contact with reality, involves abnormal thinking and perception (e.g.,hallucinations and delusions).

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6
Q

Cyclothymia

A

is a related disorder consisting of periods of hypomanic and depressive symptoms without meeting criteria for a major depressive, manic or hypomanic episode.

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7
Q

Symptoms of mania

A

Symptoms
■ Inflatedself-esteem
■ Needs less sleep
■ More talkative than normal
■ Jumping from topic to topic
■ Easilydistracted
■ Increase in goal-directed activity
■ High-risk,pleasurableactivities
(e.g.,buying sprees, sexual indiscretions, gambling)

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8
Q

Definition of mania

A

Definition
Abnormally elevated OR irritable mood for at least a week (or any duration if hospitalization is needed)

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9
Q

Diagnosis of mania

A

Diagnosis
- Exhibits >= 3 symptoms
- If mood is only irritable, exhibits >= 4 symptoms

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10
Q

Should you do any screening before diagnosis?

A

A toxicology screen should be done prior to starting treatment to rule out drug- induced mania.

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11
Q

Goal of treatment

A

The goal of treatment is to stabilize the mood without inducing a depressive or manic state.

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12
Q

What are the traditional mood stabilizers?
What do they treat?

A

The traditional mood stabilizers, such as:
- Lithium and
- Antiepileptic drugs (valproate, lamotrigine and carbamazepine),

treat both mania and depression without inducing either state.

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13
Q

What can help stabilize mood when mania occurs with psychosis?

A

Antipsychotics, while not traditional mood stabilizers, can help stabilize the mood when mania occurs with psychosis.

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14
Q

Can you give antidepressants as a monotherapy?

A

Antidepressants can induce or exacerbate a MANIC episode when used as monotherapy, so they should only be used in combination with a mood stabilizer.

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15
Q

To select treatment, consider the following:

A

■ The side effect profile of the drug.

■ The patient’s medication history and first-degree relatives’ medication history;
if the patient or a family member responded well to a drug, the same drug might be a reasonable option.

■ The drug formulations available and cost.

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16
Q

Acute Manic episode:

A

first-line treatment is:
- Valproate,
- Lithium or
- An antipsychotic.

A combination of an antipsychotic + lithium or valproate is preferred for SEVERE episodes.

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17
Q

Acute Depressive episode:

A
  • First-line treatment is lithium,
  • Lamotrigine can be used as an alternative.
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18
Q

Maintenance

A

1) Preferred monotherapy:
- Lithium
- Valproate

2) Alternatives:
- Lamotrigine,
- carbamazepine
- second-generation antipsychotics (SGAs)

3) Antipsychotics or antidepressants may be added to lithium or valproate

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19
Q

MedGuides are required with all antidepressants (primarily due to —) and with all antipsychotics (primarily due to—).

A

MedGuides are required with all antidepressants (primarily due to suicide risk) and with all antipsychotics (primarily due to increased risk of death in elderly patients with dementia- related psychosis).

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20
Q

Pregnancy and Valproate

A

Valproate exposure in pregnancy can increase the risk of fetal anomalies, including:
- neural tube defects,
- fetal valproate syndrome
- long-term adverse cognitive effects.

Avoid in pregnancy, if possible, especially during the first trimester.

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21
Q

Pregnancy and Carbamazepine

A

Carbamazepine exposure in pregnancy can cause:
- Fetal carbamazepine syndrome,
which can result in facial abnormalities and other significant issues.

Avoid in pregnancy, if possible, especially during the first trimester.

22
Q

Pregnancy and Lithium

A

Lithium exposure in pregnancy can cause:
- An increase in congenital cardiac malformations and other abnormalities.

23
Q

During pregnancy, — is a safer option relative to the other mood stabilizers mentioned in this section.

A

lamotrigine

24
Q

— are safer choices than valproate, carbamazepine or lithium.

A

SGA

25
Q

— has the most favorable safety profile in pregnancy, but its use is limited since it is only approved for —

A

Lurasidone

bipolar depression.

26
Q

Lamotrigine

A
  • Lamictal,
  • Lamictal ODT,
  • Lamictal XR,
  • Lamictal Starter Kit:

Requires a slow titration due to the risk of a severe rash.

Do not use for acute mania.

For Acute depressive episode and for maintenance

antiepileptic

27
Q

Valproate/ Valproic Acid Derivatives brand names

A
  • Depakote
  • Depacon
  • Depakene

antiepileptic

28
Q

Carbamazepine brand

A
  • Equetro
  • Antiepileptic drug
29
Q

Antipsychotics can be used only in combination?

A

alone or in combination with one of the traditional mood stabilizers

30
Q

A major concern with anti psychotics is

A

the risk of extra pyramidal symptoms (EPS).

31
Q

do we prefer FGA or SGA?

A

The first-generation antipsychotics (e.g., haloperidol) have a higher incidence of EPS than SGAs,

  • so SGAs are preferred.
32
Q

The following are the more common SGAs that can be used alone or in combination with mood stabilizers for acute mania and/or maintenance treatment:

A

■ Aripiprazole (Abilify, Abilify Maintena)

■ Olanzapine (Zyprexa, Zyprexa Relprevv, Zyprexa Zydis)

■ Quetiapine (Seroquel, Seroquel XR)

■ Risperidone (Risperdal, Risperdal Consta, Perseris)

■ Ziprasidone (Geodon)

Other common SGAsused for bipolar disorders include:

■ Lurasidone (Latuda): can use alone or in combination with mood stabilizers for bipolar DEPRESSIVE episodes.

■ Olanzapine/Fluoxetine (Symbyax): can use alone for acute DEPRESSIVE episodes.

33
Q

Lithium brand

A

Lithobid

34
Q

Lithium dosing

A

Start: 300-900 mg/day, divided BID or TID

Usual range: 900 - 1,800 mg/day, divided BID-TID

Extended-release: take BID

Titrate slowly, as tolerated

35
Q

Should you take lithium with or without food?

A

Take with or after meals to reduce nausea

36
Q

Therapeutic range of lithium

A

Therapeutic Range:

  • Trough level: 0.6 - 1.2 mEq/l
  • Acute mania may require up to 1.5 mEq/l initially
37
Q

BBW of lithium

A

Serum lithium levels should be monitored to avoid toxicity

38
Q

Toxicity with lithium:

A

> 1.5 mEq/l:
- Ataxia,
- Coarse hand tremor,
- Vomiting,
- Persistent diarrhea,
- Confusion,
- Sedation

> 2.5 mEq/l:
- CNS depression
- Arrhythmia
- Seizure
- Coma

39
Q

What can increase lithium toxicity?

A
  • Renal impairment,
  • Hyponatremia
  • Dehydration
40
Q

warning with lithium and other serotonergic drugs?

A

Serotonin syndrome

41
Q

SIDE EFFECTS of lithium Within therapeutic range:

A
  • GI upset (nausea/diarrhea),
  • Cognitive effects,
  • Cogwheel rigidity,
  • Fine hand tremor,
  • Thirst,
  • Polyuria/polydipsia,
  • Weight gain,
  • Hypothyroidism,
  • Hypercalcemia,
  • Cardiac abnormalities,
  • Edema,
  • Anorexia,
  • Worsening psoriasis,
  • Blue-gray skin pigmentation,
  • Impotence
42
Q

What should you monitor with lithium?

A
  • Serum lithium levels,
  • Renal function,
  • Thyroid function (TSH, FT4),
  • Electrolytes (calcium, potassium, sodium)
43
Q

How is lithium cleared?

A

Renally cleared; no CYP450 interactions

44
Q

Lithium in preg and breastfeeding?

A

Avoid in pregnancy; associated with cardiac malformations in first trimester; avoid in breastfeeding

45
Q

Lithium levels INCREASE with:

A

LOW salt intake, sodium loss
- with ACE inhibitors,
- ARBs,
- thiazide diuretics

NSAIDs:
- Aspirin and sulindac are safer options

46
Q

Lithium levels DECREASE with:

A
  • INCREASE salt intake,
  • Caffeine
  • Theophylline
47
Q

Inc risk of serotonin syndrome if lithium is taken with:

A
  • SSRis,
  • SNRis,
  • triptans,
  • linezolid
  • other serotonergic drugs
48
Q

Inc risk of neurotoxicity (e.g., ataxia, tremors, nausea} if
lithium is taken with:

A
  • Verapamil,
  • diltiazem,
  • phenytoin
  • carbamazepine
49
Q

Converting between lithium formulation

A

5 ml lithium citrate syrup = 8 mEq of lithium ion

8 mEq of lithium ion = 300 mg lithium carbonate
tabs/caps

50
Q

What to counsel pt on lithium?

A

■ Take with food or at end of meal to reduce nausea.

■ Maintain consistent salt intake. Changes in salt intake can alter lithium levels in the body.
- low salt - high drug level –> dec dose
- high salt - low drug level –> inc dose

■ Maintain adequate hydration with non-caffeinated fluids.
- Dehydration can inc drug level
- Caffeine can dec drug level

■ Avoid dehydration (e.g., excessive sweating, diarrhea, vomiting and prolonged heat/sun exposure). Can increase lithium levels and side effects.

■ Avoid in pregnancy/breastfeeding.

■ Notify healthcare provider immediately for worsening
nausea or diarrhea, slurred speech or confusion.

■ Can impair alertness, use caution while driving or during other tasks requiring you to be alert.

Pamela - Naplex 2023 (32 decks)

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