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Pharm: Psych > 2.16: Bipolar > Flashcards

2.16: Bipolar Flashcards

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1
Q

When is acute hypomania seen?

A

Bipolar II

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2
Q

4 Stages of Bipolar disorder that need to be treated? Which type are they seen in?

A
  1. Acute Mania: I
  2. Acute Hypomania: II
  3. Bipolar depression: I and II
  4. Bipolar maintenance: I and II
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3
Q

Consensus on how bipolar depression should NOT be treated?

A
  • Should NOT be treated ONLY with an antidepressant
  • Fear is it will bring them out of depression and flit into manic episode
  • Mood stabilized should be given with antidepressant
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4
Q

First line treatment in bipolar disorder?

A

Lithium

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5
Q

Onset of lithium?

A

2 - 3 weeks

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6
Q

What does “better from above than from below” mean?

A
  • Better at treating mania than depression

- This is case with lithium

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7
Q

Which stages does lithium treat?

A
  1. Bipolar depression
  2. Bipolar mania: better at mania
  3. Maintenance
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8
Q

What does lithium reduce the risk of?

A
  • Suicide

- Effective in BP I, II, and MDD

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9
Q

What drug reduces the risk of suicide in patients?

A
  1. Lithium

2. Clozaril

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10
Q

What is 5ht?

A

Serotonin

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11
Q

Effect of lithium on NTs?

A
  1. Increased effects of 5-ht
  2. Decreased turnover of NE and DA
  3. Increased synthesis of Ach
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12
Q

Excretion and metabolism of Li?

A
  • 100% renal excretion

- 0 hepatic metabolism

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13
Q

Therapeutic windows of lithium?

A

Acute mania: .6 - 1.2 meq/L

Maintenance: .6 - .7 meq/L

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14
Q

Absorption and binding of Li?

A
  • Well absorbed in GI tract: peak levels in .5 - 2 hrs

- NO protein binding

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15
Q

Li effects on bipolar disorder?

A
  1. Reduces suicide risk

2. Enhances antidepressant effects in MDD

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16
Q

Blood monitoring of Li?

A
  • 20 Hr. halflife

- Blood draw 5 - 7 days after first / new dose

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17
Q

Through draw of Li?

A
  • 12 hours after last dose
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18
Q

How does kidney handle Li?

A
  1. Freely filtered in glomerulus
  2. Reabsorbed with Na in proximal tubule
  3. Resorbed by principal epithelial cells in Na channel of collecting duct
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19
Q

Drugs involved in urinary alkalization?

A

“Carbonic anhydrase inhibitors”

  1. Acetazolamide
  2. Dichlorphenamide
  3. Methazolamide
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20
Q

What does carbonic anhydrase do?

A
  • Catalyzes conversion of H2O and CO2 into bicarb and H
  • Found in tubule epithelium
  • Release H into lumen to combine with bicarb
  • Without this H, Bicarb has nothing to combine with and urine is alkalized
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21
Q

Impact of carbonic anhydrase inhibitors on Li?

A
  • Decrease blood [Li]
  • Block Bicarb reabsorption in proximal tubule
  • Li and Na follow to distal tubule
  • Some is reabsorbed, but net loss in urine
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22
Q

What are the osmotic diuretics?

A
  1. Mannitol
  2. Urea
    * **Work at proximal tubule
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23
Q

Impact of osmotic diuretics on Li?

A
  • Decrease blood [Li]
  • Increase tubule osmolality
  • Increased water and Electrolyte (Na/Li) excrtion
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24
Q

Impact of loop diuretics on Li?

A
  • Little to no change

- Furosemide

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25
Impact of thiazide diuretics on Li?
Increase [Li] in blood
26
Trend of diuretic impact on Li?
- Drugs acting closer to glomerulus, decrease [Li] | - Drugs acting further from glomerulus, increases [Li]
27
Impact of K sparing diuretics on Li?
- Increased [Li] in blood - Spironolactone and Amiloride * ***Amiloride thought to be protective against NDI
28
What are the K sparing diuretics?
1. Spironolactone | 2. Amiloride
29
Impact of ACEIs and ARBs on Li?
Increased [Li] in blood
30
Impact of dehydration on Li?
Increased [Li] in blood
31
Impact of pregnancy on Li?
Decreased [Li] in blood
32
Impact of Na depletion on Li?
Increased [Li] in blood
33
Impact of renal impairment on Li?
Increased [Li] in blood
34
Impact of age on Li?
Increased [Li] in blood
35
Impact of NSAIDs on Li?
Increased [Li] in blood
36
Impact of COXII inhibitors on Li?
Increased [Li] in blood
37
Impact of caffeine on Li?
Decreased [Li] in blood
38
Impact of phyllines on Li?
Decreased [Li] in blood
39
Common side effects of Li?
1. HYPOthyroidism 2. Nausea / Diarrhea 3. Tremor 4. Decreased [] and sedation 5 Weight gain
40
Serious side effects of Li?
1. Nephrogenic diabetes insipidus 2. Renal insufficiency 3. End stage renal disease: rare
41
How to treat sever LI toxicity?
Dialysis
42
Lab tests for patients on Li?
1. TSH 2. Renal Function 3. Pregnancy test 4. ECG if > 50 yo 5. Li level every 6 - 12 months
43
Trade names for valproic acid and divalproex sodium?
Valproic acid: Depakene | Dival proex Na: Depakote
44
Difference between depakote and depakene?
Depakene: Original version, high prevalence of nausea / vomiting Depakote: powdered form with "kote," less GI effects
45
MOAs of depakene /kote?
1. GABA reuptake inhibitor 2. 2nd messenger enzyme influencer 3. Blockage of voltage dependent Na Channels
46
Kinetics of depakote?
100% Absorption 90% protein bound 12 Hour 1/2 life
47
What drugs can displace depakote from protein binding?
1. Caffeine | 2. Asparin
48
DDIs of depakote?
1. Inhibit hepatic metabolism of drugs 2. Displace drugs from protein: Phenytoin 3. Displaced by drugs: aspirin / caffeine
49
MOA for depakote causing hepatic toxicity of other drugs?
- Inhibits phase II glucuronidation pathway | * ***Does NOT involve CYP450 system
50
Drugs depakote causes hepatic toxicity in?
1. Phenytoin 2. Carbamazepine 3. Lamotrigine
51
Drugs depakote displaces?
1. Phenytoin 2. Carbamazepine 3. Diazepam
52
Depakote side effects?
1. Nausea / vomiting / diarrhea 2. Tremor 3. Sedation 4. Weight gain 5. Thrombocytopenia: check platelet levels 6. Increased ammonia levels
53
Depakote toxicity?
1. Increased LFTs (Liver Function Tests) | 2. Hepatotoxicity: Kids
54
What type of drug is depakote?
Mood stabilizer / anticonvulsant
55
What to monitor while patient on depakote?
1. LFTs 2. Platelets: thrombocytopenia 3. Pregnancy 4. [Depakote] - hit correct windows
56
MOAs of carbamazepine?
1. Decrease Na influx depressing synaptic transmission 2. Adenosine agonist 3. Decrease NE / glutamate release
57
Kinetics of carbamazepine?
1. Erratic absorption | 2. 70 - 80 % Protein binding: wont know off much
58
DDIs of carbamazepine?
1. INDUCES CYP450s increasing self and other drug absorption 2. Induces UDP glucuronosyltransferase 3. Other drugs can increase or decrease its metabolism 4. CANNOT slow down other drug metabolism
59
Difference between depakote and carbamazepine effect on glucuronidation pathway?
Depakote: INHIBITS pathway Carbamazepine: INDUCES pathway
60
Side effects of carbamazepine?
1. Nausea 2. Dizziness 3. Sedation 4. Teratogen: Neural tube defects 5. Steven Johnsons Syndrome 6. Aplastic anemia` 7. Agranulocytosis 8. Weight Gain 9. Increased Suicide Risk
61
What are the mood stabilizers?
1. Depakote 2. Lamotrigine 3. Carbamazepine
62
Indications of lamotrigine?
1. Bipolar depression 2. Bipolar maintenance 3. NOT useful for manic episodes
63
Lamotrigine MOA?
1. Inhibition of Na Channels | 2. Inhibits glutamate release
64
Lamotrigine kinetics?
1. Metabolized by glucuronidation | 2. Low protein binding
65
What is inhibition of Na channels useful in?
Anti epileptic effect
66
Which drug inhibits glucuronidation?
Depakote
67
DDIs of lamotrigine?
1. Depakote: 2x lamotrigine levels 2. Oral contraceptives: 1/2 lamotrigine levels 3. Carbamazepine: 1/2 lamotrigine levels
68
What do do when patient is on depakote and you need to put on lamotrigine?
Cut lamotrigine dose in half
69
Lamotrigine side effects?
1. Benign Rash: must assume steven Johnsons 2. Steven Johnsons syndrome: rarer 3. Nausea * **Alcohol can increase severity
70
What is stephen Johnsons syndrome?
- Toxic epidermal necrolysis, (life-threatening condition) in which cell death causes epidermis to separate from dermis. - Hypersensitivity complex that affects the skin and the mucous membranes * ***Lamotrigine
71
Drug to look out for Steven Johnson syndrome with?
Lamotrigine
72
What are SGAs?
"Second Generation Antipsychotics"
73
When is mania considered severe?
1. Patient is psychotic 2. Patient is suicidal 3. Patient puts others in danger * **Usually situations when patient is hospitalized
74
When and how are SGAs used to treat bipolar disorder?
- In severe mania when patient would be hospitalized | - In conjunction with Li or Depakote
75
Pregnancy risk of Li?
1. Ebstein's anomaly in first trimester (cardiac) | * **Risk thought to be much lower than commonly believed
76
Which bipolar med has greatest risk for birth defect?
Valproic acid
77
Pregnancy risk of depakote?
Neural tube defects: highest risk of all antipsychotics
78
Risk of carbamazepine in pregnancy?
Neural tube defects: less than depakote
79
Risk of lamotrigine in pregnancy?
Possible cleft pallet | **Least risk of all
80
Which stages of bipolar disorder does Li treat?
1. Acute mania 2. Maintenance 3. Depression
81
Which stages of bipolar disorder does Depakote treat?
1. Acute mania | 2. Maintenance
82
Which stages of bipolar disorder does carbamazepine treat?
1. Acute mania | 2. Maintenance
83
Which stages of bipolar disorder does Lamotrigine treat?
1. Depression | 2. Maintenance

Pharm: Psych (7 decks)

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