What medications may cause mania?
L- dopa and corticosteroids
In general with bipolar disorder what 5 things should you do before prescribing medication?
Asses if there is a drug/alcohol problem
D/c anti depressants
taper caffeine/stimulants
treat substance abuse
encourage diet and exercise
What drug might you chose to treat hypomania initially (4)
Lithium, valproate, carbamazepine, SGAs
If mono therapy is inadequate in treating hypomania what combonation drugs might you try?
Lithium + anticonvulsant or SGA
Anticonvolsant + SGA
What is an alternative for benzos when treating agitation?
oxcarbazepine
What drugs could you use to first treat mania?
Lithium, valproate and/or SGA and benzos
What is lorazepam especially indicated for?
Catatonia
How many drugs should you initially start off with in patients who have mania?
2-3
What is an alternative med in treating mania?
carbamazepine or oxcarbazepine
If lithium, valproate and or benzos/SGA do not work to treat mania what can be used?
Lithium + antipsychotic + anticonvulsant
Anticonvulsant + anticonvulsant + antipsychotic
What can be used in the most resistant cases of mania?
clozapine or ECT
What is preferred over valproate for treating bipolar depression?
lithium + lamotragine
What is the drug of choice for mania?
lihtium
What are the only approved mono therapies for bipolar disorder?
quetiapine- seroquel and lurasidone-latuda
How long to anti depressants take to star working with bipolar?
6-8 wks
What is lithiums half life and maintenance levels in blod?
0.6-1
24 hour half life
What are the potential side effects for lithium?
rash/psoriasis
tremor/akathesia
hypothyroidisn
teratogenicity
What drugs does lithium interact with to decrease concentration?
Pregnancy and theophylline
What 3 main categories increase lithium concentrations?
ACEI, ARBS, NSIADS by decreasing kidney function
What tests should be performed pre-lithium initiation and every 6 mos
pre :
CBC, BMP, TSH, urinalysis
6mo:
Serum Li, renal function, thyroid function
What 3 anticonvulsants can be used to treat bi-polar disorder?
divalproex - depacon(IV)
valproic acid - Depakote
Carbamazepin(Tegretol
Lamotrigine ( Lamictal)
How does divalproex work?
S/e
increases GABA available
great for mania, not so much depressive episodes
S/e: wt gain, hair loss, tremor “fat bald and shaky”
hepatotoxic and teratogenic
What drug does valproic acid have an interaction with?
lamotrigine - competes for gluconoridation so you need to decrease lamotrigine by 50%
When does carbamazepine work exceptionally well?
Head injuries for acute and maintenance biolar
What is the most drastic side effect with carbamazepine along with the other 2 side effects?
Steven johnson syndrome in Asain ancestry with HLA B gene
SIADH
agranulocytosis and liver failure
What type of inducer is carbamazepine? What does that mean?
CYP3A4 AUTOinduer… it induces itself so you progressively have to increase the dose
What drug is structurally related to carbamazepine?
oxcarbazepine
What is the MOA of lamotrigine?
What pts does it work best in?
S/e?
MOA: inhibit glutamate transmission
Works best in depressive bipolar bc glutamate is left in synapse
Steven Johnson Syndrome
What drug interactions does lamotrigine have? how do you adjust for these TWO drug interactions?
valproic acid and carbamazepine
valproic - decrease by 50%
carbamazepine - increase by 50%
What antipsychotic drugs should and should not be used with acute mania or mixed treatment?
all SGA can be used except:
brexpiprazole
cloxapine
iloperidone
What are the only two antipsychotic medications approved to treat bipolar depression?
quetiapine - seroquel
lurasidone - latuda
What should you never use as a mono therapy in bipolar patients due to the possibility of switching over to mania?
antidepressants
What drug is significant in causing akathisia like tremors when treating bipolar disorder?
Lithium