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neurology/psychiatry > Bipolar > Flashcards

Bipolar Flashcards

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1
Q

___% of patients with bipolar disorder have a relative with a mood disorder

A

80-90%

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2
Q

bipolar 1

A

criteria have been met for at least one manic episode

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3
Q

bipolar 2

A

criteria have been met for at least one hypomanic episode & at least one major depressive episode

THERE HAS NEVER BEEN A MANIC EPISODE

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4
Q

diagnosis can switch from ___ to ____

A

bipolar 2 to bipolar 1

(never the other way around)

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5
Q

criteria for a manic episode

A

abnormally & persistently elevated, expansive, or irritable mood with INCREASED GOAL-DIRECTED ACTIVITY/ENERGY lasting AT LEAST 1 WEEK and present most of the day, nearly every day. is sufficiently severe to cause impairment in functioning

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6
Q

during a manic period, 3 of the following symptoms are present

A

grandiosity
decreased sleep
pressured speech
racing thoughts
distracted
increased activity or psychomotor agitation
involvement in activities with serious consequences

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7
Q

mnemonic for manic episode

A

DIG FAST
Distractible
Impulsive
Grandiosity
Flight of ideas
Activities dangerous or hypersexual
Sleep decreased
Talkative

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8
Q

criteria for a hypomanic episode

A

lasting at least 4 DAYS, not severe enough to impair functioning or necessitate hospitalization
but otherwise basically the same as manic criteria

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9
Q

main difference between mania and hypomania

A

mania is for at least one week & severe enough to cause impairment in social/occupational functioning

hypomania is for 4 days and does not cause impairment in social/occupational functioning

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10
Q

criteria for a depressive episode

A

5 symptoms (depression symptoms) have been present during a 2 week period, at least one of the symptoms is depressed mood or loss of interest, and the symptoms cause clinically significant impairment

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11
Q

_________ is not required for a diagnosis of bipolar 1 disorder

A

major depressive episode

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12
Q

goal of bipolar treatment

A

restore euthymic mood

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13
Q

goals of acute phase

A

rapidly control behavioral symptoms, restore sleep, stabilize mood, reduce harm to self and others

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14
Q

goals of continuation phase

A

therapy continues x2-4 months during high risk of relapse, prevent relapse & optimize medications

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15
Q

goals of maintenance phase

A

after mood stability x 3 months, improve QOL, minimize number of effective agents, provide prophylaxis for future episodes
LIFETIME TREATMENT

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16
Q

2 categories of pharmacotherapy for bipolar

A

mood stabilizers
antipsychotics

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17
Q

4 mood stabilizers used for bipolar

A

lithium
lamotrigine
divalproex
carbamazepine

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18
Q

indication for lithium

A

bipolar maintenance with SUICIDALITY BENEFIT
manic, depressive, mixed episodes

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19
Q

lithium place in therapy

A

first line monotherapy & combo therapy for maintenance & acute manic, hypomanic, depressive, mixed episodes

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20
Q

lithium onset

A

7-14 days for mania
6-8 weeks for depression

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21
Q

300 mg of oral formulations of lithium= ___ mEq of Li

A

8.12

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22
Q

how is lithium eliminated

A

renally

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23
Q

boxed warning for lithium

A

toxicity is closely related to serum Li concentrations
can occur at doses close to therapeutic concentrations
prior to initiation, ensure access to TDM

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24
Q

each 300 mg increase in lithium dose results in ___ increase in level

A

0.3 mEq/L

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25
therapeutic range of lithium for maintenance
0.6-1.2
26
therapeutic range of lithium for acute mania
1-1.2
27
n/v/d, polydipsia, muscle weakness, fine hand tremor occur at what range of lithium
1.2-1.5
28
coarse hand tremor, slurred speech, confusion occur at what range of lithium
1.5-2.5
29
stupor, seizure, hypotension, coma, death occur at what range of lithium
>2.5
30
when to monitor lithium concentrations
after steady state (5 days) obtain 12-hour levels (trough)
31
baseline monitoring for lithium
renal panel (BUN, SCr, lytes) thyroid pregnancy test ECG for patients >40 or underlying risks
32
how often to monitor lithium levels
5-7 days after dose adjustments then for 1 month then every 6 months
33
how often to monitor renal & thyroid function for Lithium
every 6-12 months
34
how to take lithium
with food at bedtime
35
how to mitigate GI side effects with lithium
take with food
36
how to mitigate tremor/fatigue with lithium
HS dosing, give CR, propranolol
37
how to mitigate polyuria & polydipsia with lithium
HS dosing & avoid caffeine
38
other side effects with lithium
weight gain (diet & exercise) dermatologic (topical tx) leukocytosis (benign) hypothyroidism (supplement) diabetes insipidus
39
MILD toxicity lithium
hand tremor, GI, fatigue
40
MODERATE toxicity lithium
coarse hand tremor, confusion, slurred speech, unsteady gait
41
SEVERE toxicity lithium
seizures, stupor, coma, arrhythmia
42
how to prevent lithium toxicity
consistent hydration & salt intake
43
how to manage mild lithium toxicity
hold lithium, obtain level, educate patient
44
how to manage severe lithium toxicity
hydrate, protect airway, hemodialysis, vitals, BUN, SCr, urinalysis, CBC w/ diff, ECG
45
drugs that INCREASE lithium levels
NSAIDs thiazides ACEi/ARB
46
drugs that DECREASE lithium levels
theophylline, spironolactone, caffeine
47
indications for divalproex
bipolar mania, maintenance therapy
48
place in therapy of divalproex
first line monotherapy & combo therapy for manic, hypomanic, & mixed episodes * preferred agent for mixed episodes, may be beneficial in rapid cycling
49
dosing considerations for divalproex
can be weight based or fixed dose (ex start at 25 mg/kg/day or 500-1000 mg HS)
50
timing of monitoring for divalproex
trough levels after steady state (3-5 days) 18-24 hours post dose for once daily form 12 hours post dose for twice daily form
51
therapeutic range for divalproex
50-125 mg/L
52
effects seen at 75-100 mg/L divalproex
ataxia, sedation, lethargy, fatigue
53
effects seen at 100-175 mg/L divalproex
tremor
54
effects seen >175 mg/L divalproex
stupor, coma
55
boxed warnings for divalproex
hepatotoxicity (first 6 months, may be fatal) fetal risk pancreatitis
56
divalproex contraindications
hepatic disease, urea cycle disorders
57
common side effects divalproex
n/v, weight gain, alopecia, sedation, tremor, fatigue
58
serious side effects divalproex
hepatic failure, thrombocytopenia, pancreatitis, hyperammonemia
59
baseline monitoring divalproex
CBC w/ platelets, LFTs, pregnancy test
60
when to monitor valproate level
3-5 days after dose adjustments, valproate level every 6-12 months
61
ongoing monitoring for divalproex
CBC & LFTs q6-12 months NH3 if symptomatic or suspicion
62
drugs that INCREASE divalproex levels
aspirin, warfarin, risperidone, fluoxetine
63
drugs that DECREASE divalproex levels
carbamazepine, carbapenems, rifampin
64
which mood stabilizer does not require TDM
lamotrigine
65
lamotrigine indications
bipolar depression, maintenance therapy
66
place in therapy lamotrigine
first line as monotherapy & combo therapy for depressive episodes
67
what happens if patient misses more than 5 days of lamotrigine
restart titration
68
t/f: there is a correlation between levels and effectiveness for lamotrigine
false: no TDM
69
common side effects lamotrigine
n/v, rash, somnolence/fatigue
70
serious side effects lamotrigine
SJS, TEN, angioedema, multi organ failure
71
boxed warning for lamotrigine
life-threatening rashes (SJS & TEN) higher in children than adults coadministration w/ valproate
72
baseline monitoring for lamotrigine
BUN, SCr, LFTs
73
ongoing monitoring for lamotrigine
BUN, SCr, LFTs q6-12 months
74
carbamazepine indications
bipolar disorder, mania or mixed episodes
75
carbamazepine place in therapy
second line monotherapy & combo therapy for manic, hypomanic, mixed episodes
76
carbamazepine is an ________
an autoinducer
77
carbamazepine dosing
start at 400 mg/day (divided bid) increase by 200 mg/day every week up to 1200
78
therapeutic range carbamazepine
4-12
79
what happens at carbamazepine levels >8
n/v, HA, dizzy, blurred vision
80
what happens at carbamazepine levels >40
apnea, dystonia, coma
81
boxed warning carbamazepine
serious derm reactions & HLA-B*1501 allele aplastic anemia & agranulocytosis
82
carbamazepine contraindications
bone marrow depression, concurrent MAOI use or NNRTI, hepatic failure
83
warnings for carbamazepine
avoid if history of hepatic porphyria increased risk suicidality teratogen potential for withdrawal seizure if abrupt dc hyponatremia
84
common side effects carbamazepine
n/v, blurred vision, dizzy, somnolence
85
serious side effects carbamazepine
SJS, TEN, anemia, agranulocytosis, hepatic failure
86
baseline monitoring carbamazepine
HLA-B*1502 allele if asian CBC, LFT, BUN, SCr, lytes, pregnancy test
87
when to monitor carbamazepine levels
5 days after dose adjustments then every 6-12 months
88
ongoing monitoring carbamazepine
CBC, LFT, BUN, SCr, lytes q6-12 months
89
drugs that INCREASE carbamazepine levels
CCBs, cimetidine, erythromycin, valproic acid
90
drugs that DECREASE carbamazepine levels
phenobarbital
91
what does carbamazepine INDUCE
ITSELF (AUTO INDUCER) and decreases oral hormonal contraceptives, theophylline, warfarin
92
counseling for mood stabilizers (general)
stopping abruptly is bad (side effects, relapse) many side effects are transient lab monitoring onset of effect
93
adequate trial duration for mood stabilizers
2-3 weeks
94
first line pharmacotherapy for bipolar
mood stabilizer or atypical antipsychotic
95
atypical antipsychotics with FDA approval for bipolar 1 disorder
aripiprazole, asenapine, olanzapine, quetiapine, risperidone, ziprasidone, cariprazine, lurasidone, chlorpromazine, lumateperone
96
first line for ACUTE MANIA
lithium, divalproex, risperidone, quetiapine, aripiprazole, ziprasidone, asenapine, paliperidone
97
first line for ACUTE DEPRESSION
lithium, lamotrigine, quetiapine
98
second line for ACUTE DEPRESSION
divalproex, lurasidone

neurology/psychiatry (22 decks)

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