bipolar

Question 1

Treatment for acute mania

Answer 1

D/C any antidepressants or stimulants

SGAs: aripiprazole, quetiapine, risperidone, asenapine, paliperidone, cariprazine
Lithium
Valproate

2nd:
carbamazepine (safety profile)
olanzapine
ziprasidone
haloperidol

Question 2

Treatment for bipolar depression

Answer 2

quetiapine
lithium
lamotrigine
lurasidone

2nd:
valproate
olanzapine/fluoxetine
cariprazine
adjunctive SSRI/bupropion (never first line)

Question 3

1st line maintenance therapy

Answer 3

lithium
valproate
lamotrigine
quetiapine
aripiprazole
asenapine
olanzapine-samidorphan

Question 4

Lithium CI

Answer 4

pregnancy (cardiac malformations)
breastfeeding
renal impairment (Almost 100% renally eliminated unchanged)
dehydration
hyponatremia
severe cardiac disease

Question 5

Lithium AE (within therapeutic range)

Answer 5

GI upset
cognitive effects
tremor
polyuria/polydipsia
weight gain
alopecia
leukocytosis
rash
somnolence/sedation
AKI
hypothyroidism
neurotoxicity (SILENT)

Question 6

Lithium AE (toxicity)

Answer 6

> 1.5 coarse tremor, N/V/D
2.0 confusion, sedation, slurred speech
2.5 seizures, coma, death

Question 7

Interactions that increase lithium levels

Answer 7

NSAIDs
decreased sodium intake / sodium loss
thiazide diuretics
ACEis, ARBs
calcium channel blockers
dehydration, sweating, diarrhea
prolonged fever

Question 8

Interactions that decrease lithium levels

Answer 8

Loop diuretics
SGLT-2 inhibitors
carbonic anhydrase inhibitors
excessive sodium intake
excessive fluid intake
theophylline
caffeine

Question 9

Valproate MoA

Answer 9

enhances inhibitory GABA effects
inhibits voltage-sensitive Na+ channels (decreases glutamate excitatory neurotransmitters)

Question 10

Valproate CI

Answer 10

hepatic disease
urea cycle disorders
pregnancy (neural tube defects, craniofacial defects, cardiovascular defects)

Question 11

Valproate AE

Answer 11

N/V
Tremor
sedation
alopecia
weight gain
thrombocytopenia
LFT increase
hepatotoxicity (BBW)
encephalopathy
pancreatitis (BBW)
agranulocytosis
PCOS
metabolic syndrome
rash

Question 12

Interactions that decrease valproate levels

Answer 12

carbamazepine
phenytoin
rifampin
combined oral contraceptives

Question 13

Valproate has increased hepatotoxicity risk when combined with

Answer 13

topiramate

Question 14

Valproate can increases levels of which drugs?

Answer 14

lamotrigine
lorazepam

Question 15

Carbamazepine MoA

Answer 15

enhances inhibitory GABA effects
inhibits voltage-sensitive Na+ channels (decreases glutamate excitatory neurotransmitters)
inhibits glutamate release
anti-kindling effect

Question 16

What is Equetro?

Answer 16

the only form of carbamazepine approved for mania

Question 17

What is considered toxic levels of carbamazepine?

Answer 17

> 15 mcg/mL

Question 18

Carbamazepine CI

Answer 18

myelosuppression
hepatic disease
TCA hypersensitivity
pregnancy (cranial defects, cardiac malformations, neural tube defects)

Question 19

Safer drugs to use for bipolar pregnant patients

Answer 19

SGAs
lamotrigine (not the best for mania)
lurasidone (for bipolar depression)
possibly chlorpromazine (only FGA approved for mania)

Question 20

Carbamazepine AE

Answer 20

N/V
Drowsiness
ataxia, dizziness, confusion
blurred vision
hyponatremia (SIADH)
hematologic effects (BBW)
hepatotoxicity
rash (SJS, toxic epidermal necrolysis/TEN)
increase seizures (rarely)

Question 21

Which agents have a warning for suicidal thoughts and behavior?

Answer 21

carbamazepine, valproate, lamotrigine (anticonvulsants)

NOT lithium - actually prevents suicide, self harm and death in mood disorder patients

Question 22

Carbamazepine interactions

Answer 22

many CYP interactions (3A4, 2C9, 2C19, 1A2, 2B6)
decreases valproate and lamotrigine levels
autoinducer
decreases effectiveness of oral contraceptives

Question 23

Carbamazepine CI

Answer 23

nefazodone
NNRTIs
MAOis

Question 24

For patients with Asian ancestry, which allele should they be screened for, and for which drug? Why?

Answer 24

HLA-B*1502 allele
Before treatment on carbamazepine
Due to risk of SJS (flu-like symptoms, rash)

Question 25

What agents have interactions with oral contraceptives?

Answer 25

valproate carbamazepine lamotrigine topiramate

Question 26

Lamotrigine MoA

Answer 26

inhibit voltage-sensitive Na+ channels inhibit release of glutamate weak 5-HT3 inhibitor

Question 27

Lamotrigine AE

Answer 27

serious rash (SJS, toxic epidermal necrosis/TEN) headache somnolence ataxia diplopia (double vision) tremor dizziness N/V

Question 28

What are risk factors for experiencing serious rash when taking lamotrigine?

Answer 28

fast titration high doses co-administration with valproate pediatric patients cleft lip and palate (in pregnancy)

Question 29

Which agents have warning for arrhythmia?

Answer 29

lamotrigine lithium - not warning, but intermediate side effect

Question 30

Lamotrigine Interactions

Answer 30

increased by valproate decreased by carbamazepine decreased efficacy by folic acid hormonal contraceptives (estrogen, progestin)

Question 31

Topiramate uses

Answer 31

limited data for monotherapy mostly as adjunctive therapy or to treat AE/comorbidities (weight loss, alcohol use disorder) may decrease efficacy of oral contraceptives

Question 32

Gabapentin uses

Answer 32

limited data for mood benefits mostly to treat comorbidities (anxiety, pain, insomnia)

Question 33

What are FDA approved options for SGA maintenance treatment?

Answer 33

Abilify Maintena (aripiprazole once monthly LAI) Risperidal Consta (risperidone microsphere LAI)

Question 34

When can antidepressants be used for bipolar disorder?

Answer 34

only during acute depressive phase (SSRI or bupropion) only in combination with anti-manic agents especially in bipolar I, recent mania, or rapid cycling