Bipolar

Question 1

Bipolar I

Answer 1

One or more manic or mixed episodes

Most also have some depression

Question 2

Bipolar II

Answer 2

One or more depressive episodes + at least one hypomanic episode

Often misdiagnosed as MDD

Question 3

Cyclothymic disorder

Answer 3

Several periods of hypomania and mild depression but do not meet criteria for mania, major depressive

Question 4

Rapid cycling

Answer 4

At least 4 episodes of mania, hypomania, or depression in 1 year with 2 months between episodes

Question 5

Bipolar I treatment of choice

Answer 5

Lithium

Question 6

Lithium onset

Answer 6

Antimania: 1-2 weeks. May need adjunctive benzo or antipsychotic to control symptoms

Antidepressant effect: 6-8 weeks

Question 7

Lithium monitoring labs

Answer 7

Baseline: CBC, electrolytes, renal function, thyroid function, UA, ECG, pregnancy test

every 6-12 months: Renal function, thyroid function, UA

Order serum concentration 12 hours after last dose, 5-6 days after initiation

Question 8

Lithium serum concentration for acute mania

Answer 8

0.8-1.2

Question 9

Lithium serum concentration for maintenance

Answer 9

0.6-1.0

Question 10

Lithium toxicity

Answer 10

Lethargy
Coarse tremor
Confusion
Seizures
Coma
Death

Treatment of choice if severe: hemodialysis

Question 11

Intervention if rash, psoriasis from lithium

Answer 11

D/C drug (temporary or permanent)

Question 12

Intervention of tremor from lithium

Answer 12

Decrease dose
Add BB

Question 13

Intervention if CNS toxicity from lithium

Answer 13

Reduce dose

Question 14

Intervention if GI upset from lithium

Answer 14

Reduce dose
Try ER
Split doses

Question 15

Intervention if hypothyroid from lithium

Answer 15

Levothyroxine
D/C lithium if necessary

Question 16

Intervention if polydipsia or polyuria from lithium

Answer 16

Reduce dose
Manage fluid intake
Change to single bedtime dose

Question 17

Intervention if interstitial fibrosis or glomerulosclerosis from lithium

Answer 17

Lower dose to achieve lowest effective concentration

Avoid dehydration

Question 18

Lithium and pregnancy

Answer 18

Avoid during first trimester

Question 19

Agents to avoid with lithium

Answer 19

Thiazides
Furosemide
NSAIDs
ACE-Is

All increase lithium plasma concentrations and could cause toxicity

Question 20

Theophylline and lithium

Answer 20

lowers lithium concentration

Question 21

Neuromuscular blockers and lithium

Answer 21

lithium may prolong neuromuscular blocker effect

Question 22

Lithium and carbamazepine

Answer 22

Increase CNS toxicity
Not contraindication, but not commonly combined in practice

Question 23

Lithium and neuroleptics

Answer 23

Lithium may potentiate EPS

Question 24

Lithium and the thyroid

Answer 24

Lithium decreases synthesis and release of thyroid hormone, thus causing hypothyroidism

Question 25

Dehydration, salt restriction, extrarenal salt loss on lithium

Answer 25

Increases sodium reabsorption which increases lithium plasma concentration

Question 26

Decreased renal function and lithium

Answer 26

Decreased GFR and increased creatinine/BUN will increase lithium plasma concentration

Question 27

Aging and lithium

Answer 27

Aging decreases GFR and increases sensitivity to ADRs. Will need to decrease lithium requirements.

Question 28

Divalproex/Valproate for bipolar

Answer 28

As effective as lithium Better for rapid cycling than depressive episodes

Question 29

Divalproex/valproate BBW

Answer 29

Hepatotoxicity (LFTs monitored routinely) Mitochondrial disease (increases risk for liver failure) Fetal risk Pancreatitis

Question 30

Divalproex/valproate serum concentration

Answer 30

50-125 but usually target level at when achieve clinical response >80: neurotoxicity, sedation, hair loss, thrombocytopenia

Question 31

Divalproex enteric coated to ER dosage form

Answer 31

Increase dose 8-20% due to less bioavailability with ER form

Question 32

Carbamazepine for bipolar

Answer 32

Only for acute mania and maintenance therapy Strong inducer and autoinducer, so can take time to come to steady state

Question 33

Lamotrigine in bipolar

Answer 33

Approved for maintenance therapy. Best at preventing depressive episodes compared to manic episodes Not effective in acute phase due to long titration

Question 34

Missed lamotrigine doses

Answer 34

If miss >3-5 half lives (5 days), reinitiate from starting dose

Question 35

Lamotrigine + valproic acid

Answer 35

increased risk for SJS rash

Question 36

Lamotrigine rare ADRs

Answer 36

SJS Aseptic meningitis Hemophagocytic lymphohistiocytosis (HLH)

Question 37

SGAs for acute bipolar treatment

Answer 37

All FDA approval except brexpiprazole, clozapine, iloperidone, lumateperone, lurasidone First line agents for acute mania: Aripiprazole Asenapine Cariprazine Paliperidone Quetiapine Risperidone

Question 38

SGAs for bipolar depression

Answer 38

Cariprazine Quetiapine Lumateperone Lurasidone Olanzapine + fluoxetine

Question 39

SGA for bipolar maintenance

Answer 39

Risperal Consta Abilify Maintena Olanzapine Quetiapine

Question 40

Antidepressants and Bipolar

Answer 40

Avoid monotherapy as it can switch to manic phase (highest risk with TCA and SNRI) Avoid if symptoms of mania present

Question 41

Type II Bipolar treatment

Answer 41

First-line agent = lithium, but remember takes 6-8 weeks for depressive symptom resolution Acute phase: Quetiapine, lurasidone Maintenance: lamotrigine Olanzapine + fluoxetine