Bipolar

Question 1

what is bipolar?

Answer 1

• Characterised by periods of high moods (mania/hypomania), and low moods (depression).
o Sometimes people may not get back to their baseline function
o Rapid cycle from high to low moods

Question 2

what is bipolar I?

Answer 2

at least one manic episode with or without history of major depressive episodes.

Question 3

what is bipolar II?

Answer 3

one or more major depressive episodes, and at least one hypomanic episode, but no evidence of mania.

Question 4

what is mania?

Answer 4

distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week, accompanied by at least 3 additional symptoms (e.g. increased energy/activity, pressure of/incomprehensible speech, flight of ideas, poor concentration, disinhibition, extravagant/impractical plans, delusions or hallucinations)

Question 5

what is hypomania?

Answer 5

similar to mania, but symptoms only need to have lasted for 4 days, not severe enough to cause marked impairment/hospitalisation, and no psychotic features.

Question 6

how do you treat mania and hypomania?

Answer 6

• Consider stopping any antidepressants.
o As these can push a patient into mania
• If patient already on mood stabiliser, maximise dose to try and bring them out
• Use antipsychotics – Haloperidol, Risperidone, Olanzapine, Quetiapine.
o If one doesn’t work then use another
• If not tolerated or ineffective, switch to a different antipsychotic.
• If only on antipsychotic, and still insufficient response, consider adding Lithium, or Valproate.
• Do not use Lamotrigine for mania.

Question 7

what is bipolar depression?

Answer 7

Symptoms and diagnosis as for unipolar depression. BUT – different treatment approach, as need to consider risk of switching with antidepressants as they can push you into mania

Question 8

how do you treat bipolar depression?

Answer 8

 For moderate to severe bipolar depression:
 If already on mood stabiliser, maximise dose.
 Fluoxetine (SSRI) AND Olanzapine(antidepressant), or Quetiapine (on its own)
 Can also consider – Olanzapine on its own, or Lamotrigine.
 If no response to Fluoxetine and Olanzapine, or Quetiapine, use Lamotrigine.

Question 9

what are the options for maintenance of BPAD?

Answer 9

• Want to prevent an episode from happening
• Consider drugs used effectively in acute episodes – if they worked for the episode can they stay on it for the future
• Lithium is most effective.
• Other options if Lithium cannot be used/ineffective:
- Add/switch to Valproate
- Or Olanzapine
- Or Quetiapine if used in acute phase and effective.

Question 10

what is lithium?

Answer 10

tkaes 4-7 days to reach steady state

has a narrow therapeutic window

Question 11

what is the narrow therapeutic window of lithoum?

Answer 11

o Less then 0.4 doesn’t work and above 1 you are worried about the risks of toxicity which is level 5

Question 12

what levels do you want of lithium?

Answer 12

• Levels – 12 hours post dose, range 0.4 – 0.8mmol/l (with some exceptions – up to 1mmol/l). Check weekly until stable, then 3 monthly for first year, then every 6 months after. If level 1 then you need to have it tested weekly.
o We check this and then adjust depending if it is too high or too low

Question 13

what are the drug interactions with lithium?

Answer 13

• Drug interactions – NSAIDs, diuretics, ACE inhibitors.
o Means you would check the levels to make sure these arent going too high. But NSAIDS they can buy OTC this is an issue, warn them don’t to buy anything apart from through a pharmacy so they can advise them what is best as ibuprofen could make them go toxic

Question 14

what other monitoring do you need to do with lithium?

Answer 14

U&Es, eGFR, TFTs, Bone, FBC, ECG, BMI.

Question 15

what can lithium cause?

Answer 15

nephrotoxicity, hypothyroidism, hypercalcaemia.

Question 16

what are the signs of toxicity of lithium?

Answer 16

vomiting and diarrhoea, coarse tremor, CNS disturbances…. Need to get levels done if they have these symptoms

Question 17

what are the counselling points of lithium?

Answer 17

• Indication, dose, time of dose, frequency
• Brand, MR formulation
• Duration of treatment
• Physical and lithium monitoring
• Why we do monitoring (toxicity), when we do levels, frequency
• Side effects
• Causes of toxicity – dehydration, changes to salt, other medicines
• Signs of toxicity
• What to do if toxicity occurs – if you suspect need to go GP or A and E straight away to have levels checked
• Drug interactions – only buy OTC medicines from a pharmacy, tell pharmacist that you are taking Lithium.
• Pregnancy – if you are thinking of becoming pregnant or have become pregnant you need to speak to you GP. But stopping abruptly is also a danger so need to refer

Question 18

what is valporate?

Answer 18

• Sodium Valproate, and Semisodium Valproate

- Twice daily dosing

Question 19

what do you need to monitor with valporate?

Answer 19

regular BMI, FBC, LFTs – after 6 months, then annually

Question 20

wwhat is teratogenicity?

Answer 20

• 10.73% of children exposed to Valproate during pregnancy suffer from congenital malformations. Risk greatest at higher doses.
• Dose dependent risk of developmental disorders. Up to 30-40% of children exposed to Valproate in utero experience delays in early development.
• Approximately 3-fold increased risk of autistic spectrum disorder.
• Approximately 5-fold increased risk of childhood autism.

Question 21

what do you need to do if you give valporate to a woman of chuld bearing age?

Answer 21

pregnancy prevention programme. Annual acknowledgement of risk and review, highly effective contraception, referral if pregnant/planning pregnancy. Patient card at every dispensing, patient guide. Warnings on packaging. If patient unaware of risks, not been reviewed, dispense and refer to GP.

Question 22

what is the treatment pathway of bipolar?

Answer 22

 Treat acute episodes.
 Review medication once improvement.
 get back to baseline.
 Maintenance treatment.
 Consider patient factors when choosing medication – age, gender, preference, allergies/intolerances, co-morbidities, concurrent medication, previous responses.
 Minimum of medication, lowest dose possible.

Question 23

what is the role of a pharmacist?

Answer 23

• Medication reconciliation and history
• Medication options
• Counselling and discussion with patient
• Monitoring compliance, levels
• Advice re: interactions, pregnancy, complications of treatment
• Side effect monitoring and advice
• Recognising toxicity
• Reviewing treatment
• Recognising relapse