Bipolar Disorder Flashcards
(73 cards)
1
Q
What are the excitatory neurotransmitters?
A
- Norepinephrine
- Dopamine
- Glutamine
- Aspartate
2
Q
What are the inhibitory neurotransmitters?
A
- Serotonin
- GABA
3
Q
Kindling effect
A
Acceleration of episode frequency and treatment resistance with inadequate treatment
4
Q
Manic episode (Bipolar I disorder)
A
Criteria have met for at least one manic episode
5
Q
Major Depressive Episode (Bipolar II disorder)
A
- Criteria have been met for at least one hypomanic episode AND at least one major depressive episode
- NO manic episode
6
Q
What is the diagnostic criteria of a manic episode?
A
- Abnormally and 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
- Symptoms occur for at least one week
- Mood disturbances is severe enough to cause impairment in occupational or social functioning
- 3 or more of the symptoms must occur
7
Q
What are the presentations of a manic episode?
A
- Grandiosity
- Decreased sleep
- Pressured sleep
- Racing thoughts
- Distracted
- Increased activity or pscyhomotor agitation
- Involvement in activities with serious consequences
8
Q
What are the diagnostic criteria of a hypomanic episode?
A
- Abnormally and persistently elevated, expansive, or irritable mood with increased goal-directed activity/energy lasting at least 4 consecutive days and present most of the day, nearly every day
- Associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic
- The disturbance in mood and the change in functioning are observable by others
- The episode is NOT severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization
- 3 or more of the symptoms must be present
9
Q
What are the diagnostic criteria of a depressive episode?
A
- Five or more of the symptoms during the same 2- week period and represent change from previous functioning
- At least one symptoms is depressed mood or loss of interest
- The symptoms cause clinically signified distress or impairment in social, occupational, or other important areas of functioning
- Major depressive episode is NOT required for a diagnosis of bipolar I disorder
10
Q
Lithium
A
- Bipolar disorder, maintenance therapy, suicidality benefit
- Manic, depressive, mixed episodes
- First-line as monotherapy and combination therapy for maintenance therapy and acute manic, hypomanic, depressive, and mixed episodes
11
Q
What are the mechanisms of Lithium?
A
Unknown but current hypothesis:
* Inhibits second messenger systems (inostol, adenylate cyclase, G protein) which dampens neurotransmission
* Enhanced GABA and serotonin transmission
* Increases neurogenesis and neuroprotection
12
Q
What is the dosing of Lithium?
A
- Initial: 300-900 mg/day
- Maintenance: 900-1200 mg/day
13
Q
What is the onset of effect of Lithium?
A
- Mania: 7-14 days
- Depression: 6-8 weeks
- 300 mg of oral formulations if lithium = 8.12 mEq
14
Q
How is lithium eliminated?
A
Renally
15
Q
What is the box warning of lithium?
A
Lithium toxicity
16
Q
Symptoms of mild toxicity of lithium
A
Hand tremor, GI, fatigue
17
Q
Symptoms of modertate lithium toxicity
A
Course hand tremor, confusion, slurred speech, unsteady gait
18
Q
Symptoms of severe lithium toxicity
A
Seizures, stupor, coma, arrhythmia
19
Q
What are some key points of lithium?
A
- After steady state (approx. 5 days)
- Obtain 12-hour levels for monitoring (trough)
- Linear dose to level response
20
Q
What are the baseline labs for lithium?
A
- Renal panel (BUN, SCr, electrolytes)
- Thyroid function status
- Pregnancy test (as indicated)
- ECG for patients > 40 days old or underlying cardiac risk factors
21
Q
What are some monitoring parameters of lithium?
A
- Li+ levels 5-7 days after dose adjustments
- Li+ levels for 1 month
- Li+ levels every 6 month
- BUN, SCr, electrolytes every 6-12 months
- Thyroid function status every 6-12 months
22
Q
What are some side effects of lithium?
A
- GI
- Tremor/fatigue
- Polyuria/polydipsia
- Weight gain
- Dermatologic
- Leukocytosis
- Hypothyroidism
- Diabetes
23
Q
What are some drugs that increase lithium levels?
A
- NSAIDs
- Thiazide diuretics
- ACEis/ARBs
24
Q
What are drugs decrease Li levels?
A
- Theophylline
- Potassium-sparing diuretics
- Caffeine
25
Divalproex
* Bipolar mania, maintenance therapy
* First line therapy as monotherapy and combination therapy for manic, hypomanic, and mixed episode
* Preferred agent for mixed episodes
* May be beneficial in rapid cycling
26
What is the mechanism of Divalproex?
* Mechanism not understood
* Enhanced GABA
27
What is the dosing of Divalproex?
* Can be weight-based or fixed dose
* Start: 25 mg/kg/day
* Start: 500-1000 mg HS and increase by 250-500 mg every 1-3 days
* Target dose: 1500-2000 mg/day
28
How do you monitor Divalproex?
* Trough levels
* After steady state (approx. 3-5 days)
- Once daily ER formulations: 18-24 hours post-dose
- Twice daily DR formulation: ~12 hours post-dose
29
What is the therapeutic range of divalproex?
50-125 mg/L
30
What are the levels of divalproex and its effects?
* 75-100 mg/L: Ataxia, sedation, lethargy, fatigue
* 100-175 mg/L: Tremor
* > 175: Stupor or coma
31
What are the boxed warnings of divalproex?
* Hepatotoxicity (usually during the 6 months)
* Fetal risk
* Pancreatitis
32
What are some contraindications of divalproex?
* Hepatic disease or severe hepatic impairment
* Urea cycle disorders
33
What are some common side effects of divalproex?
* Nausea/vomiting
* Weight gain
* Alopecia
* Sedation
* Tremor
* Fatigue
34
What are some serious side effects of divalproex?
* Hepatic failure
* Thrombocytopenia (decrease Plt)
* Pancreatitis
* Hyperammonemai (increase NH3)--treat w/ levocarnitine
35
What are some baseline labs of divalproex?
* CBC with platelets
* LFTs (hepatic function)
* Pregnancy test
36
What are some ongoing labs for divalproex?
* Valproate level 3-5 days after dose adjustments
* Valproate level every 6-12 months
* CBC every 6-12 months
* LFTs every 6-12 months
* NH3 if symptomatic or suspicion
37
What are some drugs that increase valproate levels?
* Aspirin
* Warfarin
* Risperidone
* Fluoxetine
38
What are some drugs that decrease valproate levels?
* Carbamazepine
* Carbapenems
* Rifampin
39
Lamotrigine
* Bipolar depression, maintenance therapy
* First line as monotherapy and combination therapy for depressive episodes
40
What is the mechanism of Lamotrigine?
* Exact mechanism not well understood
* Sodium channel blockade, decrease glutamate
41
What happens if patients misses more than 5 days of lamotrigine?
Restart titration
42
What are some common side effects of lamotrigine?
* Nausea/vomiting
* Rash
* Somnolence/fatigue
43
What are some serious side effects of lamotrigine?
* Stevens-Johnson Syndrome and toxic epidermal necrolysis (TEN)
* Angioedema
* Multi-organ failure
44
What is the boxed warning of lamotrigine?
Life-threatening rashes (SJS and TEN)
45
What are the baseline labs of lamotrigine?
* BUN, SCr
* LFTs
46
What are the ongoing labs of lamotrigine?
* BUN, SCr every 6-12 months
* LFTs every 6-12 months
47
Carbamazepine
* Bipolar disorder, mania, or mixed episodes
* Second-line as monotherapy and combination therapy for manic, hypomanic, and mixed episodes
48
What is the dosing of carbamazepine?
* Initial: 400 mg/day (divided BID)
Increase by 200 mg/day q5-7 days
* Usual dose: 600-1200 mg/day
49
What are the therapeutic levels of carbamazepine?
4-12 mg/L
50
What are the carbamazepine's levels and its effect?
* > 8 mg/L: Nausea, vomiting, headache, dizziness, blurred, vision
* > 40 mg/dL: Apnea, dystonia, coma
51
What is the boxed warning of carbamazepine?
* Serious dermatologic reactions and HLA-B 1501 allele
* Aplastic anemia & agranulocytosis
52
What are some contraindications of carbamazepine?
* Bone marrow depression
* Concurrent MAOI use
* Concurrent NNRTI
* Hepatic failure
53
What are the warnings of carbamazepine?
* Avoid if history of hepatic porphyria
* Increased suicidality
* Teratogenicity
* Potential for withdrawal seizure if discontinued abruptly
* Hyponatremia
54
What are the common side effects of carbamazepine?
* Nauea/vomiting
* Blurred vision
* Dizziness
* Somnelence
55
What are some serious side effects of carbamazepine?
* Stevens-Johnsons Syndrome
* Toxic Epidermal Necrolysis
* Anemia
* Agranulocytosis
* Hepatic failure
56
What is the baseline monitoring of carbamazepine?
* HLA-B 1502 allele patients of Asian descent (risk of fatal rash)
* CBC
* LFTs
* BUN, SCr, electrolyte
* Pregnancy test
57
What are the ongoing monitoring labs of carbamazepine?
* Carbamazepine level 5 days after dose adjustments
* Carbamazepine level every 6-12 months
* CBC every 6-12 months
* BUN, SCr, electrolytes every 6-12 months
58
What are drugs that increase of carbamazepine level?
Phenobarbital
59
What are the CYP metabolism of carbamazepine?
Induces CYP1A2, 2C19, 2C8, 2C9, 3A4, P-gp
-decrease oral hormonal contraceptives, theophylline, warfarin, and itself (auto-inducers)
60
What are some patient counseling of carbamazepine?
* Stopping medication abruptly may lead to adverse effect
* Adequate trial duration: 2-3 weeks
61
What is the 1st line monotherapy of acute mania?
* Lithium
* Divalproex
* Risperidone
* Quetiapine
* Aripiprazole
* Ziprasidone
* Asenapine
* Paliperidone
62
What is the 2nd line adjunctive therapy for acute mania?
With lithium or divalproex:
* Risperidone
* Quetiapine
* Olanzapine
* Aripiprazole
* Asenapine
63
What is the 2nd line monotherapy of acute mania?
* Carbamazepine
* ECT
* Haloperidol
64
What is the 2nd line adjunctive therapy of acute mania?
Lithium and divalproex
65
What is the 3rd line monotherapy of acute mania?
* Chlorpromazine
* Clozapine
* Oxcarbazepine
* Tamoxifen
* Cariprazine
66
What is the 3rd line combination therapy of acute mania?
* Lithium or divalproex and haloperidol
* Lithium and carbamazepine
* Adjunctive tamoxifen
67
What monotherapy is not recommended for acute mania?
* Gabapentin
* Topiramate
* Lamotrigine
* Verapamil
* Tiagabine
68
What are the combination therapy that is not recommended for acute mania?
* Risperidone and carbamazepine
* Olanzepine and carbamazepine
69
What is the 1st line monotherapy for acute depression?
* Lithium
* Lamotrigine
* Quetiapine
70
What is the 1st line combination therapy of acute depression?
* Lithium or divalproex and SSRI
* Olanzapine and SSRI
* Lithium and divalproex
* Lithium or divalproex and bupropion
71
What is the 2nd line monotherapy of acute depression?
* Divalproex
* Lurasidone
72
What is the 2nd line combination therapy of acute depression?
* Quetiapine and SSRI
* Adjunctive modafinil
* Lithium or divalproex and lamotrigine
* Lithium or divalproex and lurasidone
73
What is the third line monotherapy of acute depression?
* Carbamazepine
* Olanzepine
* ECT
