Bipolar Disorder

Question 1

DSM-5 Bipolar I classification

Answer 1

≥ 1 manic episode, generally last ≥ 1 week

Question 2

DSM-5 Bipolar II classification

Answer 2

hypomanic episodes, generally last ≥ 4 days

Question 3

Which drug used for bipolar disorder has a narrow therapeutic index and is therefore important to evaluate if the patient has a suicidal plan?

Answer 3

Lithium

Question 4

Lithium acute treatment serum concentration range

Answer 4

0.9-1.2 mEq/L

Question 5

Lithium maintenance serum concentration range

Answer 5

0.6-0.9 mEq/L

Question 6

Lithium toxicity serum concentration range

Answer 6

1.5 - 3.0 - mild
> 3.0 - severe

Question 7

How soon after dose initiation of lithium should you draw trough serum concentrations?

Answer 7

72 hours

Question 8

Lithium toxicities

Answer 8

GI
Ataxia
Coarse hand tremor
Altered mental status
Seizure
Lethargy
Confusion + agitation

Question 9

Lithium side effects

Answer 9

Fine hand tremor
Hypothyroidism
Polyuria
Polydipsia
Acne
Dry mouth
Weight gain
ECG changes

Question 10

Why is lithium avoided in 1st trimester of pregnancy?

Answer 10

Teratogenic - cardiac structural abnormalities (Ebstein’s anomaly)

Question 11

Lithium laboratory monitoring

Answer 11

-SCr + BUN (almost entirely renally excreted)
-Electrolytes (Na, K, Ca)
-ECG
-Thryoid function
-CBC
-Weight
-Pregnancy test

Question 12

What drugs can decrease Li renal clearance and therefore increase Li levels?

Answer 12

NSAIDs
Thiazides
ACEi/ARB

Question 13

Which dosage forms of valproate have a higher risk for GI ulcerations? (esophageal)

Answer 13

Valproic acid syrup (IR)
Capsule sprinkle form

Question 14

Valproate ER dosage form is about ________ % less bioavailable than DR dosage form

Answer 14

10-15%

Question 15

What serum levels of valproate are associated with most efficacy in mania? When should this level be obtained after first dose or dose increase?

Answer 15

Serum levels = 80 - 125 mcg/mL

Obtain level at least 96 hours after first dose or after dose increase

Question 16

What teratogenic effects can valproate cause?

Answer 16

neural tube defects
negative effects on IQ of offspring

Question 17

Valproate laboratory monitoring

Answer 17

Pregnancy test
LFTs
CBC
Serum ammonia (routine monitoring is not necessary, only if suspicion)

Question 18

There is significant concern with combination use of valproate with what other drug? Why?

Answer 18

Lamotrigine - increased lamotrigine serum concentrations increases risk for SJS

Question 19

What CYP enzyme does oxcarbazepine induce?

Answer 19

CYP3A4 (not auto-induction)

Question 20

Oxcarbazepine is associated with what adverse effect?

Answer 20

Hyponatremia

Question 21

Carbamazepine is associated with what adverse effect?

Answer 21

Thrombocytopenia/hematologic effects

Question 22

What is the first line treatment for DEPRESSIVE symptoms in bipolar disorder?

Answer 22

Lamotrigine

Question 23

T/F: Lamotrigine is not useful for acute treatment of BPD or for manic episodes

Answer 23

TRUE

Question 24

What teratogenic effects can topiramate possibly cause?

Answer 24

Cardiac structural defects

Question 25

Topiramate adverse effects

Answer 25

-(may cause) weight loss
-heat intolerance/hypohidrosis
-metabolic acidosis and kidney stones

Question 26

Valproate adverse effects

Answer 26

1. Increased appetite/weight gain
2. Thrombocytopenia/platelet dysfunction
3. Hyperammonemia
4. GI - n/v/d, dyspepsia, ulceration
5. Teratogenic

Question 27

What drugs can cause increased Li renal clearance and therefore decrease lithium levels?

Answer 27

Caffeine
Osmotic diuretics
Loop diuretics