Bipolar disorder

Question 1

Lithium dosing

Answer 1

Narrow therapeutic index

Acute treatment: 0.9-1.2 mEq/L

Maintenance: 0.6-0.9 mEq/L

Toxicity: 1.5- > 3.0 mEq/L

Question 2

Lithium side effects

Answer 2

Fine hand tremor

Hypothyroidism

Polyuria

Dry mouth

ECG changes

Diabetes

Weight gain

Polydipsia

Acne

Question 3

Lithium toxicities

Answer 3

Coarse hand tremor

GI

Ataxia

Altered mental status

Lethargy

Confusion

Agitation

Seizure

Question 4

Lithium Teratogenic

Answer 4

Cardiac structure abnormality (Ebstein’s anomaly)

Avoid in 1st trimester

Question 5

Lithium monitoring

Answer 5

Scr,BUN
Urine specific gravity
Na, K, Ca
ECG (esp. > 40 yo)
TSH, T4
CBC
Parathyroid hormone
Weight
Pregnancy test

Question 6

Lithium drug interactions

Answer 6

Increase levels with: ACE/ARB, Thiazides, NSAIDS

Decrease levels with: caffeine, osmotic diuretics, loop diuretics, NaHCO3, high Na

Question 7

Valproate

Answer 7

inhibits Na and Ca channels
Increase GABA levels

Question 8

Valproate dosages

Answer 8

ER is 10-15% less bioavailable than DR

1:1 conversion, expect lower serum concentration with the ER form usually not clinically significant

Valproic acid syrup (IR) and capsule sprinkle–> increase risk for GI ulcers

Serum levels 80-125 mcg/mL

Question 9

Valproate side effects

Answer 9

GI symptoms

Hyperammonemia

Hepatotoxicity (LFT)

Thrombocytopenia

PCOS, weight gain, sedation

Question 10

Contraindication with valproate

Answer 10

Pregnancy (neural tube defects and decrease IQ)

Baseline pregnancy test

Question 11

Valproate drug interaction

Answer 11

LAMOTRIGINE

steven johnson syndrome

Question 12

Carbamazepine

Answer 12

2nd/3rd line

associated with thrombocytopenia/hematologic effects

Question 13

Oxcarbazepine

Answer 13

hyponatremia

Question 14

Lamotrigine

Answer 14

1st line for depressive symptoms

not useful for acute treatment/manic episodes

retitrate if non-adherence for > 3-5 days

Question 15

Topiramate

Answer 15

May cause weight loss

Heat intolerance/hypohidrosis

Metabolic acidosis and kidney stones

Possible teratogen–cardiac structural defects

Question 16

Mood symptoms

Answer 16

euphoria, depression, liability, irritability, hospitality, dissatisfaction

Question 17

Cognitive symptoms

Answer 17

flight of ideas, racing thoughts, delusions, grandiosity, hallucinations, fragmented thoughts

Question 18

Activity/behavior

Answer 18

pressured speech, impulsivity, insomnia, aggression panic, increased sexual dysfunction

Question 19

Lithium MOA

Answer 19

depletion of PIP2 while inhibiting the recycling of IP3

Decrease in suicidal ideation

Question 20

Atypical antipsychotics in bipolar

Answer 20

ALL EXCEPT clozapine, brexpiprazole, iloperidone, paliperidone

Question 21

Quetiapine

Answer 21

bipolar depression

Question 22

Aripiprazole

Answer 22

adjunct treatment in depression + antidepressant

Question 23

Olanzapine/fluoxetine

Answer 23

bipolar depression + drug resistant depression

Question 24

Lurasidone

Answer 24

bipolar depression

Question 25

DO NOT USE 2 ANTIPSYCHOTICS

Answer 25

Lithium + valproate

Lithium +antipsychotic/antidepressant

Valproate + antipsychotic/antidepressant

Question 26

Bipolar treatment in pregnancy

Answer 26

Lithium, valproate, topiramate, carbamazepine are all non teratogens

Atypical antipsychotics: olanzapine and clozapine should be avoided–> gestational diabetes

Question 27

Antidepressants in bipolar

Answer 27

Must have mood stabilizer + antidepressant

Mood stabilizers of choice: lithium, lamotrigine, lurasidone, quetiapine

If anxiety: mood stabilizer + SSRI/SNRI