Bipolar Disorder

Question 0

Types of bipolar disorder?

Answer 0

Bipolar I

Bipolar II

Cyclothymic disorder (where the criteria for depression or mania are not fully met)

Question 1

What’s bipolar disorder?

Answer 1

Mood disorder where moods can fluctuate from depression to elevated moods referred to as “mania”

Question 2

Which type is the most severe version of bipolar?

Answer 2

Bipolar I disorder

Question 3

What’s mania xterized by?

Answer 3

Elevated mood where pts have a lot of energy

Sx of mania in bipolar I can be so severe that they may req psychiatric hospitalization, impair social or occupational functioning or have features of psychosis such as hearing voices or delusions (false beliefs)

Question 4

Difference btw bipolar I and II?

Answer 4

Bipolar II has the same sx as bipolar I, however sx are described as “hypomania” bcuz they are less severe than in pure mania

Question 5

What’s hypomania?

Answer 5

Will not affect social or occupational fxning and pts with bipolar II will not require hospitalization for hypomania or have psychotics features

Question 6

What’s the first like for treating mania and maintaining a stable mood?

Answer 6

Mood stabilizers (lithium, valproate, lamitrigine)

AND

2nd gen anti-psychotics (SGAs)

Question 7

What’s a mood stabilizer?

Answer 7

By definition, a mood stabilizer is a med that can treat either mania or depression without inducing either.

T/4 antidepressants are not considered mood stabilizers

Question 8

Which of the SGAs have NO indications for bipolar mania?

Answer 8

CLIP

Clozapine

Lurasidone

Iloperidone

Paliperidone

Question 9

Which SGAs have an indication for bipolar DEPRESSION?

Answer 9

Lurasidone

Question 10

Why are first gen antipsychotics no longer used for mania?

Answer 10

Pts with bipolar are more susceptible to EPS and FGAs have an increased risk of causing EPS

Question 11

What does the most current guidelines recommend?

Answer 11

Either a mood stabilizer, SGAs or a combo of mood stabilizer + SGAs

Question 12

If psychotic features are present, what’s reasonable to start with?

Answer 12

SGAs

Question 13

What meds have a role as adjunctive therapy in depression and can also be used for mania and maintenance?

Answer 13

Aripiprazole

Quetiapine ext-release

Question 14

Uses of Lamotrigine?

Answer 14

Used in bipolar DEPRESSION and maintenance, however is not beneficial in mania dut to SLOW TITRATION

Question 15

Uses of lithium?

Answer 15

Mania, depression and maintenance

More commonly used in combo with SGAs in severe cases

Question 16

Whats valproate and carbamazepine approved for?

Answer 16

Bipolar MANIA

Question 17

When is antidepressant used in bipolar?

Answer 17

When the pt is already on mood stabilizer

Question 18

What class of meds used in bipolar req medguides?

Answer 18

Antidepressants, anticonvulsants, antipsychotics

Question 19

Whats the preferred mood stabilizer during pregnancy?

Answer 19

Lamotrigine (Cat. C)

Question 20

Should mood stabilizers (even Lamotrigine that’s preferred) be avoided during 1st trimester?

Answer 20

Yes, if possible

Question 21

The SGAs are approved for pregnancy (Category C), which SGAs is cat B?

Answer 21

Lurasidone

Question 22

Effect of lithium in pregnancy?

Answer 22

Ass with increase in congenital cardiac malformations

Question 23

Effects of valproate in pregnancy?

Answer 23

Increased risk of fetal anomalies, including neural tube defects, fetal valproate syndrome and long-term adverse cognitive effects

It should be avoided in preg, esp 1st trimester

Question 24

Effects of CBC in pregnancy?

Answer 24

Fetal CBZ syndrome

Question 25

Which antidepressant should NOT be used, if an antidepressant is needed in pregnancy?

Answer 25

Paroxetine (due to risk of cardiac defects)

Question 26

How do u rule out illicit drug use from bipolar mania?

Answer 26

Toxicology screen should be taken prior to start of tx and as needed, to rule out mania due to illicit drug use

Question 27

MOA of Valproic acid/Valproate

Answer 27

T-type Ca channel blocker and fast Na channel blocker that increases gamma-aminobutyric activity (GABA), an inhibitory neurotransmitter

Question 28

What's the brand name of Valproic acid/Valproate?

Answer 28

Depakene Stavzor (delayed-release) Depacon

Question 29

What's the brand name of Divalproex?

Answer 29

Depakote Depakote ER Depakote Sprinkle (also used for migraine prophylaxis)

Question 30

Whats the range of acceptable serum levels to maintain while on Valproic acid/valproate/ Divalproex?

Answer 30

50-125 mcg/mL

Question 31

Can Depakote ER be substituted for Depakote (delayed release)?

Answer 31

Can't substitute Depakote ER for delayed release Depakote Need to increase Depakote ER by 8-20%

Question 32

What do you do if albumin is low? (<3.5)

Answer 32

Adjust using phenytoin formula (bcuz true valproate level will be higher than it appears)

Question 33

What's the blackbox warning of Valproic acid/valproate/ Divalproex?

Answer 33

PTH Pancreatitis Teratogenicity Hepatic failure

Question 34

What may be used as supplementation when using Valproic acid/valproate/ Divalproex?

Answer 34

Calcium and Vit. D

Question 35

What may reduce stomach upset associated with Valproic acid?

Answer 35

Switch to delayed release Divalproex (Depakote) may reduce stomach upset

Question 36

Because valproate is a weak inhibitor of 2C9, what drug level may be increased if co-admin?

Answer 36

Carbamazepine Lamotrigine Phenobarbital Warfarin Zidovudine

Question 37

What may occur if valproate + Lamotrigine are used today?

Answer 37

Risk of serious rash

Question 38

Effects of using Salicylates with Valproic acid?

Answer 38

Salicylates may displace Valproic acid from protein-binding site, leading to toxicity

Question 39

Effects of using valproate with phenytoin?

Answer 39

Valproate can displace phenytoin from albumin, resulting in phenytoin toxicity

Question 40

Effects of using valproate with warfarin?

Answer 40

Warfarin is highly protein-bound; valproate can displace warfarin and can cause an increase in INR

Question 41

Effects of using Carbapenems with Valproate?

Answer 41

Carbapenems can reduce valproate levels leading to seizures

Question 42

What are the sx of pancreatitis that may develop from Valproic acid use?

Answer 42

Nausea Vomiting Severe abdominal pain Loss of appetite

Question 43

Should you use a regular eating spoon to measure Valproic acid?

Answer 43

No! Use a special dose-measuring spoon or cup

Question 44

How should Valproic acid be taken?

Answer 44

Take each dose with a full glass of water Take with food to avoid stomach upset

Question 45

What tests do u need when on Valproic acid?

Answer 45

Blood test and liver function test

Question 46

MOA of Lamotrigine?

Answer 46

Inhibits release of glutamate and aspartate (excitatory amino acids), fast Na channel blocker and t-type Ca channel blocker stabilizing neuronal membranes

Question 47

What's the brand name of Lamotrigine?

Answer 47

Lamictal Lamictal ODT Lamictal CD (chewable) Lamictal XR

Question 48

How's Lamotrigine (Lamictal) dosed in children?

Answer 48

By body weight. Divide bid (unless using XR)

Question 49

What changes do you make to Lamotrigine when using Valproic acid, CBZ, phenytoin, or phenobarbital?

Answer 49

Reduce Lamotrigine dose - Valproic acid/valproate/Divalproex (increase Lamotrigine levels) (Higher titration schedules are req here) Increase Lamotrigine dose - CBZ, phenytoin, phenobarbital (they decrease Lamotrigine) (Higher titration schedules are req here)

Question 50

Is Lamotrigine used in mania?

Answer 50

No! Not used in mania

Question 51

When a higher titration schedule of Lamotrigine is req (due to co-admin with strong inducers e.g. CBZ, phenytoin, phenobarbital)?

Answer 51

Lamotrigine is started at 50mg daily

Question 52

When a LOWER titration schedule of Lamotrigine is req (due to co-admin with Valproate/Divalproex, which are inhibitors and increase Lamotrigine levels leading to a significant increase in the risk of rash)?

Answer 52

Lamotrigine 25mg Q other day

Question 53

What grp of people have a higher chance of developing rash while on Lamotrigine?

Answer 53

Children 2-16 yrs

Question 54

What other factors may increase the risk of developing a rash?

Answer 54

Using Lamotrigine + Valproate (Valproic acid, or Depakene, Stavzor, or Depacon) or Divalproex (Depakote) Using a higher starting dose than prescribed Increase dose faster than prescribed

Question 55

What condition does Lamotrigine rarely causes, but it's very severe if it causes it?

Answer 55

Ascetic meningitis

Question 56

What's the brand name of Lithium?

Answer 56

Lithobid

Question 57

What's the trough therapeutic range of lithium?

Answer 57

0.6-1.2 mEq/L (trough) Acute mania may need up to 1.5 mEq/L

Question 58

Can lithium be used in renal impairment?

Answer 58

No! Lithium (Lithobid) is 100% renally cleared

Question 59

SE of lithium (Lithobid)?

Answer 59

GI upset (take with food or change to ER forms) Cognitive effects, Cogwheel rigidity, Fine hand tremor, Weight gain Polyuria/polydipsia, hypothyroidism - must monitor Serotegenic (avoid co-admin with other serotonergic agents)

Question 60

What's the result of lithium (Lithobid) toxicity levels > 1.5 mEq/L?

Answer 60

V CCAP Vomiting Confusion Coarse hand tremor Ataxia Persistent diarrhea

Question 61

What's the result of lithium (Lithobid) toxicity levels > 3 mEq/L?

Answer 61

CNS depression Arrhythmia Seizures Irreversible brain damage Coma

Question 62

What may increase lithium levels?

Answer 62

Reduced salt intake NSAIDs ACE-I, ARBs Diuretics

Question 63

What are safer options of NSAIDs when pt is on lithium?

Answer 63

Aspirin Sulindac

Question 64

What may decrease lithium levels?

Answer 64

Increased salt intake Caffeine Theophylline

Question 65

What may increase risk of 5HT-syndrome if given with lithium?

Answer 65

SSRIs SNRIs Triptans Linezolid And other serotonergic drugs

Question 66

What may increase neurotoxicity risk (Ataxia, Tremors, Nausea) if used with lithium (Lithobid)?

Answer 66

Verapamil, Diltiazem Phenytoin CBZ

Question 67

How much water should be drank daily while on lithium (Lithobid), not including any caffeinated sodas, coffee or tea?

Answer 67

8 to 12 glasses of water

Question 68

What's the relationship btw lithium and salt consumption?

Answer 68

Don't change the amt of salt consumed

Question 69

List SGAs in bipolar disorder

Answer 69

Aripiprazole (Abilify, Abilify Discmelt) Olanzapine/Fluoxetine (Symbyax) Olanzapine (Zyprexa, Zydis ODT, Relprevv inj) Quetiapine extended release (Seroquel, Seroquel XR) Risperidone (Risperdal) Ziprasidone (Geodon) Asenapine (Saphris) Lurasidone (Latuda)

Question 70

What's the brand name of Aripiprazole? (SGAs)

Answer 70

Abilify Abilify Discmelt

Question 71

What's the brand name of Quetiapine extended release? (SGAs)

Answer 71

Seroquel Seroquel XR

Question 72

What's the brand name of Risperidone? (SGAs)

Answer 72

Risperdal

Question 73

What's the brand name of Ziprasidone? (SGAs)

Answer 73

Geodon

Question 74

What's the brand name of Lurasidone? (SGAs)

Answer 74

Latuda

Question 75

Can SGAs cause metabolic issues?

Answer 75

Yes Dyslipidemia Weight gain Diabetes

Question 76

What other SE can be seen from SGAs use?

Answer 76

Risk of Neuroleptic Malignant Syndrome Risk of Tardive Dyskinesia Risk of leukopenia, neutropenia, agranulocytosis Orthostasis/dizziness

Question 77

What common SE is associated with Aripiprazole (Abilify, Abilify Discmelt)?

Answer 77

Akathisia (esp in younger pts) Restlessness Insomnia Constipation Fatigue Blurred vision

Question 78

What common SE is associated with Olanzapine?

Answer 78

Cognitive dysfunction Dry mouth Fatigue Sedation Increased appetite/weight Peripheral edema Tremor Blurred vision Reduced CVD risk than other listed APs

Question 79

What common SE is associated with Quetiapine (Seroquel, Seroquel XR)?

Answer 79

QT risk Sedation Dry mouth Constipation Dizziness Increased appetite/weight

Question 80

What common SE is associated with Risperidone (Risperdal)?

Answer 80

Sedation Increased appetite Fatigue Insomnia Parkinsonism Akathiasia Nausea Some QT risk Nausea

Question 81

What common SE is associated with Ziprasidone (Geodon)?

Answer 81

QT risk (greatest) Sedation EPS Dizziness Akathisia Abnormal vision Asthenia Nausea

Question 82

What common SE is associated with Asenapine?

Answer 82

Numbs mouth Sedation (avoid driving when initiating or titrating therapy) Dizziness Weight gain (less than Risperidone and Olanzapine) Some QT risk

Question 83

Which SGAs carry the greatest QT risk?

Answer 83

Ziprasidone

Question 84

Which SGAs have EPS as a SE?

Answer 84

Ziprasidone

Question 85

What's ADA screening recommendations for pt on SGAs?

Answer 85

B4 starting pt on antipsychotics, pt should be screened for Overweight and obesity Dyslipidemia Hyperglycemia HTN Personal and FH of risk

Question 86

What's ADA monitoring recommendations for pt on SGAs?

Answer 86

While being treated pt should be monitored for tx-emergent changes in weight Waist circumference Plasma lipids Glucose levels Acute sx of diabetes e.g. Polyuria, polydipsia

Question 87

Effect of Lisinopril in lithium levels?

Answer 87

Lisinopril can increase lithium levels

Question 88

List antipsychotics that have QT prolongation?

Answer 88

Quetiapine Risperidone Ziprasidone Thioridazine Haloperidol

Question 89

What's one of the benefit of using Quetiapine extended-release?

Answer 89

Little risk of movement disorders