CH 23: Meds for Bipolar Disorder

Question 1

Anticonvulsant / Antiepileptic Meds

Answer 1

• valproate/valproic acid (50-120 mcg/mL)
• carbamazepine (4-12 mcg/mL
• lamotrigine

Question 2

Complications of carbamazepine

Answer 2

• CNS effects
• blood dyscrasias
• teratogenesis
• hypoosmolarity
• skin disorders

Question 3

CNS effects

Carbamazepine Complication

Answer 3

nystagmus, diplopia, vertigo, headache, staggering gait
- low dose, gradually increase
- admin HS
edu: side effects subside within a few weeks

Question 4

Blood dyscrasias

Carbamazepine Complication

Answer 4

leukopenia, anemia, thrombocytopenia
- baseline CBC and platelet (ongoing monitoring)
- bruising and bleeding gums=thrombocytopenia
- monitor for infection (fever, lethargy)

Question 5

Teratogenesis

All Anticonvulsant Med Complication

Answer 5

category D; do not use while pregnant

Question 6

hypoosmolarity

Carbamazepine Complication

Answer 6

promotes antidiuretic -> inhibits water excretion
- clients w/ heart failure at risk for fluid overload
- monitor blood Na+, edema, decreased output, hypertension

Question 7

Skin disorders

Carbamazepine & Lamotrigine Complication

Answer 7

rash; Stevens-Johnson syndrome
- withhold med and notify provider

Question 8

Contraindications of carbamazepine

Answer 8

• bone marrow suppresion
• bleeding disorders

Question 9

Interactions of carbamazepine and lamotrigine

Answer 9

oral contraceptive decrease
- use alternative contraceptive

Question 10

Interaction of carbamazepine

Answer 10

grapefruit inhibits metabolism enzyme -> increases carbamazepine

Question 11

Interaction of carbamazepine and valproate

Answer 11

anticonvulsants affect the effectiveness of the drug

Question 12

Complications of valproate

Answer 12

• GI upset
• hepatotoxicity
• pancreatitis
• thrombocytopenia
• teratogenesis
• weight gain

Question 13

GI upset

Valproate Complication

Answer 13

N/V, indigestion
- self-limiting; take w/ food or enteric-coated

Question 14

Hepatotoxicity

Valproate Complication

Answer 14

evidenced by anorexia, N/V, abdominal pain, fatigue, jaundice
- baseline liver function regularly (every 2 months for the first 6 months
- do not admin to 2 years or younger
- admin lowest effective dose

Question 15

Pancreatitis

Valproate Complication

Answer 15

evidenced by N/V, abdominal pain
- monitor amylase
- D/C if pancreatisis occurs

Question 16

Weight gain

Valproate Complication

Answer 16

ensure healthy diet and regular exercise

Question 17

Complications of lamotrigine

Answer 17

• double/blurred vision, headache, dizziness, N/V
• serious skin rash (Stevens)

Question 18

Precaution of lamotrigine

Answer 18

slowly titrate to prevent adverse side effects

Question 19

Interactions of lamotrigine

Answer 19

• carbamazepin, phenytoin decrease its effects
• valproate increase its half-life

Question 20

Normal ranges of lithium

Answer 20

• maintenance: 0.6-1.2 mEq/L
• during manic episode: 0.8-1.4 mEq/L

Question 21

Complications of litium

Answer 21

• GI distress
• fine hand tremors
• polyuria, mild thirst
• weight gain
• renal toxicity
• goiter and hypothyroidism
• bradydysrhythmias, hypotension, electrolyte imbalances

Question 22

GI distress

Lithium Complication

Answer 22

nausea, diarrhea, abdominal pain
- usually transient
- take w/ food or milk

Question 23

fine hand tremors

Lithium Complication

Answer 23

• exacerbated by stress and caffeine
• admin beta blocker (propranolol)
• adjust dosage to as low as possible; give in divided doses; use long-acting formulations
• report an increase in tremors (lithium toxicity)

Question 24

polyuria, mild thirst

Lithium Complication

Answer 24

• use potassium sparing (spiranolactone)
• 1.5-3 L of fluid/day

Question 25

weight gain ## Footnote Lithium Complication

Answer 25

healthy diet and regular exercise

Question 26

Renal toxicity ## Footnote Lithium Complication

Answer 26

- monitor I&O - keep dose at lowest - asses BUN and creatine periodically

Question 27

Goiter and hypothyroidism ## Footnote Lithium Complication

Answer 27

- baseline T3, T4, and TSH prior, then continue annually - admin levothyroxine - hypothyroidism: cold, dry skin; decrease HR; weight gain

Question 28

bradydysrhythmias, hypotension, electrolyte imbalance ## Footnote Lithium Complication

Answer 28

adequate h2o and Na+

Question 29

Contraindications/Precautions on lithium

Answer 29

- category D - do not breastfeed while on therapy - contra for renal/cardiac disease, hypovolemia, schizophrenia - caution in older adults, thyroid disease, seizure, DM

Question 30

Interactions of lithium

Answer 30

- diuretics decrease Na+ -> decreases excretion of lithium - NSAID causes toxicity (aspirin is okay) - anticholinergics result in abdominal dicomfort

Question 31

Common adverse effects | < 1.5 mEq/ L ## Footnote Lithium Toxicity

Answer 31

- diarrhea, N/V - thirst, polyuria - muscle weakness, fine hand tremors - slurred speech, lethargy - *ACTION: often improves over time*

Question 32

Early indications | 1.5-2.0 mEq/L ## Footnote Lithium Toxicity

Answer 32

- mental confusion, sedation - poor coordination, coarse tremors - GI distress (N/V/D) - *ACTION: withhold and notify; admin new dose based on blood lithium & Na+ levels; excretion can be promoted*

Question 33

Advanced indications | 2.0-2.5 mEq/L ## Footnote Lithium Toxicity

Answer 33

- extreme polyuria of dilute urine - tinnitus, blurred vison - giddiness, ataxion, jerking movements, seizure - severe hypotension & stupor leading to coma and possibly death due to respiratory depression - *ACTION: admin emetics to alert client or gastric lavage; urea, mannitol, or aminophylline admin to increase excretion*

Question 34

Sever toxicity | > 2.5 mEq/L ## Footnote Lithium Toxicity

Answer 34

- rapid progression leading to coma and death - *ACTION: hemodialysis*

Question 35

Administration of lithium

Answer 35

- initiation of tx, monitor levels every 2-3 days until stable and then every 1-3 months (higher levels can be required 1-1.5 mEq/L) - levels should be obtained in the morning, 10-12 hours after last does - effects begin within 5-7 days; max effects seen in 2-3 weeks - admin 2-3 doses/day due to short half-life