Final Bipolar Disorder

Question 1

What are the symptoms of bipolar disorder?

Answer 1

Mania
Hypomania
Depression
Mixed Mania with Depression

Question 2

What are the types of Bipolar disorder?

Answer 2

Bipolar I Disorder
Bipolar II Disorder
Cyclothymia Disorder
Unspecified Bipolar and Related Disorder
Substance-Induced Mood Disorder

Question 3

What is hypomania?

Answer 3

Less severe mania

Question 4

What is the primary drug used to treat bipolar disorder?

Answer 4

Lithium

Question 5

What is the mechanism of Lithium?

Answer 5

Not completely understood

-Is an ion similar to Na, goes everywhere in the cell, and has lots of different effects

*Depletes PIP2 and associated signaling (membrane lipid that serves as a substrate for phospholipase c)

-Lithium blocks the recycling of PIP2 which causes the Phospholipase C (PLC) to have no substrate and be unable to signal

Question 6

What are the anticonvulsant drugs used in Bipolar Disorder?

Answer 6

Valproic Acid
Sodium Valproate
Carbamazepine/Oxcarbazepine
Lamotrigine (Lamictal)
Topiramate (Topamax)

Question 7

Which mood is experienced most in bipolar disorder?

Answer 7

Depression

*can lead to misdiagnosis

Question 8

What are the comorbidities often associated with bipolar disorder?

Answer 8

Alcohol and substance use (50-60%)

Anxiety disorders (can significantly impact remission of mood episodes if left untreated or inadequately treated)

Question 9

What is the criteria for Bipolar I Disorder?

Answer 9

> or = 1 manic episode

*only need one manic episode to be diagnostic

Question 10

What is the criteria for Bipolar II Disorder?

Answer 10

Hypomanic Episodes

Question 11

What is the main drug used in bipolar disorder treatment?

Answer 11

Lithium

Question 12

True or False: Lithium is associated with increased suicidality

Answer 12

FALSE
-decrease in suicidality in bipolar disorder

Question 13

What concern is there about lithium dosing?

Answer 13

Narrow Therapeutic Index (NTI) drug

*need to make sure patient does not plan on committing suicide by pill overdose

Above 1.2-1.5 mEq/L starts running into toxicity

Question 14

What is the conversion between different lithium dosage forms?

Answer 14

1:1

Question 15

What are the toxicities associated with Lithium?

Answer 15

GI
Ataxia
Course hand tremor
Altered mental status
Seizure
Lethargy
Confusion
Agitation

Question 16

What are the side effects associated with lithium?

Answer 16

Fine hand tremor
Hypothyroidism
Polyuria
Polydipsia
Acne
Dry Mouth
Weight Gain
ECG Changes

Teratogen
-Ebstein’s abnormality

Question 17

What drug should be avoided in the first trimester of pregnancy?

Answer 17

Lithium

Question 18

What labs should be monitored with lithium use?

Answer 18

Na, K, Ca

Parathyroid hormone

Question 19

What drugs interact with lithium?

Answer 19

-ACEi
-ARBs
-Thiazide Diuretics
-NSAIDs*

Dehydration

Question 20

Besides lithium, what is another common first-line agent for bipolar disorder?

Answer 20

Valproate

Question 21

What is a risk with the dosing of valproate?

Answer 21

Comes in many dosage forms so risk for med errors

Question 22

How does the bioavailability of the extended release lithium form compare to the bioavailability of the delayed release form?

Answer 22

Extended release (ER) dosage form is 10-15% LESS bioavailable than the delayed release (DR) form

Question 23

What is the conversion factor between the valproate dosage forms?

Answer 23

1:1

*Lower concentrations with ER dosage form but not clinically significant

Question 24

What valproate dosage form has the highest risk for GI ulcerations (esophageal)?

Answer 24

Valproic acid syrup (IR) and capsule sprinkle form

Question 25

What valproate serum level is associated with the most efficacy in mania?

Answer 25

180-125 mcg/ml

Question 26

When should valproate levels be obtained?

Answer 26

96 hours (4 days) after first dose or dose increase

Question 27

What are the side effects associated with valproate?

Answer 27

GI: anorexia, N/V/D, dyspepsia, ulceration Increased appetite (weight gain of 6-8 kg) Thrombocytopenia (platelet dysfunction) Teratogenic (neural tube defects and lower IQ) Hyperammonemia PCOS in up to 50% of women

Question 28

What trimester of pregnancy is valproic acid unsafe in?

Answer 28

ALL -obtain baseline pregnancy test

Question 29

What labs should be monitored with valproate use?

Answer 29

Baseline: Pregnancy test, LFTs, CBC with differential Serum ammonia (if hyperammonemia suspected, not routine)

Question 30

What drugs interact with valproate?

Answer 30

Lamotrigine -increased lamotrigine serum concentrations increase risk for Stevens-Johnson syndrome **Dose needs to be cut in half

Question 31

What other mood stabilizers can be used in bipolar disorder?

Answer 31

Carbamazepine (Tegretol) Oxcarbazepine (Trilepta) Lamotrigine (Lamictal) Topiramate (Topamax)

Question 32

What important side effect are associated with Carbamazepine (Tegretol)?

Answer 32

Thrombocytopenia Hematologic effects

Question 33

What does oxcarbazepine induce?

Answer 33

CYP450 3A4

Question 34

What side effect is associated with oxcarbazepine?

Answer 34

Hyponatremia

Question 35

When is Lamotrigine the 1st line treatment in bipolar disorder?

Answer 35

For depressive episodes!

Question 36

When is lamotrigine not a good drug option in bipolar disorder?

Answer 36

Not useful for acute treatment or manic episodes

Question 37

What are the side effects associated with Topiramate?

Answer 37

-Weight loss -Heat intolerance/ Hypohidrosis -Metabolic acidosis/Kidney stones *Possible teratogen (cardiac structural defects)

Question 38

When would we use atypical antipsychotics for bipolar disorder?

Answer 38

As monotherapy or can be used in combination with other mood stabilizers (lithium or valproate)

Question 39

What are the monitoring parameters for antipsychotics?

Answer 39

Metabolic syndrome and movement side effects

Question 40

What combination therapies can be used in bipolar disorder?

Answer 40

Lithium + Valproate Lithium + Antipsychotic Valproate + Antipsychotic Combination with antidepressants **DO NOT USE TWO ANTIPSYCHOTICS TOGETHER*

Question 41

How long do we use mood stabilizers in bipolar disorder?

Answer 41

Long-term *Considered maintenance treatment to reduce time to subsequent mood episodes

Question 42

What needs to be monitored closely when starting bipolar medications?

Answer 42

Suicide attempt risk is high in both poles of bipolar disorder *monitor closely and use lithium cautiously

Question 43

What are the teratogens used in bipolar treatment?

Answer 43

Lithium **first trimester Valproic Acid Carbamazepine Topiramate

Question 44

What is the first-line choice of drug for use during pregnancy?

Answer 44

Atypical antipsychotics

Question 45

What are some things to keep in mind with antidepressant use in bipolar disorder?

Answer 45

-Need to have maintenance mood stabilizer therapy in combination with antidepressant therapy -Use serotonergic antidepressants to treat anxiety -Prefer to use mood stabilizers that target the depressive pole

Question 46

What mood stabilizers target the depressive pole?

Answer 46

Lamotrigine Lithium Lurasidone Quetiapine