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PR3153 finals > ic13 bipolar disorder > Flashcards

ic13 bipolar disorder Flashcards

1
Q

what treatment can induce bipolar disorder

A

1) antidepressants may induce mania in the initial few days - 2 weeks.

2) ECT

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2
Q

medications that may induce mania

A

drugs of abuse: eg alcohol

drug withdrawal states (from BZP, barbiturates, antidepressants, alpah2 agonists, opioids)

antidepressants

DA or NE augmenting agents

steroids (inc corticosteroids, anaboic…)

thyroid prep (t3, t4)

xanthine (caffeine, theophylline)

decongestants (pseudoephedrine)

otc weight loss (ephedra)

herbal (st john wort)

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3
Q

presentation of mania/hypomania

A

abnormal and persistently elevated/expansive/irritable mood.

DIGFAST
distractibility & easily frustrated
irresponsible/erratic uninhibited behaviour
grandiosity
flight of ideas
activity increase
sleep (need is decreased)
talkativeness

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4
Q

descriptors for mood episodes

A

major depressive: sx >2 wks + functional impairment

manic: sx ≥1 wk + functional impairment

hypomanic: ≥4 days (no functional impairment or psychosis)

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5
Q

criteria for manic episode

A

at least 3 sx
+
elevated/expansive mood

(4 if mood is only irritable)

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6
Q

non phx tx for bipolar

A

1) psychoeducation about disorder, tx, monitoring for pt and caregiver
- recognising early s/sx of mania/depression
- charting mood changes

2) psychotherapy (group, individual, family), CBT

3) stress reduction techniques, relaxation therapy

4) sleep hygiene (regular sleep schedule, avoid alcohol/caffeine prior to bedtime)

5) nutrition (regular intake of protein rich foods, essential fatty acids, supplements, vitamins…)

6) exercise (regular aerobic and weight training at least 3 times a week)

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7
Q

treatment algorithm for bipolar disorder?

include mania vs depression

A

1) short course PRN benzodiazepines
- to help the patient sleep and relax
- onset within hours
eg lorazepam 0.5mg DS max 10mg.day
or clonazepam 0.25mg BD max 4mg/day

2) mood stabiliser for acute treatment
for mania: either
(a) SGA: olanzapine, quetiapine, risperidone, ariprazole or FGA: haloperidol
(b) lithium (1st line for maintenance and suicide prevention)
(c) valproate (3rd line)
(d) carbamazepine (4th line)

for depression either
(a) lithium
(b) SGA: quetiapine, olanazapine + fluoxetine, OR lurisdone, capirazine
(c) lamotrigine

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8
Q

what is the MOA of lithium

A

inhibits secondary messengers in the phosphatidylinositol system

may reduce protein kinase c

decrease 5ht reuptake and dopamine release.

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9
Q

what labs to monitor for lithium?

A

TFT
electrolytes (ca2+)
renal function
FBC
physical exam: ( pregnancy test, urinalysis, ECG)

ECG important esp if >40y/o OR cardiac disease.

  • watch for rashes*
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10
Q

what is the target level of lithium (USUALLY how many days) and sampling time

A

should reach steady state in 5 days

for acute mania: 0.8-1.0 mEq/L
for maintenance: 0.6-1.0mEq/L

take 12h after previous dose, 5-7 days after initiation OR dose/formulation change OR introducing interacting medication

FOR 2 WEEKLY in acute stage until stable.

then q3 months in first year
q3-6 months afterwards.

HIGHEST 1.2

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11
Q

side effects of lithium

A

acne,
tremors (fine to coarse),
polyuria (urinate more than normal),
hypothyroidism,
ECG changes,
nausea,
weight gain,
fatigue,
cognitive impairment,
diabetes insipidus (frequent thirst and urination

more common at >0.8mEq/L

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12
Q

drug and disease interactions with lithium?

A

lithium toxicity with (lithium resembles sodium and may cause reuptake in low fluid status)
(i) condition
- decreased sodium
- dehydration
(ii) drug
- thiazides
- acei/arb
- nsaids

neurotoxicity with
- anticonvulsants (CBZ, phenytoin, diltiazem)
- antihypertensive (lorsartan, methyldopa, verapamil)
- metronidazole

enhanced renal elimination
- caffeine and theophylline

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13
Q

different levels of lithium toxicity?

A

increasing GI and CNS side effects

mild: 1.5-2.0
- GI: N/V/D
- CNS: lethargy, confusion, coarse hand tremors, drowsy, lightheaded

moderate: 2.0-2.5
- GI: similar
- CNS: profound lethargy, worsening confusion, ataxia, apathy, sensory disturbances (slurred speech, blurred vision, tinnitus)

severe >3.0
- GI: similar
- CNS: seriously impaired consciousness, increased deep tendon reflexes, stupor, coma, seizure, death.

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14
Q

what is the metabolism of lithium

A

100% renally cleared

not affected by the liver.

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15
Q

sodium valproate labs to monitor

A

LFTs,
FBC (watch for thrmobocytopenia),
metabolic (FBG, lipids, BMI)
general (pregnancy, rahs, SJS/TEN)

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16
Q

sodium valproate PK

A

undergoes hepatic metabolism,

no need for dose adjustment in renal impairment… can be used if renally impaired.

17
Q

sodium valproate TDM range and sampling time

A

50 - 125 mcg/ml

ss in 3-5 days

take trough sample before 1st dose of the day, at least 2-3 days after initiation or changing dose.

TDM not routinely required.

18
Q

SE of sodium valproate

A

rash, SJS/TEN

common:
N/V, weight gain, ataxia (no coordination), tremors. dizziness, somnolencence

other:
hepatotoxicity, thrombocytopenia, pancreatitis, hyperammonemia, alopecia

neonatal birth defects.

19
Q

drug interactions w/ valproate

A

SJS risk w lamotrigine

20
Q

cyp interactions with valproate

A

substrate: 2c19
inhibitor: 2c9, 2d6, 3a3, 3a4

21
Q

target CBZ TDM? and sampling time

A

4-12 mg/L in 4 weeks
>7mg/L for bipolar

take trough sample before first dose
TDM q6 monthly in the first year, then annually.

22
Q

SE of CBZ

A

GI and CNS toxicity
hyponatremia
blood dyscrasia (incl leukopenia , agranulocytosis).
rash
SLE/TEN

23
Q

what to avoid adding with CBZ

A

CLOZAPINE
risk of agranulocytosis

24
Q

CBZ labs

A

FBC (agranulocytosis)
LFT
electrolytes (hyponatremia, monitor na+ at baseline, then repeat 2wk after initiation, then monthly for 1st three months)
general (pregnancy, agranulocytosis, rash, SJS/TEN)

hla*b1502

25
Q

cyp interactions with CBZ (inducer, substrate, inhibitor)

A

INDUCER of
1A2
2C9
2C10
3A3
3A4

SUBSTRATE of 2c8,
3a3
3a4

26
Q

CBZ pk?

A

hepatic metabolism

induces metabolism (of itself and other drugs)

27
Q

lamotrigine SE (and special considerations)

A

rash esp in initial 8 weeks
less sedation and weight gain effects

max 100mg if combined with VPA

28
Q

lamotrigine labs

A

LFT
FBC
Physical exam: rash, SJS/TEN

29
Q

what is the approach to manage poor response

A

if no response after 2-4 weeks, then augment with a second first like agent or SGA

consider ECT if severe or treatment resistant (stop lithium, anticonvulsants, benzo at least 12h before ECT).

30
Q

MANAGEMENT of bipolar disorder with rapid cycling (define also)

A

≥4 mood episodes per year

avoid antidepressants/stimulants in rapid cycling (or if patient has PMH for antidepressant induced mania).

evaluate and treat any underlying conditions: hypothyroid, hormonal imbalance, substance abuse…

  • optimise mood stabiliser tx.
31
Q

treatment considerations for pregnancy?

A

weigh risk vs benefits, gradually taper off medications

avoid lithium, valproate, CBZ

can consider SGA or FGA but monitor for side effects (gestational diabetes)

OR ECT

32
Q

treatment considerations for breastfeeding?

A

weight risk vs benefits as all mood stabilisers are secreted into breast milk

33
Q

treatment considerations for cardiac disease

A

consider valproate

monitor increase BP, HR, peripheral oedema

34
Q

treatment considerations for liver impairment

A

lithium

35
Q

treatment considerations for renal impairment

A

valproate

monitor serum levels closely

36
Q

treatment considerations for children/adolescents

A

lithium
valproate

37
Q

treatment considerations for elderly

A

consider lamotrigine

all psychotropics increase risk of side effects

avoid renally excreted drugs,

38
Q

treatment considerations for aggression/violence

A

optimise dose and levels of lithium or valproate.

consider adding antipsychotic

PR3153 finals (17 decks)

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