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MPharm Y3S2 > Mental Health Clinical Bipolar > Flashcards

Mental Health Clinical Bipolar Flashcards

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1
Q

What does euthymia mean?

A

Mood is stable

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2
Q

Describe the epidemiology of BPD:

A

1% of pop
Up to 5% on bipolar spectrum
Incidence is similar in both genders and all ages, races, ethnic groups and social classes
Can occur at any age, first diagnosed 18-24

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3
Q

Describe the aetiology of BPD:

A

70% of BPD patients have at least one close relative with it or unipolar depression
6th leading cause of disability in the world

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4
Q

What are the risk factors for BPD?

A

FHx- genetics, combo of many genes
Being male (only slightly increased)

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5
Q

What are the trigger factors of an episode of BPD?

A

Life events e.g trauma, abuse
Stopping a mood stabiliser suddenly esp lithium
Potentially being on an AD without mood stabiliser if bipolar
Goal attainment events
Disrupted circadian rhythm e.g shift working
Spring/ summer - mania/ hypomania

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6
Q

What is the physical health risk to an individual having BPD?

A

Obesity
Heart disease and HTN 5x increase
Dying from resp 3x increase
Dying from infection 2x
Poor memory more likely
Life expectant lowered by 10 yrs

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7
Q

What is the mental health risk to an individual having BPD?

A

Suicidal 4x increase
Substance misuse is common
1 in 2 dependent on alcohol and 2 in 5 dependent on other drugs

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8
Q

Name the most common symptoms of drug induced mania:

A

Increased activity
Rapid speech
Elevated mood
Insomnia

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9
Q

What are the drugs that can induce mania?

A

Hallucinogens e.g LSD
CNS stimulants e.g amphetamines, caffeine
Antidepressants- switch from depression to mania
Antipsychotics- newer gen rather than haloperidol

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10
Q

What are the general prescribing points for mania?

A
  1. discontinue any manicogenic agents, inc ADs and stimulants
  2. stabilise any medical conditions
  3. start non specific calming meds e.g benzos, antipsychotics
  4. start specific mood stabilisers or relapse prevention agents, preferable when pt is able to consent
  5. hypnotic/ sedative should be considered
  6. any co-morbid substance misuse must be tackled
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11
Q

Name the first line mood stabilisers/ relapse prevention agents for BPD:

A

Lithium
Quetiapine
Olanzapine
Aripiprazole
Lamotrigine
Valproate

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12
Q

Describe the licensing of quetiapine for BPD:

A

Licensed as monotherapy for acute mania and relapse prevention acute BPD (only one licensed) and relapse prevention
Also acute mania and relapse prevention in people who response in acute state over 2 years

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13
Q

Name the baseline monitoring for quetiapine:

A

Weight/ BMI
Pulse/ BP (HTN risk)
Lipid abnormality
ECG if at risk (as can increase QT)

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14
Q

Name the ongoing monitoring for quetiapine:

A

Pulse and BP after each dose change
Weight/ BMI weekly for 6 weeks, then at 12 weeks
BG or HBA1C
Blood lipid profile at 12 weeks
Response to treatment
SEs
Emergence of movement disorders
Adherence

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15
Q

Name the SEs of quetiapine:

A

Very common: sleepiness, dizziness, dry mouth (anticholinergic), weight gain, post hypo
Common: headache, akathisia, anticholinergic SEs

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16
Q

Describe the prescribing advice for quetiapine:

A

Initial dose titration must be slow due to risk of post hypotension an about 16% of pts
Although highly sedative at low doses (e,g 25mg) the sedation is not proportional to dose

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17
Q

Describe the licensing for olanzepine in BPD:

A

Licensed for mania and relapse prevention in people who have responded to it acutely and are lithium or valproate non responders
Widely used as an anti manic and as a mood stabilisers

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18
Q

Name the formulations of olanzapine:

A

Tabs
IM injection
Orodispersible tabs
Depot (restricted use)- rare but serious section and sudden cardiac death

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19
Q

Describe the monitoring requirements for olanzapine:

A

Same as quetiapine

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20
Q

What are the very common SEs of olanzapine?

A

Sedation- so take at night
Weight gain

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21
Q

What are the common SEs of olanzapine?

A

Post hypotension
Dry mouth, constipation
Peripheral oedema
Diabetes
Long term weight gain
Metabolic syndrome e.g diabetes, raised lipids and cholesterol

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22
Q

Describe the smoking interaction with olanzapine:

A

Smoking induces CYP1A2 enzyme that metabolised olanzapine
If stopping smoking can increase levels

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23
Q

What is the prescribing advice for olanzapine?

A

Starting dose in acute mania is 15mg/d as monotherpay or 10mg/d as adjunct
Don’t give benzo within an hour of short acting IM olanzapine as reports of death

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24
Q

Describe the licensing of aripiprazole in BPD:

A

Licensed for acute mania and main presentation in people who have responded acutely including in adolescents aged 13 years or older

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25
What are the monitoring requirements of aripiprazole?
Same as quetiapine
26
What are the formulations of aripiprazole?
Tabs Oridisperisble tabs Liquid Injection- long acting depot
27
What are the very common SEs of aripiprazole?
Akathisia Insomnia- take in morning Stomach upset Constipation Blurred vision
28
What are the common SEs of aripiprazole?
Movement disorders (extra-pyramidal SEs) Post hypotension Palpitations
29
What is the prescribing advice for aripiprazole?
For mania start at 15mg and increased to 30mg/d Relapse prevention dose can be 15-30mg/d Due to its partial agonism, start it at 5mg/d if patient has had another antipsychotic in their system
30
Describe the licensing of lamotrigine for BPD:
Licensed for prevention of relapse of BPD No efficacy in mania, mixed, rapid-cycling or unipolar depression nor acute BPD (due to long titration) Efficacy shown in severely depressed pts
31
Describe the prescribing points of lamotrigine:
Must be titrated 'by the book' Starting dose must be low and slowly titrated as per BNF 25mg/d for 2 weeks, 50mg/d for 2 weeks then increase by 50-100mg/d every 1-2 weeks Half this if used with valproate (e.g 25mg alternative days for 2 weeks, taking 6 weeks to reach 200mg/d)
32
Why is the dosing of lamotrigine so specific?
Almost abolished the risk of potential fatal rashes
33
What are the most common SEs of lamotrigine?
Drowsiness, headache, dizziness, nausea, blurred vision
34
What are the rare but serious SEs of lamotrigine?
Oedema Bone marrow suppression Skin rashes
35
Describe the skin rash side effect of lamotrigine:
Stevens-Johnson syndrome (SJS) or Toxic Epidermal Necrolysis (TEN) Red rashes across the face and body, blisters and inflammation in the nose, mouth and eyes, looks like serious sunburn
36
Describe the licensing of valproate for BPD:
For mania and relapse prevention Depakote (semi sodium valproate) and Episenta are licensed for BPD Epilim is available in tabs, MR and liquid
37
What is the baseline monitoring for valproate?
Height, weight, FBC, LFTs Blood cell count, inc platelet count, bleeding time and anticoagulation before treatment starts then during first 6 months LFTs then at 6 months
38
What is the dosing of valproate?
Oral LD 20mg/kg/ day may give a rapid response often within 3 days MD not full established
39
What are the very common SEs of valproate?
Weight gain, increased appetite
40
What are the common SEs of valproate?
Gastric irritation, diarrhoea, hair loss, nausea
41
What are the uncommon SEs of valproate?
Sleepiness, impaired liver function
42
What are the rare but serious SEs of valproate?
Thrombocytopenia and impaired platelet function Hepatic dysfunction in first 6 months Pancreatitis- abdominal pain, N&V PCOS
43
What are interactions with valproate?
Carbapenem antibiotics decrease valproate Lamotrigine (variable effects): -34% have more 25% increase in V levels -14% have an increase of more 50% in V levels -5% have a more 25% decrease in V levels
44
What is the patient and carer advice for people on valproate?
PPP Infertility and testicular toxicity for males MRHA risk acknowledgement forms are mandatory for males and females below 55 Blood hepatic disorders- recognising Pancreatitis- recognising
45
What are the options for women already on valproate?
Stop valproate gradually Switch to another medicine Continue: -two specialists must agree -PPP
46
What are the valproate risks in those of fathering potential?
Can cause infertility, this may be reversible upon withdrawl or reduction Animal studies show testicular toxicity with decrease rate of testicular development MHRA determine high risk in under 55
47
What is the action in those of fathering potential taking valproate?
All males under 55 must have risk acknowledgement form complete when starting Two specialists confirm Pt must be informed of risk and provided with patient guide No mandatory requirement in users over 55 but risk may still be present
48
Name other second line treatments for BPD:
Carbamazepine Haloperidol Risperidone Benzodiazepines Antidepressants
49
Describe carbamazepine as a treatment for BPD:
Acute mania, relapse prevention, lithium non responder Limited efficacy, blood disorders, TCA interaction
50
Describe haloperidol as a treatment for BPD:
Mania and hypomania With benzodiazepine
51
Describe risperidone as a treatment for BPD:
Monotherapy of bipolar mania- not widely used
52
Describe benzodiazepines as a treatment for BPD:
Not licensed but calming
53
Describe the use of antidepressants as a treatment for BPD:
Lacks evidence but use is common Potential for switching to mania but can be safe if combined with a mood stabiliser (short term) If someone is manic/hypomanic and on AD, must be stopped stepwise
54
What is the combination therapy for bipolar mania?
Antipsychotic and/ or mood stabiliser+ benzo
55
What is the combination therapy for bipolar depression?
Any combo of lithium, lamotrigine or valproate, quetiapine, risperidone or olanzepine
56
What is the combination therapy for relapse prevention?
Mood stabilisers Mood stabilisers plus ADs Lamotrigine plus ADs
57
Which mood stabilisers pose the greatest risk during pregnancy?
No safe mood stabiliser in pregnancy Lithium, valproate and carbamazepine pose greatest risk
58
What is the mood stabiliser used in hepatic impairment?
Amisulpride exception, everything else metabolised by liver
59
What is the mood stabiliser used in renal impairment?
Avoid lithium and amisulpride
60
Name some bipolar support groups?
Bipolar UK Mind SANE Carers UK Rethink Samaritains
61
What are the main diagnostic symptoms of mania/hypomania?
Abnormal elevation of mood Inability to conc/ easily distracted Flight of ideas Obsessive preoccupation with some idea, activity or desire May be over active and intrusive Risk taking and disinhibition e.g spending money
62
What are the main presenting symptoms of mania/hypomania?
Euphoric and labile mood Bright or untidy appearance Low sleep requirement Increase drive/ energy Reduced insight Pressure of speech, intrusive manner
63
What is the DSM V diagnosis of mania?
Duration of elevated and irritable mood needs to be for 7 days or more Severe functional impairment May have psychotic symptoms
64
What are the DSM V diagnosis of hypomania?
Duration of elevated and irritable mood needs to be for 4 days or more Decrease or increased function Psychotic features absent
65
What are the clinical features of bipolar depression?
Decreased energy and fatigue Sleeping badly Doing less Poor sleep (increased or decreased) Loss of interest in things that used to be enjoyable Feelings of wanting to self harm
66
Name the different categories of BPD?
Bipolar I (classic manic- depression) Bipolar II Bipolar III (pseudounipolar bipolar disorder) Rapid-cycling
67
Describe bipolar I:
Mania and severe depression, mania alone
68
Describe bipolar II:
Depression with at least one hypomanic episode May be genetically distinct from bipolar I
69
Describe bipolar III:
Recurrent depression and mixed states (high and low symptoms at same time) ADs may induce this
70
Describe rapid-cycling:
4 or more mood episodes in a year
71
What is the therapeutic indication of lithium?
Prophylaxis against bipolar disorders In the management of acute manic or hypomanic episodes (must have previously responded to lithium and symptoms not severe) Recurrent depression Control of aggressive behaviour/self harm Not often used for mania as takes 5-7 days to work and need high doses, testing blood levels are difficult GOLD standard for relapse prevention
72
Describe the MoA of lithium:
Is an alkali metal available for medical use as lithium carbonate (tabs) or lithium citrate (liquid) MoA not fully understood, modifies the production and turnover of certain NTs, particularly serotonin and it may also block dopamine receptors
73
Describe how preparations of lithium vary widely in bioavailability:
Need to always stay on same brand Priadel MR tabs 200/400 and Priadel liquid 520mg/5ml 5ml of liquid is equal to ONE lithium carbonate 200mg tab
74
What are the CI of lithium therapy?
Hypersensitivity to lithium Cardiac disease/ insufficiency (QT) Severe renal impairment Untreated hypothyroidism, Addison's Breast feeding Pt with low body Na e.g dehydrated or low Na diets Brugada syndrome hereditary disease of the cardiac sodium channel
75
What are the cautions of lithium therapy?
Pregnancy- AVOID unless exceptional circumstances esp in first trimester Renal impairment (mild-moderate) ECT and other meds that can decrease epileptic threshold QT interval prolongation and other meds that do this
76
What is the monitoring prior to initiating lithium theory?
ECG- QT interval increased Renal function (eGFR)- excreted via kidneys Thyroid function- hypo can be mistaken for depression Weigh gain/BMI, Ca (hyper), U&E, FBC
77
What are the dose monitoring requirements during lithium therapy?
Regular blood tests required to ensure therapeutic dose maintained as narrow window Plasma levels must be taken weekly until stable conc maintained for 4 weeks Plasma levels should 4-7 days after each dose change NICE- take plasma every 3 months for 1st year then 6 monthly unless at risk
78
What patients would be at risk and therefore need more frequent lithium dose monitoring?
Elderly- interactions at risk of impaired renal/ thyroid Raised Ca levels, poor symptom control, poor adherence Plasma levels 0.8mmol/L or higher
79
When should blood tests be taken to measure lithium dose?
12 hours post dose so take it at night
80
What should the blood test range be for lithium therapy?
0.4-1mmol/L (higher 0.8mmol in mania) Lower in elderly
81
What are additional ongoing monitoring requirements with lithium therapy?
Renal function Thyroid (TSH, T4) Every 6 months ^ Weight, BMI, Ca, U&E's
82
What is the dosage of lithium?
Individualised depending on serum lithium levels and clinical response Usually staring dose 200mg in elderly and 400mg in adults- usual dose range 400-1.2g daily at night
83
What are specific patient factors which would mean they have a reduced dose of lithium?
Renal impairment (avoid if possible) Patients less than 50kg
84
What are the SEs of lithium?
Upset stomach- esp at start FINE tremor of hands Metallic taste in mouth Swelling of ankles- dose reduction Increase thirst and urine output- renal impairment Weight gain- up to 27kg
85
Describe blood results which would indicate lithium toxicity:
Blood conc over 1.5mmol/L (overdose) and may be fatal and toxic effect Blood conc over 2mmol/L (severe overdose) requires urgent medical attention- check compliance
86
What are the signs and symptoms of lithium toxicity?
SEVERE hand tremor Stomach ache with nausea and diarrhoea Muscle weakness Unsteady on feet Slurring of words Blurred vision Confusion Unusually sleepy Muscle twitches
87
What could severe lithium toxicity lead to?
Convulsions Coma Renal and circulatory failure Hyperflexia- over active reflexes Toxic psychoses
88
Name drug interactions that can increase lithium levels:
ACEi/ ARBs (renal, increase Na+ loss) NSAIDs COX2i e.g ketorolac avoid Metronidazole SSRIs Diuretics and aldosterone agonists (thiazides worst) e.g bumetanide/ furosemide (least risk)
89
Name drug interactions that can decrease lithium levels:
Sodium bicarbonate containing products Caffeine
90
Name other drug interactions with lithium:
Ventricular arrythmia can be caused by concomitant use with amiodarone- avoid Increase risk of neurotoxicity with methyldopa and some antipsychotics e.g clozapine
91
What are other risk which can increase lithium levels?
Sodium depletion increases lithium concentration due to competitive reabsorption at the renal level Pts should be monitored for: -dehydration -changes in salt levels -infection -V&D
92
Describe the counselling points for lithium:
OD at night Effectiveness takes 6/12 months to fully establish Duration of treatment 2-3 years min Stop stepwise over at least 4 weeks, preferably longer Plasma levels monitoring (3 months) Medical attention if d&v May lose efficacy if stopped and restarted No OTC NSAIDs

MPharm Y3S2 (22 decks)

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