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Flashcards in Mood Stabilizers Deck (54)
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1

Neurochemical theories of BD

-Catecholamine hypothesis
-Permissive theory
-GABA and glutamate involvement

2

Catecholamine hypothesis of BD

-Mania may be related to excess NE and DA
-Depression may be related to deficits in NE, 5HT, DA

3

Permissive theory of BD

-Underlying decrease in 5HT with increased NE resulting in mania
-Decreased NE resulting in depression

4

What is necessary to rule out in evaluation of BD?

-Medical or drug induced causes
-Other psych diagnoses

5

Complete work-up prior to diagnosing BD?

-PE
-Basic labs (CBC, thyroid, electrolytes)
-Toxicology screen

6

Treatment goals for BD

1. Resolve acute symptoms
2. Facilitate pt's return to pre-morbid functioning
3. Prevent further episodes
4. Pharm is cornerstone of treatment

7

Pharm treatment of BD

-Mood stabilizers
-Other agents (adjunctive anxiolytic or short term antipsychotic)

8

How long does it take mood stabilizers to elicit a response in BD?

7-10 days

9

How long does it take anxiolytic or short term antipsychotics to elicit a response in BD?

3-5 days

10

What are mood stabilizer agents used in BD?

-Lithium
-Valproic acid/divalproex sodium
-Lamotrigine
-Carbamazepine
-Oxcarbazepine

11

Drug of choice for "classic" mania?

Lithium

12

Lithium is FDA approved for:

-Acute mania
-Maintenance of BPD 1

13

What is shown to reduce risk of suicide in patients with depressive episodes in BD?

Lithium

14

Lithium MOA

-Unclear
-May involve 5HT, DA, GABA

15

Lithium metabolism

Excreted unchanged in the urine

16

Early ADEs of Lithium

Dose related and worse at peak serum concentrations
-GI
-Muscle weakness/lethargy
-Polydipsia w/polyuria (70%)
-HA, memory impairments, confusion (40%)
-Fine hand tremor (50%)

17

ADEs of Lithium later in treatment

-Nephrogenic DI
-Morphological renal changes
-Hypothyroidism (30%)
-Cardiac effects (30%)
-Wt gain
-Decreased libido

18

Monitoring parameters of Lithium

-Plasma concentration taken 8-12 hrs after last dose (trough)
-Renal function
-Thyroid function
-ECG
-CBC
-Serum electrolytes
-Pregnancy test

19

Lithium toxicity

-Plasma concentrations over 1.5: GI, decrease in coordination
-Plasma concentrations over 2: seizures, cardiac arrhythmias, neuro impairment, kidney damage, coma, death

20

What situations predispose a patient to Lithium toxicity?

-Na restriction (aka DASH diet)
-Dehydration
-Vomiting, diarrhea
-Drug interactions that lower Li clearance

21

How to treat Lithium toxicity?

Dialysis

22

What drugs cause decreased Lithium clearance?

FANTS
-Fluoxetine
-ACE inhibitors
-NSAIDs
-Thiazides
-Salt restricted diets

23

What drugs cause increased Lithium clearance?

-Caffeine
-Theophylline

24

Lithium in pregnant/lactating patients

-Category D
-Crosses placenta
-May cause floppy infant syndrome
-Present in breast milk

25

What is Valproic acid FDA approved for?

-Acute mania in BPD 1
-NOT approved for maintenance, but commonly used as monotherapy or in combo w/other agents

26

How does Valproic acid compare to Lithium?

Better efficacy for mixed states and rapid cycling

27

Valproic acid MOA

Proposed mechanisms:
-Increases GABA in CNS
-Antikindling properties (may decrease rapid cycling/mixed states)

28

Valproic acid drug interactions

Inhibits Lamotrigine and Carbamazepine metabolism (competes with hepatic glucuronidation site)

29

Valproic acid use in pregnant/lactating pts

-Category D (neural tube defects during 1st trimester)
-Considered compatible with breast feeding

30

Valproic acid monitoring

-Therapeutic plasma concentrations
-CBC w/diff
-Chem panel w/electrolytes
-LFTs

31

What is Lamotrigine FDA approved for?

Maintenance of BPD 1
-Has both antidepressant and mood stabilizing effects
-May prevent bipolar depression

32

Lamotrigine MOA

Proposed mechanisms:
-Modulates or decreases glutamate release
-Antikindling properties

33

Which mood stabilizers may cause a rash leading to SJS?

-Valproic acid
-Lamotrigine

34

How does lamotrigine affect weight?

It doesn't (Li and VA do)

35

Lamotrigine use in pregnant/lactating

-Category C
-NOT recommended in breast feeding

36

Lamotrigine monitoring

Derm (assess for rash)

37

Carbamazepine MOA

Proposed mechanisms:
-Modulates or decreases glutamate release
-Antikindling properties

38

Use of Carbamazepine in BPD

Monotherapy or in combo for acute and maintenance (NOT 1st line)

39

What is unique regarding Carbamazepine?

Pan-inducer: induces its own metabolism (and others)

40

Carbamazepine ADEs

-CNS toxicity (up to 60% pts)
-GI
-Hyponatremia
-Wt gain
-Agranulocytosis
-Derm reactions

41

Carbamazepine toxicity

-At over 15 mcg/mL
-Ataxia, choreiform movements, diplopia, nystagmus, etc.

42

Carbamazepine use in pregnant/lactating

-Category D (craniofacial deformities, spina bifida, low birth wt)
-Considered ok w/breast feeding

43

Carbamazepine serum levels monitoring

-Every 1-2 wks during first 2 mos then every 3-6 mos
-10-12 hrs post-dose and at least 5-7 days after a dosage change

44

Carbamazepine monitoring

-CBC w/diff
-LFTs
-Serum electrolytes
-Derm monitoring

45

Describe oxcarbazepine

-Analog of CBZ
-May have fewer ADEs
-NOT FDA approved for BPD so not 1st line
-Preg Cat C, not recommended in breast feeding

46

Which meds are FDA approved for acute mania BPD?

Lithium
Divalproex (Depakote)
Carbamazepine

47

Which meds are FDA approved for acute mixed BPD?

Divalproex (Depakote)
Carbamazepine

48

Which meds are FDA approved for BPD maintenance?

Lithium
Lamotrigine

49

Which meds are FDA approved for depressive episodes in BPD?

Lamotrigine

50

How are antipsychotics used in BPD?

-Acute mania (monotherapy or adjunctive)
-Bipolar depression

51

Which antipsychotics are used to treat acute mania in BPD?

-Aripiprazole
-Olanzapine
-Risperidone
-Haloperidol
-Quetiapine
-Ziprasidone
*Lithium or VA plus antipsychotic has better efficacy than any of these alone

52

Which antipsychotics are used for treatment of bipolar depression?

-Quetiapine XR
-Lurasidone
-Fluoxetine/Olanzapine

53

How are BZDs used in BPD?

-Can be used as an alternative or in combo w/antipsychotics for acute mania
-Alternative to mood stabilizers in 1st trimester of pregnancy

54

Antidepressant use in BPD

-Concern of mood switching in pts w/BP depression
-Can precipitate a manic episode
-Higher w/TCAs or Venlafaxine
-No better than placebo