Mood stabilizers

Question 1

3 “classes” of mood stabilizers

Answer 1

Lithium, anti convulsants, anti psychotics

Question 2

gold standard for treatment of bipolar disorder

Answer 2

Lithium

Question 3

4 examples of anti convulsants used as mood stabilizers

Answer 3

Valproate, lamotrigine, carbamazepine, topiramate (yet not efficacious in bipolar disorder)

Question 4

6 examples of anti psychotics used as mood stabilizers

Answer 4

Olanzapine, quetiapaine, risperidone (paliperidone), aripiprazole, clozapine, haloperidol

Question 5

Indications for lithium treatment

Answer 5

Treatment of mania/bipolar depression, maintenance treatment of bipolar disorder, adjunctive treatment of MDD

Question 6

Work up required prior to starting lithium?

Answer 6

BUN/Cr, TSH, lytes, CBCd, ECG if >50 yo or cardiac hx, consider diabetes screening, BMI, lipids

Question 7

Adverse effects of lithium

Answer 7

fine tremor
memory problems/cognitive blunting
polyuria/polydipsia (nephrogenic DI)
diarrhea/nausea
weight gain
sedation
hypothyroidism
reduced GFR
avoid in pregnancy!!

Question 8

Lithium dosing and monitoring

Answer 8

Initial dose - 300 mg bid or tid
adjust via plasma levels: 0.8-1.2 mEq/L for acute treatment, 0.6-1 for chronic treatment
measure level at trough (9-13 hours after last dose)
check level 5 days after initiation, a week after that and following changes to dose

Question 9

Lithium drug interactions

Answer 9

drugs that increase Li = NSAIDs, diuretics, ACE inhibs, metronidazole, methyldopa, carbamazepine, phenytoin, CCBs
drugs that decrease Li = acetazolamide, alkalizing agents

Question 10

Li Toxicity Tx

Answer 10

Mild (Li 1.5-2 = ataxia, coarse tremor, confusion, diarrhea, drowsiness, fasciculation, slurred speech) = tx hold Li
mod/severe (Li >2 = acute delirium or catatonic stupor, coma ECG changes, seizures, acute renal failure, death), Tx = restore fluid and lyte balance, dialysis if necessary, increase excretion with Acetazolamide

Question 11

what is divalproex

Answer 11

enteric coated tab with valproic acid + sodium valproate

Question 12

dosing of valproic acid

Answer 12

start 250-1000 mg daily - divide BID, max 60 mg/kg

Question 13

adverse effects of valproic acid

Answer 13

sedation, tremor, dizziness, ataxia, headaches, GI symptoms, alopecia, weight gain, PCOS
C/I in pregnancy

Question 14

indications for lamotrigine

Answer 14

maintenance of bipolar I, acute bipolar depression

NOT adequate in acute mania

Question 15

Lamotrigine dosing

Answer 15

100-200 mg day split bid

very slow titration - start with 25 mg bid

Question 16

adverse effects of lamotrigine

Answer 16

sedation, GI symps, headache

rash (benign or serious - stevens johnson syndrome, toxic epidermal necrosis)

Question 17

Carbamazepine dosing

Answer 17

start with 200 mg/day, increase gradually based on blood level and adverse effects

Question 18

Carbamazepine adverse effects

Answer 18

++ sedation, dizziness, confusion, GI symps, weight gain, rash *rarely severe), benign leukopenia, agranulocytosis, SIADH

Question 19

When is topiramate useful

Answer 19

trials do not suggest significant efficacy in Bipolar disorder, however can cause weight loss so can be useful as an adjunct to other mood stabilizers

Question 20

what is a mood stabilizer

Answer 20

any medication that can treat any or all of 4 distinct phases of bipolar disorder:

• reduce symptoms of acute mania
• prevent relapse and recurrence of Mania
• reduce symptoms of acute bipolar depression
• prevent relapse and recurrence of bipolar depression