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PMHNP > Mood Stabilizers (Week 7/8) > Flashcards

Mood Stabilizers (Week 7/8) Flashcards

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1
Q

Cyclothymic Disorder

A
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2
Q

Hypomanic Episode

A
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3
Q

Manic episode

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4
Q

Bipolar 1

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5
Q

Bipolar 2

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6
Q

Alterations of brain regions in Bipolar Disorder

A

Amygdala (mood)
Hypothalamus(decreased sleep)
Basal Forebrain(decrased sleep
Nucleus Accumbens(racing thoughts, goal-directed grandiosity
Prefrontal cortex: racing thoughts, grandiosity, distractability, pressured speech.

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7
Q

Diagnostic Criteria for Bipolar 1

A

-Must have one or more episodes of mania
-Must have one or more depressive episodes
-manic episode must last for at least 1 week.
-depressive episodes may last for weeks or months
-may have hypomania
-not a result of medical condition or intoxication

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8
Q

Mania mneumonic

A

D:Distractibility (low concentration, easily distractible)
I:Insomnia
G:Grandiosity (feelings of greatness, superiority, uniqueness)
F:Flight of ideas (multiple ideas expressed together in speech, making it barely understandable)
A: increase in goal-directedActivities (continuous search for pleasurable activities: spending money, hypersexuality, smoking, drinking alcohol, taking drugs,…)
S: pressuredSpeech (rapid speech, talking too much, almost unstoppably)
T:Thoughtlessness (high risk activities: sex, projects, drugs,…)

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9
Q

Diagnostic criteria for bipolar 2 disorder

A

Major depressive symptoms lasting for 2 weeks
At least one hypomanic episode: less severe than a full blown manic episode
Not a result of drug intoxication or medical condition.

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10
Q

Diagnostic criteria for Cyclothymic disorder

A

Mood swings between major depressive symptoms and
Hypomanic symptoms episode: less severe than a full blown manic episode
Cycle of symptoms present more than 2 years
Not a result of intoxication or medical condition.

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11
Q

What is the gold standard for Bipolar 1 treatment?

A

Lithium

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12
Q

Lithium

A

Natural occurring element, Li+ on the periodic table
FDA Approved to treat bipolar disorder: Acute Manic, Mixed episodes and maintenance therapy
Off label: Augment antidepressants, to treat rage reactions, prophylactic agent for cluster headache, schizoaffective disorder
Mechanism of Action: Unknown. Possibly neuroprotective and neuro-proliferative effects preserve grey matter
Protective benefit against suicide

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13
Q

Lithium Pharmacokinetics

A

Absorption: GI tract
Excretion: Exclusively in kidneys
Narrow therapeutic index
0.6 to 1.2 mEq/L

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14
Q

Lithium Dosing

A

Dosing: (300-2,400 mg/day divided in 24 hours)
Increasing lithium dose by 300mg/day should increase lithium level by 0.3mEq/L
Onset of action: 6-10 days in mania, up to 3 weeks in depression
Target level: 0.6-1.0 mEq/L
Baseline serum level and after each dose change or annually

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15
Q

Lithium therapeutic Index

A

Narrow therapeutic index
0.6 to 1.2 mEq/L

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16
Q

Contraindications for Lithium use

A

Kidney Failure
Cardiovascular Insufficiency
Untreated hypothyroidism
Pregnancy: Ebstein’s anomaly during first trimester
Long term use can cause kidney changes
Significant fluid loss: increases risk of lithium toxicity

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17
Q

Common Lithium Side effects

A

Nausea
May improve with food or ER formulation
Dry mouth, thirst
Offer ice chips, sugarless gum or hydration
Acne
Resolves after 1 month of use
Alopecia (usually in women)
Check thyroid function
Mild fine tremor
Avoid caffeine
Treat with propanolol
Polyuria/polydipsia (occur in 70% of patients)
Weight gain (average of 4-6kg)
Behavior modification counseling
Leukocytosis
Usually not treated, benign
Psoriasis (common over 50 y/o)
Order topicals for mild/moderate symptoms
Refer to dermatology for severe symptoms

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18
Q

Mild Lithium Toxicity: 1.5-2.0 mEq/L

A

Toxic serum level of lithium is greater than 1.5 mEq/L to 2.0 mEq/L
GI: Nausea, Vomiting, Diarrhea
Neuro: Lethargy
Muscular: Coarse hand tremor, muscle weakness
Muscle twitching
T-wave depression noted on EKG
Usually benign and treatable

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19
Q

Moderate Toxicity: 2.0-2.5 mEq/L

A

Severe nausea, vomiting, diarrhea
Confusion, slurred speech
Ataxia, muscle twitching
EKG Changes
Seizures
Oliguria
Circulatory failure
Coma
Death

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20
Q

Severe Toxicity: >2.5 mEq/L

A

Impaired level of consciousness, coma
Increased deep tendon reflexes
Syncope
Seizures
Death

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21
Q

Important relationships with Lithium:

A

Diuretics increase Retention of Li
NSAIDs Increase Retention of Li
Renal disease Increases Half-life
Decreased Doses required
Increased Dietary Na decreases Li levels
Decreased Dietary Na Increases Li levels
Decreased Na in blood via sweating, diarrhea increases Li levels

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22
Q

Causes of lithium toxicity

A

Intentional or accidental overdose
Decreased lithium renal clearance
Kidney disease, sodium deficiency, water deprivation, or medication interactions
A low or no salt diet, use of diuretics, fever and excessive sweating, vomiting, diarrhea
Failure to regular lithium level checks
Prescription of high doses of lithium

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23
Q

Lithium Drug/Drug interactions

A

Non Steroidal Anti-Inflammatory Drugs
Increase lithium levels by up to 60%
Angiotensin Converter Enzyme Inhibitors
Increases lithium levels by up to 40%
Angiotensin II Receptor Blockers
Increases lithium levels by up to 20%
Diuretics
Decrease lithium levels by up to 40%
Can cause lithium toxicity
Methylxanthines (Caffeine, theophylline)
Decrease lithium by up to 60%

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24
Q

Lithium Toxicity Treatment

Study These Flashcards
A

-Discontinue lithium treatment immediately
-If due to an overdose, a gastric lavage or induced emesis should be used
-Hemodialysis may be necessary
-Repeated lithium levels are necessary

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Lithium Toxicity prevention strategies
-Educate the patient about side effects and signs of toxicity if lithium levels continue to elevated -Clear instructions must be provided to patients, coarse tremor -Identify other medications that could exacerbate lithium toxicity (e.g. diuretics) -Perform regular lithium levels -Assess risk factors for lithium toxicity in special populations
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Lithium Patient Guidelines
-Take at same time daily. -Mild side effects are transient. Report vomiting, coarse hand tremor, sedation, weakness, and vertigo. -Maintain salt intake and a balanced diet. -Illness with fever, excessive sweating Might require dose adjustment -Lithium level: morning blood draw 8 to 12 hours after last dose
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Anticonvulsants for Bipolar
Valproate and derivatives (divalproex sodium - Depakote) Carbamazepine (Tegretol) Gabapentin (Neurontin) (least side effects) Lamotrigine (Lamictal) Topiramate (Topamax) Highly protein bound Metabolized by the cytochrome P-540 system Side effects:  dizziness, drowsiness, tremor, visual disturbance, nausea, & vomiting
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Valproic Acid
Off label use: treat acute manic phase of bipolar disorder Dosing: 250-500mg po tid, Max 60mg/kg/day Long term use to minimize future manic episodes It may help prevent future depressive episodes It can help treat rapid cycling and mixed episodes of mania Valproic Acid’s characteristics Inhibition of voltage sodium channels Boosts GABA actions and regulation of downstream signal transduction cascades Antimanic actions possibly caused by excessive neurotransmission.
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Valproic Acid Recommendations
Monitor Valproic Acid blood levels 50-125 mcg/ml, toxic levels at 150 mcg/ml.
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Valproic Acid Common Side Effects
-Weight gain -Metabolic Complications -Menstrual disturbances
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Valproic Acid Black Box Warning
-may cause hepatotoxicity, fetal injury, pancreatitis
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Carbamazepine(tegretol)
Used off label: Manic phase of bipolar disorder Formulation: ER cap, tab, ER tab, chewable and suspension. Used when patients have not responded to lithium Dosing: 800mg-1,600mg po bid-qid Mechanism of action hypotheses include: Blockage of voltage-sensitive sodium channels Pharmacokinetics Highly protein bound, metabolized by P450 system (potential drug-drug interaction) Carbamazepine’s characteristic and side effects Inducer of CYP450 and Self-Inducer Sedation Bone marrow suppressor Fetal toxicity
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Tegretol Recommended blood levels
6-12 mg /dl
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Tegretol Black Box Warning
Black box warning: 1) Serious and fatal skin reactions increased with persons with HLA-B*1502 allele (primarily Asian patients) and, 2) risk for aplastic anemia or agranulocytosis
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Lamotrigine
FDA Approved: Bipolar I Disorder maintenance Off label: First-line treatment for bipolar depression, Not approved for acute bipolar mania Formulation: tabs, dose pack Gradual dosing: Week 1-2, 25mg daily, Week 3-4, 50mg daily, then adjust as needed by 50mg/daily Lamotrigine’s characteristics and side effects Binds to the open channel conformation of voltage-sensitive sodium channels (VSSC) Lower potency at the sodium channels Reduces the release of excitatory neurotransmitter glutamate Increased likelihood to cause serious rashes/Stevens Johnson Syndrome Lamotrigine levels are not required
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Lamotrigine Black box Warning
Black box warning: Stephen-Johnson’s syndrome is a medical emergency (life threatening)
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Oxycarbazepine (trileptal)
Off label use: bipolar disorder Formulation: tablets and suspension Dosing: 600mg-1,200mg po bid Oxcarbazepine’s characteristics and side effects MOA: Similar mechanism of action of carbamazepine Binds open change conformation of the VSSC Less sedative than carbamazepine Less bone marrow toxicity Fewer CYP 3A4 interactions May cause Stevens-Johnson syndrome
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Gabapentin(Neurontin), Pregabalin(lyrica)
Used as an adjunctive agent for bipolar disorder Very limited action as mood stabilizers Formulation: Caps and solution Gabapentin Dosing: 300mg-600mg po tid Off label use: neuropathic pain, fibromyalgia, alcohol dependence and anxiety disorders Blocks VSCCs, which can help improve seizures, pain, and anxiety Pregabalin is considered a schedule V drug Gabapentin may be considered a scheduled drug in some states
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Topiramate (Topamax)
FDA Approved: Anticonvulsant, Migraine headache prophylaxis, and in combination with Phentermine for weight loss for obese patients Off label use: alcohol dependence, bulimia Formulation: tablets and capsules Dosing: 100-150mg po bid alcohol dependence Topiramate’s characteristics and side effects Potentiates the inhibition of GABA Effects as a mood stabilizer have been limited Used as an adjunctive agent for bipolar disorder to manage weight gain, insomnia, anxiety
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Atypical Antipsychotics for bipolar disorder
D2 antagonistic actions Mechanism of action to manage mania is unknown Used as an adjunctive agent in bipolar disorder Believed to reduce glutamate hyperactivity via antagonistic actions of 5HT2A leading to reduction of manic and depressive symptoms Used to manage psychotic symptoms associated with mania Used to prevent recurrence of mania
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Benzodiazepine use in Bipolar disorder
Not formally approved as mood stabilizers Used as a calming agent Used as need for agitation, insomnia, and to attempt to halt manic symptoms Used intermittently with mood stabilizers to prevent more severe symptoms They need to be used with caution
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Wakefulness Drugs in bipolar disorder
Modafinil and Armodafinil Off label use: bipolar depression Used as adjunctive agent to atypical antipsychotics
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Hormones and natural products in bipolar disorder
Omega 3 fatty acid Believed to have mood-stabilizing properties Inositol used as an augmenting agent Vitamin folate is used with a mood stabilizing anticonvulsants
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Antidepressants in bipolar disorder
Used in case by case basis Monotherapy is not recommended May be used in combination with mood stabilizers Wellbutrin the most recommended antidepressant and TCAs the least recommended
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Choosing the right treatment for the patient for Bipolar disorder.
Prudent assessment of patient’s symptoms Avoid antidepressant monotherapy A combination of mood stabilizers is a recommended approach to manage symptoms Best evidence-based combinations include: Lithium and an antipsychotic agent Valproic Acid and an antipsychotic agent Practice-based evidence combinations include: Lithium and Valproic Acid Lamotrigine and Valproic Acid (use with caution) Lamotrigine, Lithium, and Valproic Acid (use with caution) Lamotrigine and Seroquel
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Gender considerations in Bipolar
Gender considerations Women with bipolar disorder are more prone to experience depression compared to men Women are more likely than men to report atypical or vegetative symptoms (e.g. increased appetitive and weight gain) Anxiety and eating disorders are more frequent in women with bipolar disorder A postpartum period is a critical period for women to experience depressive, manic, mixed, or psychotic symptoms associated with bipolar disorder
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Antipsychotic drugs
Chlorpromazine-Thorazine Clozapine—Clozaril Lurasidone-Latuda Olanzapine—Zyprexa Quetiapine—Seroquel Risperidone—Risperdal Ziprasidone—Geodon Aripiprazole—Abilify
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Chlorpromazine (Thorazine):
Typical, 1st generation antipsychotic FDA Approved for bipolar mania in adults, severe behavioral problems in children Available in tabs and IM injection Weight gain Erectile dysfunction, retrograde ejaculation, loss of libido and anorgasmia in men and women Seizures - generalized grand mal
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Chlorpromazine Adverse Effects
Neuroleptic malignant syndrome: combination of motor rigidity, hyperthermia, and autonomic dysregulation of blood pressure and heart rate (both go up) Can be fatal if untreated Drug collects in skin and sunlight causes pigmentation changes – grayish-purple splotching like bruising) Can also occur in eye and cause brown in cornea Agranulocytosis
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Chlorpromazine Black Box/Beers Criteria
Black box warning and Beers Criteria list: Avoid in patients with dementia
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Clozapine (clozaril)
Atypical Antipsychotic Used when other antipsychotics have failed Reduces the risk of suicide in patients with schizophrenia Neutropenia (WBC <3,000/mcL and Agranulocytosis <500/mcL may occur Major side effects include seizures in high doses, increased weight gain, increased cardiovascular risks Strict ANC monitoring must be adhered to
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Lurasidone(Latuda)
Atypical, 2nd Generation Antipsychotic FDA Approved: Bipolar I Disorder acute depression Less risk for sedation, lesser risk of weight gain and dyslipidemia Moderate EPS, recommended to be given at night
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Asenaphine (Saphris)
Atypical, 2nd generation Antipsychotic FDA Approved: Bipolar I Disorder, acute manic or mixed presentation Antagonist to D2 and 5-HT2A receptors Usual dose 5mg to 10mg bid Given sublingually as an oral disintegrating tab to enhance absorption. May be used as a rapid PRN agent Major side effects include sedation, lower risk of EPS, weight gain, dyslipidemia, mouth numbing and foul taste Do not eat or drink for 10 minutes after administration
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Quetiapine(Seroquel)
Atypical, 2nd Generation Antipsychotic Multiple formulations FDA Approved: Bipolar depression, maintenance and bipolar adjunctive therapy Higher potency on D2 receptor Available in tabs and ER Major side effects include weight gain, increased triglycerides, insulin resistance 
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Risperidone (Risperdal)
Atypical, 2nd Generation Antipsychotics Used to treat bipolar mania Also used to treat irritability in children and adolescents with autistic disorder Available in tablets, dissolvable tablets, liquid, and depot injectable formulations Major side effects include sedation, lower risk of EPS, weight gain, dyslipidemia
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Ziprasidone(Geodon)
Atypical 2nd Generation Antipsychotic It may have antidepressant actions Given with at least 500 calories of food Available in tablets and intramuscular forms Less risk of weight gain, less risk of triglyceride elevation, insulin resistance, dyslipidemia
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Olanzapine(Zyprexa)
Atypical, 2nd Generation Antipsychotic Widely prescribed and used in combination with other agents (e.g. antidepressants) Can help improve mood Major side effects include significant weight gain, cardiometabolic risks, increased triglycerides, and insulin resistance may occur Available in tablets, disintegrating tablets, and injection
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