Therapeutics of Bipolar Disorder

Question 1

DSM IV Criteria for Manic Episode

Answer 1

3+ sx >1week persisting all day long

Question 2

Sx: DIG FAST

Answer 2

Distractible
Impulsive
Grandiosity
Flight of ideas
Activities = risky
Sleep = none
Talkative

Question 3

Bipolar I

Answer 3

Manic > depressive

Question 4

Bipolar II

Answer 4

Manic < depressive

Question 5

Which state do most bipolar patients spend their lives in?

Answer 5

Depressive

Question 6

3 Classes of Mood Stabilizers

Answer 6

Lithium
SGAs
Anticonvulsants

Question 7

What is the onset of effect of Lithium for mania vs depressive episodes?

Answer 7

Mania: 7-14 days
Depression: 6-8 weeks

Question 8

Lithium Pregnancy Category and why

Answer 8

D - heart defects

Question 9

Lithium significant kinetics

Answer 9

Absorbed readily - not bound
Distributed widely
Linear kinetics
Renally excreted

Question 10

Lithium TDM

Answer 10

Maintenance range: 0.6-1.2
Acute mania range: 1-1.2
>1.2 = NV, diarrhea, tremor, MS changes then seizure and death

Question 11

Lithium Toxicity

Answer 11

Mild: hold dose and get level
Sever: hold dose, get level, hydration, O2, monitor regularly and get labs

Question 12

Lithium Side Effects

Answer 12

NV: Take with food
Tremor: decrease dose
Weight gain: diet and exercise
Polyuria: decrease dose
Hypothyroidism: synthroid
Acne: topicals
NEPHROTOXIC

Question 13

Lithium Monitoring

Answer 13

Labs
Levels 5-7 days after dose adjustments
Levels and labs every 6 months

Question 14

Drugs Increasing Li Levels

Answer 14

NSAIDs, thiazide diuretics, loops, ACEis

Question 15

Drugs Decreasing Li Levels

Answer 15

K+ sparing diuretics, loop diuretics, theophylline, caffeine

Question 16

Depakote Preferred Use

Answer 16

Mix episodes

Question 17

Depakote Onset

Answer 17

Mania: 3-5 days

Question 18

Depakote Kinetics

Answer 18

Absorbed readily
Highly protein bound
Hepatic excretion

Question 19

Depakote Pregnancy Category

Answer 19

D: neural tube defects

Question 20

Depakote TDM

Answer 20

At steady state 12 hours after first dose

TD: 50-100mg/L

Question 21

Depakote Side Effects

Answer 21

Tremor, fatigue, NV, weight gain, hair loss, liver and pancreas toxicity, thrombocytopenia

Question 22

Depakote Monitoring

Answer 22

Levels at steady state after adjustments

Levels and Lab every 6 months

Question 23

Drugs Increasing Depakote

Answer 23

Aspirin, warfarin, fluoxetine, risperidone

Question 24

Drugs Decreasing Depakote

Answer 24

Carbamazepine, carbapenems, rifampicin

Question 25

Carbamazepine Onset

Answer 25

Second line | Mania: 7-14 days (like Lithium!)

Question 26

Carbamazepine PK

Answer 26

Erratic absorption Highly protein bound Hepatically metabolize Autoinduction starts <7 days and stops in 3-5 weeks

Question 27

Carbamazepine Pregnancy Category

Answer 27

D: Neural tube defects

Question 28

Carbamazepine TDM

Answer 28

After 5 days (steady state) After 3-5 weeks (post auto-induction) Range: 4-12

Question 29

Carbamazepine Side Effects

Answer 29

``` NV Blurry vision Dizzy SJS Anemia Agranulocytosis Liver failure ```

Question 30

Carbamazepine CIs

Answer 30

MAOi use Bone marrow depression Hepatic failure

Question 31

Carbamazepine Monitoring

Answer 31

HLA - rash Levels 5 days after adjustments and every 6 months Labs every 6 months

Question 32

Drugs Increase Carbamazepine

Answer 32

Depakote, CCBs, cimetidine, erythromycin

Question 33

Drugs Decreasing Carbamazepine

Answer 33

Phenobarbital

Question 34

Drug Carbamazepine Affects

Answer 34

Decrease levels of oral contraceptives, theophylline and warfarin

Question 35

Oxcarbazepine Onset

Answer 35

Mania: 7-14 days | NOT FDA approved

Question 36

Oxcarbazepine Pregnancy Category

Answer 36

C!

Question 37

Oxcarbazepine Interactions and Side Effects

Answer 37

Similar but milder than carbamazepine No autoinduction CYP inducer - decrease oral contraceptives NO TDM

Question 38

Lamotrigine Onset

Answer 38

First line for depressive episodes | Onset: 6-8 weeks

Question 39

Lamotrigine Dosing

Answer 39

SPECIFIC titration schedule Start over if miss 3-5 doses in a row With Tegretol: double dose With depakote: 1/2 dose

Question 40

Lamotrigine Pregnancy

Answer 40

C (maybe cleft palate)

Question 41

Lamotrigine Side Effects

Answer 41

NV Fatigue SJS Rash

Question 42

Lamotrigine Monitoring

Answer 42

Labs every 6 months | No TDM

Question 43

SGAs Onset

Answer 43

3-5 days | Emergency management of agitation

Question 44

First Line Acute Mania

Answer 44

Lithium Depakote Atypical antipsychotics

Question 45

First Line Acute Depression

Answer 45

Lithium Lamotrigine Zyprexa and SSRI Seroquel