week 3 mood regulators

Question 1

MOA

Lithium (including Lithium Carbonate, Lithium Citrate, SR)

Answer 1

affects neurotransmission (decrease excitatory, increase inhibitory) and second messenger systems

1. Stabilizing poles: mood stabilizers (e.g. lithium, valproate, carbamazepine, lamotrigine, antipsychotics) 2. Stabilizing chair lift: lithium treats bipolar disorder (acute mania and maintenance) 3. Narrow window: lithium has a very narrow therapeutic index 4. Early nausea: acute lithium toxicity causes GI symptoms (e.g. nausea, vomiting, diarrhea) 5. Late trembling: chronic lithium toxicity causes neurologic symptoms (e.g. tremor) 6. Late falling: chronic lithium toxicity causes neurologic symptoms (e.g. ataxia) 7. Undone bowtie: lithium therapy can cause hypothyroid 8. Hefty snowboarder: signs of lithium induced hypothyroidism include weight gain, dry skin, hair loss, and constipation 9. Insipidus fountain: lithium can cause nephrogenic diabetes insipidus 10. Thighs on high dive: thiazide diuretics (increase lithium levels) 11. "Low clearance": diuretics (e.g. thiazides) and NSAIDs decrease clearance of lithium (decrease GFR) 12. Tarantula: lithium is teratogenic (Ebstein's anomaly) 13. Large right head: atrialization of the right ventricle (seen in Ebstein's anomaly with ASD and malformed tricuspid)

Question 2

Clinical Use: Lithium (including Lithium Carbonate, Lithium Citrate, SR)

Answer 2

Mood stabilizer for bipolar disorder

Acute mania

Prevention of mood episodes

1. Stabilizing poles: mood stabilizers (e.g. lithium, valproate, carbamazepine, lamotrigine, antipsychotics) 2. Stabilizing chair lift: lithium treats bipolar disorder (acute mania and maintenance) 3. Narrow window: lithium has a very narrow therapeutic index 4. Early nausea: acute lithium toxicity causes GI symptoms (e.g. nausea, vomiting, diarrhea) 5. Late trembling: chronic lithium toxicity causes neurologic symptoms (e.g. tremor) 6. Late falling: chronic lithium toxicity causes neurologic symptoms (e.g. ataxia) 7. Undone bowtie: lithium therapy can cause hypothyroid 8. Hefty snowboarder: signs of lithium induced hypothyroidism include weight gain, dry skin, hair loss, and constipation 9. Insipidus fountain: lithium can cause nephrogenic diabetes insipidus 10. Thighs on high dive: thiazide diuretics (increase lithium levels) 11. "Low clearance": diuretics (e.g. thiazides) and NSAIDs decrease clearance of lithium (decrease GFR) 12. Tarantula: lithium is teratogenic (Ebstein's anomaly) 13. Large right head: atrialization of the right ventricle (seen in Ebstein's anomaly with ASD and malformed tricuspid)

Question 3

Side Effects- Lithium

Answer 3

LiTHIUM-
Low Thyroid
Heart (ebstein anomaly seen when taken during pregnancy)
Insipidus
Unwanted Movements

1. Stabilizing poles: mood stabilizers (e.g. lithium, valproate, carbamazepine, lamotrigine, antipsychotics) 2. Stabilizing chair lift: lithium treats bipolar disorder (acute mania and maintenance) 3. Narrow window: lithium has a very narrow therapeutic index 4. Early nausea: acute lithium toxicity causes GI symptoms (e.g. nausea, vomiting, diarrhea) 5. Late trembling: chronic lithium toxicity causes neurologic symptoms (e.g. tremor) 6. Late falling: chronic lithium toxicity causes neurologic symptoms (e.g. ataxia) 7. Undone bowtie: lithium therapy can cause hypothyroid 8. Hefty snowboarder: signs of lithium induced hypothyroidism include weight gain, dry skin, hair loss, and constipation 9. Insipidus fountain: lithium can cause nephrogenic diabetes insipidus 10. Thighs on high dive: thiazide diuretics (increase lithium levels) 11. "Low clearance": diuretics (e.g. thiazides) and NSAIDs decrease clearance of lithium (decrease GFR) 12. Tarantula: lithium is teratogenic (Ebstein's anomaly) 13. Large right head: atrialization of the right ventricle (seen in Ebstein's anomaly with ASD and malformed tricuspid)

Question 4

Step 1 Must-Knows:

Lithium

Answer 4

Narrow therapeutic index—monitor serum levels

Renally excreted—avoid with thiazides, NSAIDs, ACE inhibitors (↑ lithium levels)

Ebstein anomaly: congenital heart defect if taken during pregnancy (teratogenic)

Question 5

MOA: Valproic Acid / Divalproex Sodium / Sodium Valproate

Answer 5

Increases GABA levels by inhibiting GABA transaminase; also blocks Na⁺ channels.

Question 6

Clinical Use: valproic acid, divalproex sodium, sodium valproate

Answer 6

Bipolar disorder (acute mania + maintenance)

Epilepsy (generalized seizures)

Migraine prophylaxis

4. Shaking Man FestiVAL: Valproate (aka sodium valproate, valproic acid) is a broad-spectrum antiepileptic; used in focal and generalized seizures, bipolar disorder (mood stabilizer) 5. Sold Out peanuts and Calci-Yum icecream: Valproate blocks Na+ channels (at a different site from carbamazepine or phenytoin) and T-type calcium channels → prevents repetitive neuronal discharge 6. CAB-A: Valproate ↑ GABA levels in the CNS due to enhanced GABA release via GABA(B) receptors, inhibition of GABA transaminase, activation of glutamic acid decarboxylase 7. Nauseated reveller: Valproate can cause GI distress (e.g. nausea, vomiting); valproate can be taken with food to reduce nausea 8. Heavy box: Valproate can cause increased appetite and weight gain; monitor diet to avoid unwanted weight gain 9. Tremoring antenna: Valproate can cause tremor (at higher doses) 10. Liver fanny pack + ammonia cleaner: Valproate can cause hyperammonemia and rare, fatal hepatotoxicity; measure LFTs at baseline and monitor at frequent intervals thereafter, even though monitoring of liver aminotransferase (does not predict hepatic failure) 11. Squeezed pancreas sponge: Valproate can cause pancreatitis (rare); not related to dose or duration of therapy

Question 7

Side Effects: valproic acid, divalproex, sodium, sodium valproate

Answer 7

Side Effects:

Hepatotoxicity (monitor LFTs)

Neural tube defects (teratogenic – spina bifida)

Weight gain

GI distress

Tremor

Pancreatitis

Question 8

Step 1 Must-Knows: valproic acid, divalproex sodium, sodium valproate

Answer 8

Contraindicated in pregnancy (NTDs via ↓ folate)

Enzyme inhibitor (↑ levels of other drugs)

Monitor LFTs and amylase/lipase for pancreatitis risk

Question 9

MOA of Carbamazepine

Answer 9

Carbamazepine binds to voltage-gated Na⁺ channels in their inactivated state and prolongs inactivation, especially in rapidly firing neurons.

This does two things:

Prevents repetitive firing of action potentials.

Stabilizes overexcited neuronal membranes.

Question 10

clinical use: lamotrigine

Answer 10

Clinical Use:

Bipolar disorder (esp. for bipolar depression)

Epilepsy (partial, tonic-clonic, Lennox-Gastaut)

Question 11

Side Effects: carbamazepine

Answer 11

Aplastic anemia, agranulocytosis (monitor CBC)

SIADH/hyponatremia

Diplopia, ataxia

Stevens-Johnson syndrome (SJS)

Hepatotoxicity

Teratogen (neural tube defects)

Step 1 Must-Knows:

Induces CYP450 → ↓ efficacy of other drugs (oral contraceptives, warfarin)

HLA-B*1502 allele → ↑ SJS risk in Asians → screen before use

Question 12

clinical use: carbamazipine

Answer 12

Bipolar disorder (especially acute mania and maintenance)

Trigeminal neuralgia (first-line)

Partial and tonic-clonic seizures

Question 13

moa- lamotrigine

Answer 13

ca channel inhibition, and 5HT release

Question 14

Side Effects: Lamotrigine

Answer 14

Stevens-Johnson syndrome (titrate slowly to avoid)

Headache

Nausea

Diplopia

Step 1 Must-Knows:

Slow titration is key to reduce SJS risk

Generally well tolerated; good option for bipolar depression