Week 5 - Bipolar Therapeutics Flashcards
Bipolar Affective Disorder background info.
Affective = mood | Bipolar = mood fluctuates up and down
- Its a mood disorder
- episodes of depression (low mood) AND mania (elation / elevated mood)
- differs to depression (unipolar - mood goes in 1 direction)
- people diagnsoed with depression may be screened for mania too = bipolar diagnosis - Patients move between mania, depression and normal / baseline mood
- may show symptoms of them both OR cycle in and out of episodes - Rapid-cycling = get 4 or more episodes within 12 months
- Onset between ages 15-25 (rarely seen >50)
- ## Similar rates in male and females
What are the 2 types of bipolar
Bipolar I:
- 1 manic episode with/without depressive episodes
- MORE common
Bipolar II:
- 1 hypomanic episode (not mania yet but close) AND 1 depresive episode
- High risk of suicide attempts + completion
Define Mania and symtptoms required for diagnosis
Mania - periods of abnormal + persistent elevated mood
- lasts AT LEAST 1 week
- patient will have AT LEAST 3 additional symptoms
DIAGNOSIS:
(above plus…)
- causes marked impairment of function / hospital admission
- OR includes psychotic features
Additional Symptoms:
- increased energy, ↓ need for sleep
- incomprehesible speech (i.e. speaking quickly, no pauses)
- Racing thoughts / ideas
- Poor concentration / ↑ distractability
- ↑ libido
- disinhibition
- extravagant / impractical ideas
NOTE: during manic episodes patients aren’t aware of potential consequences
Define Hypomania and symptoms required for diagnosis
Hypomania - symptoms of mania BUT not severe enough to cause marked functional impairment
- last AT LEAST 4 days
- NO psychotic features
Symptoms:
- Slight elevation in mood BUT it doesnt have the same consequences as mania
- ↑ energy, activtiy and irritability
- ↑ sociability, talkativeness
Explain the NICE GUIDELINES for treating acute bipolar disorder (mania)
NOTE: Mania and Hypomania are treated in the SAME way
- Is it their 1st manic episode
- YES = given antipsychotics
- NO = look at meds (STOP anti-depressants, if already on bipolar meds check adherance, appropriate dose) - Start antipsychotic
- inc. haloperidol, risperidone, olanzapine, quetiapine - If chosen antipsychotic doesnt work, switch to another one
- If switching causes no imporvement consider adding lithium or valporate
- If patient is VERY distressed, manic etc. use benzodiazepine
- used SHORT-TERM to calm patient down whilst waiting for a.psychotics to kick in
NOTE:
- If previosuly had unipolar (depression) disorder = on antidepressants
- Antidepressants lift mood BUT can lift it too high = mania
- STOP / avoid anti-depressants in bipolar to prevent pushing patinet into mania
- may reduce dose slowly OR abruptly stop (if benefits outweigh withdrawal SE)
Explain the NICE GUIDELINES for treating bipolar disorder (depression)
Depression episodes in bipolar disprder have the SAME symptoms as unipolar depression
- LOOK at WEEK 3 FLASHCARDS
2 types of depressions have DIFF. TREATMENT
- bipolar depression its NOT recommeneded to use anti-depressants
- Is patient on medication for it
- YES = optimise treatment (check adherance, appropriate dose or ↑ dose) - If patient is NOT on medication
- start Olanzapine (a-psychotic) AND Fluoxetine (a-depressant)
- a-depressant not recommended but combo stops patient becoming manic (but can take olanzapine alone)
- OR start Quetiapine (a-psychotic) - If none of above work, use Lamotrigine (anti-epilieptic)
What are the aims of treatment
AIM:
- manage acute episodes of mania
- manage episodes of depression
- bring patients mood back to baseline (normal)
- mania = bring mood down to normal
- depression = bring mood up
- prevent further episodes
- when patient is at baseline we use meds to prevent episodes
NOTE:
- Treating 3 diff. stages (normal, mania and depression) = treat each episode differently
What are the treatments for managing acute episodes of bipolar disorder
List the 3 maintenance treatments for bipolar disorder
- Lithium (1st line)
- Antipsychotics (2nd line)
- Valproate
How is lithium used for maintenance
1st line
Best at preventing mania and depression
- Comes in 2 salts (carbonate / citrate)
- need to stick to same salt + brand due to diff. in bioavailability and therapuetic window
- Dose titrations due to narrow window = lithium levels can go out of range easily
- START on 200mg (can ↑ to 400mg)
- do NOT stop abruptly (reduce gradually over 4-12 weeks) unless severe SE
- patients are given purple lithium booklet
- AVOID in pregnancy can cause congenital defects (not to extreme of valporate but still cautious)
SIDE EFFECTS (when in range):
- fine tremor
- metallic taste
- polyutia
- hypothyroidism (recovers when stop Li)
SIDE EFFECTS (when above range):
- coarse tremor
- vomitting, diarrhoea
- dizziness, drowsiness, blurred vission
- generally unwell
Signs of toxicity
How is lithium linked to hydration
Li is linked as it is removed from body when patient pees
- if dehydrated = Li builds up in body = toxic levels = SE like vomit / diarrhoea
- excercise, sweating, fever can also cause dehydration = SE
Renal Impairment also causes Li toxicity
- as kidneys unable to clear Li from body
Li toxicity / high levels also damages the kidneys
What monitoring is required for lithium
- WEEKLY lithium levels (in blood) until reach steady state
- TARGET: 0.4-0.8mmol/l (0.6 is therapuetic cut off)
- up to 1.0 in extreme cases (NEVER ABIVE) ~ monitor as this is close to toxicity
- take level (in morning) 12 hrs after dose (administered at night)
- then monitor every 3 months for 1 year THEN every 3 or 6 months after
- keep ↑ dose until dose and level doesnt change
Other TESTS:
- eGFR (renal function)
- TFTs (thyroid function)
- weight, BMI
How is antipsychotics used for maintenance
2nd line
If patient is already on antipsychotics wont insist they switch to lithium
Includes:
- Olanzapine
- Quetiapine
- Risperidone
How is valporate used for maintenance
side effects, monitoitng
Was popular (2nd line), but is no longer preferred
- Use Depakote (for mania)
- BANNED in PREGNANCY (due to teratogenicity)
MONITORING:
- FBC
- LFTs
SIDE EFFECTS:
- Blood disorders
- Liver disorders
- Pancreatitis
- GI issues
- hair loss
- weight gain
Valporate - Teratogenicity
teratogenicity - ability to cause defects in a developing fetus
This is the biggest issue with valporate
- Need to counsel patient
- Can cause congenital malformations, ↑ risk of developmental abnormalities e.g.
- memory problems
- poor speecg / language skills
- late learning to walk / talk
