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Pharm for Bipolar

From ANCC Review

QuestionAnswer
Bipolar disorder acute phase goals control symptoms of agitation, aggression and impulsivity. return to usual levels of psychosocial functioning. if depressed, avoid precipitation of manic episode.
Bipolar disorder acute phase Tx: severe mania and some mixed episodes initiate lithium or valproate in combination with an antipsychotic
Bipolar disorder acute phase Tx: for less severely ill: may use monotherapy with lithium, valproate or an atypical antipsychotic
Bipolar disorder acute phase Tx: if symptoms are inadequately controlled after 10-14 days add another first line medication
baseline labs for lithium BUN, Creatinine, thyroid, EKG, CBC w Diff, BMP, glucose, urine specific gravity, pregnancy test
baseline labs for valproate assess for hepatic, hematological and bleeding abnormalities and pregnancy
Bipolar disorder stabilization and maintenance phase goals prevent relapse and recurrence, reduce subthreshold symptoms, reduce suicide risk, reduce cycling frequency or milder degrees of mood instability, improve overall function
Bipolar disorder stabilization and maintenance phase Tx maintenance medication is recommended following a manic or depressive episode. Monitor lithium or valproic levels, hematologic and hepatic functioning at least every 6 months
Valproic acid makes this condition worse PCOS
Treatment of bipolar disorder in children and adolescents current approach is to tx acute mania or severe aggressive behavior with atypical antipsychotic or combination with mood stabilizer.
This is not approved for pre-pubertal children lithium but studies show useful for severe aggression
When treated with mood stabilizing agents, children tend to gain weight compared to adults (lithium, anticonvulsants, atypical antipsychotics)
Atypical antipsychotics are useful in tx bipolar disorder in children and adolescents because they have a more rapid onset of action than lithium and mood stabilizers
Lithium is indicated for acute euphoric mania and mood stabilization
Lithium is excreted in the kidneys - must r/o renal impairment
Lithium dosage for the acute phase 900-2400mg/day (adult) in divided doses SR dose 900-1800mg/day 1200-1800mg/day (child) in divided doses start at 300mg 2-3x/day and adjust
Maintenance dosage of lithium adolescent or adults 900-1200mg /day
lithium has a __ half life and __ therapeutic index long half life narrow therapeutic index
Response to lithium in acute mania may take 7-14 days
Maintenance with lithium lasts 18 months to 2 years then taper gradually
Due to the narrow therapeutic index, lithium requires frequent physical exams and labs. Check twice a week when starting, weekly with dose change Check dose 3-4 days after dose increases and every 3-6 months after achieving maintenance dose
When should blood draws for lithium occur 8-12 hours after last dose
Lithium Blood Levels - Acute Episodes 0.6-1.2mEq/L
Lithium Blood Levels - Maintenance Episodes 0.4-1.0mEq/L
Common adverse effects of lithium tremor, weight gain, sedation, stomach upset, polyuria, thirst, edema of lower legs, hypothyroid, acne LITHIUM Leukocytosis, Insipidus, Tremor, Hypothyroid, Increased Urine, Mom's beware
Signs of lithium toxicity nausea, vomiting, diarrhea, drowsiness, tremor, muscle weakness, giddiness, ataxia, vertical nystagmus, tinnitus, diabetes insipidus, multiorgan toxicity.
Lithium toxicity is a medical emergency, do the following: discontinue immediately, emesis or lavage, check labs and EKG, dialysis may be required. Emesis is not usually recommended due to aspiration. Lithium will not bind to activated charcoal
lithium affects the kidneys at this time Each time it peaks, ok to dose once a day
Lithium instructions to patients avoid dehydration!!! excessive salt or excessive fluid intake take with meals to reduce GI upset
Excess sodium = Low sodium = excess sodium = decreased lithium levels, low sodium = toxic lithium levels
These are associated with increased lithium levels NSAIDS, thiazide, diuretics, use potassium sparing diuretics, ACE inhibitors, low sodium dehydration, renal disease
These are associated with decreased lithium levels caffeine, theophylline = decreased response
These may reduce tremor associated with lithium propranolol 20-30mg tid and reduced caffeine.
EKG should be checked for ST segment changes, T wave flattening, arrythmias, conduction disturbances Done baseline and annually
Lithium is in this class Mood Stabilizer
Anticonvulsant mood stabilizers have therapeutic effects on reducing mania after days, but mood stabilization takes weeks to months
Common transient adverse effects of anticonvulsants N/V/D and sedation
Common maintained adverse effects of anticonvulsants weight gain, tremor, increased risk for thrombocytopenia, risk for agranulocytosis
for weight gain with anticonvulsants monitor weight and BMI, encourage diet and exercise
these anticonvulsants have the lowest risk for weight gain lamotrigine and topirimate
to combat tremor with an anticonvulsant consider low dose beta blocker
for increased risk of thrombocytopenia with an anticonvulsant monitor PT and platelets
for risk of agranulocytosis with an anticonvulsant monitor WBC
This anticonvulsant is known for causing issues with WBC Carbamazepine
valproate/divalproex depakene/depakote is useful for acute mania, mixed and euphoric mania. Less effective for maintenance and bipolar depression
Dosing for valproate 1200-2500mg/day (adult) up to 20mg/kg/day for child/adolescent can use loading dose - 2mg/kg in divided doses
side effects for valproate weight gain, alopecia, nausea, diarrhea, tremor, thrombocytopenia, spina bifida- if pregnant, pancreatitis, elevated LFTs, PCOD
Labs for monitoring valproate LFTs - monthly and in the first 6 months then q6 months amylase HCG CBC w Diff PT/PTT baseline and q 6 mo depakote level 2 weeks after starting then q3-6 mo
Depakote level should be 50-125
Depakote has a black box warning for pancreatitis
valproate is contraindicated in liver disease
if acute mental status change, check ammonia level
carbamazepine (Tegretol) dosing 400-1200mg/day (adult) 20-30mg/kg/day (child/adolescent)
carbamazepine (Tegretol) good for augmenting agent for acute mania rapid cycling
Tegretol is an enzyme inducer
carbamazepine (Tegretol) side effects aplastic anemia, liver problems, thrombocyctosis, hyponatremia
if at risk for aplastic anemia/agranulocytosis monitor WBC q 2 weeks x 2 months then q3 months
someone on tegretol is at risk for this serious side effect stevens johnson's syndrome
labs for carbamazepine (Tegretol) LFTs, CBC w diff, renal function, EKG, HCG
Blood levels for tegretol range 6-12
gabapentin (Neurontin) dosage 900-3600mg/day
this is not used for mood stabilization anymore gabapentin - well tolerated but questionably effective.
Neurontin is good for anti-anxiety, pain control effects, fibromyalgia and anti - craving
Side effects of neurontin sedation, ataxia, decreased coordination
lamotrigine (Lamictal) dosage 100-400mg/day start at 25mg/day
lamictal is indicated for bipolar maintenance, useful for bipolar depression
major risk with lamictal Steven Johnson Syndrome. Start low and go slow Children/adolescents have higher risk of rash than adults
this increases risk of rash associated with lamictal valproate exceeding dose recommended exceeding dose escalation abrupt withdrawal
side effects of lamictal insomnia, headache, dizziness
if a pt misses more than 5 days of lamictal, need to restart and titrate
topiramate (Topamax) dosage 50-300mg/day
use for topamax adjunct in bipolar disorder. Not effective as first line
topamax may cause weight loss
side effects of topamax short term memory loss, cognitive slowing, paresthesias, nephrolithiasis DOPAMAX - Cognitive slowing
topamax is contraindicated if chronic nephrolithiasis or glaucoma
oxcarbazepine (Trileptal) dosage 300-1200mg/day
side effects of oxcarbazepine (Trileptal) hyponatremia, somnolence
oxcarbazepine (Tegretol) interferes with this medication birth control
Other anticonvulsants Keppra, Gabitril, Zonegran, Equetro
Created by: jonquil