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Pharm for Bipolar
From ANCC Review
| Question | Answer |
|---|---|
| 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 |
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jonquil
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