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46 Cards in this Set

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FDA indications: Lithium
mania associated w/ bipolar d/o
Valproic acid
-mania associated w/ bipolar d/o
-migraine prophylaxis
-epilepsy
Carbamazepine
-bipolar d/o (Equetro only)
-trigeminal neuralgia
-epilepsy
Lamotrigine
-long-term maintenance treatment of bipolar I d/o
-adjunctive treatment of partial szrs
-lennox-gastaut syndrome
-conversion to monotherapy in adults w/ partial szrs
What types of patients may lithium be most effective in?
1)pure mania
2)fewer prior epsodes
3)hx of euthymia
4)lacking neurological impariment
5)lacking psychotic sxs
6)no hx of substance abuse
valproic acid may be most effective in what type of patients?
1)rapid cyclers
2)mixed mania
3)mania due to medical conditions
carbamazepine may be most effective in what type of patients?
1)rapid cyclers
2)mixed episodes
3)neurological disease
4)negative FH of mood d/o
lithium adverse effects (6)
1)weight gain
2)leukocytosis
3)diabetes insipidus/polyuria
4)hypothyroidism
5)cardiac dysrhythmias
6)hand tremor
VPA adverse effects (7)
1)hepatotoxicity
2)pancreatitis
3)polycystic ovarian syndrome
4)thrombocytopenia
5)GI upset
6)sedation
7)weight gain
carbamazepine adverse effects (9)
1)aplastic anemia
2)agranulocytosis
3)thrombocytopenia
4)leukopenia
5)nystagmus 6)ataxia 7)blurry vision 8)stevens-johnson syndrome/rash
9)hyponatremia
lamotrigine adverse effects (5)
1)rash
2)tremor
3)dizziness
4)HA
5)sedation
Lithium drug interactions
increase lithium levels= ACEI, ARBs, diuretics, sodium depletion

decrease lithium levels= NaHCO3, NaCl, theophylline, caffeine
this NSAID has little effect on lithium clearance
aspirin
this agent may increase risk of neurotoxicity when used with lithium
haloperidol
VPA drug interactions
1)lamotrigine-decrease VPA levels, increase lamotrigine
2)warfarin-increase INR
CBZ drug interactions
decreases levels of:
1)oral contraceptives
2)anticoagulants
3)BZDs, bupropion, barbiturates
4)antipsychotics
5)anticonvulsants
lamotrigine drug interactions
1)valproic acid-inhibits metabolism of lamotrigine=may increase lamotrigine concentrations by 200%
if taking VPA concurrently w/ lamotrigine, what dosing adjustment should be made?
cut lamotrigine dose in 1/2 and titrate slowly to avoid rash
Lithium drug monitoring
1)upon initiation-level taken 12hrs after last dose q4-5d
2)lithium levels indicated 5-10d after dosing changes,etc.
3)baseline: thyroid function tests, renal function tests, CBC, electrolytes, weight, EKG
4)followup: serum drug levels, renal/thyroid function tests, wt, and CBC monthly x 1st 3 months then q6-12months
VPA monitoring
1)baseline=chem-7, LFTs, CBC, weight
2)followup=serum druglevels, LFTs, CBC, weight monthly x 1st 3 months then q6-12months
3)amylase and lipase levels periodically
carbamazepine monitoring
1)baseline=CBC w/diff, chem-7, LFTs, CBZ level
agent associated with epstein's anomaly during first trimester
lithium
lithium is widely distributed through tissues including...?
kidney, thyroid, bone
agent that has no protein binding and is not metabolized
lithium
onset of action is 7-10d
lithium, CBZ (NOT VPA)
desired lithium serum concentration
0.6-1.2mEq/L
this agent has rapid distribution into the CNS and is 90-95% protein bound
VPA
VPA recommended plasma level
50-125mcg/mL
this agent has been found to have acute antimanic, antidepressent, and prophylactic effects comparable w/ lithium in bipolar d/o
CBZ
effect of CBZ clearance with chronic therapy
due to autoinduction, CBC clearance can double w/ chronic therapy
mood stabilizers that are sedating
lithium, VPA, CBZ
mood stabilizers that precipitate weight gain
lithium, VPA
mood stabilizers that cause sexual dysfunction
lithium
CBZ recommended plasma level
6-12mcg/mL
When should CBZ be d/c?
platelets are <100,000/mm3 or WBC <3000/mm3
antipsychotics that have achieved FDA approval for treatment of acute episodes of mania
risperidone, quetiapine, ziprasidone, aripiprazole
antipsychotics used for bipolar maintenance therapy
olanzapine
management of an acute episode of mania
mood stablizer + BZD +/- atypical AP
role of BZDs in acute mania
-adjunctive treatment
-useful in minimizing agitation, anxiety, and insomnia
what BZD may worsen mania
alprazolam
1st line antidepressants in bipolar depression
bupropion and SSRIs
what antidepressants have the greatest potential to precipitate mania?
TCAs
use of antidepressants for patients who develop acute mania
d/c antidepressant
what must be done before the addition of an antidepressant in bipolar depression?
maximize dose of mood stabilizer
what should be evaluated in bipolar depression?
thyroid function
these agents should be tapered and discontinued once the patient is stabilized
BZDs and antidepressants