Behavioral Science - Mood Stabilizers

Front 1

Agents that do NOT work as mood stabilizers

Back 1

Gabapentin (Neurontin)
Topiramate (Topamax)
other anticonvulsants not studied

Front 2

Lithium Pharmacology

Back 2

Half life: 24hrs
Excreted unchanged by kidney (if inc GFR like prego, inc excrete; if dec GFR like kidney disease, dec excrete)
THERAPUTIC LEVEL: .6-1.2 mEq/L

Front 3

What is the proposed site of action of Lithium?

Back 3

May inhibit INOSITOL MONOPHOSPHATASE -> phosphatidyl inositol sys -> modulate G proteins
May modulate PROTEIN KINASE C -> regulate gene expression

Front 4

What are the side effects of Lithium?

Back 4

GI, tremor, polydipsia, nephrogenic DI (inhibit vasopressin = diuretic), hypothyroidism, weight gain, alopecia, skin probs (psoriasis, acne), lymphocytosis, EKG (T wave, SA node), hyperparathyroidism (inc Ca), Ebstein's anomoly, change renal morphology

Front 5

What are Lithium's renal effects?

Back 5

inhibit vasopressin -> nephrogenic DI (multiple dose, high blood levels, usually reversible)
treat with Amiloride (blocks Li absorption in renal tubules)
Also interstitial nephritis, sclerotic glomeruli, atrophic tubules (all reversible)

Front 6

What lab tests are ordered before starting Lithium?

Back 6

BUN/creatinine, thyroid function, prego, EKG (if >45yo)

Start 300 mg (1-3xday) increase to theraputic level

Front 7

What are the levels and sx of Lithium Toxicity?

Back 7

Mild (1.5-2): vomit, diarrhea, hand tremor, lethargy
Moderate (2-2.5): dysarthria, hyperreflexia, fasiculations, myoclonus, nystagmus, sz, confusion, arrhythmias
Severe: coma, renal failure, death (treat = hemodialysis)
70% full recovery (20%die)

Front 8

What are the clinical uses of Lithium?

Back 8

mood stabilizer, augment effect of antidepressants

Front 9

What are some drugs that interact with Lithium?

Back 9

NSAIDs, Cox-2 inhibitors, thiazide diuretics, ACE inhibitors

Front 10

Anticonvulsant pharmacology

Back 10

Inhibit Na, K, Ca related activities
Increase GABA
Decrease glutamate

Front 11

Valproate (VPA, Depakote) Pharmacology

Back 11

Mech: dec PKC, inc GABA, stabilize membrane (Na, Ca)
Metabolized in liver (inhibits CYP450); converted to valproic acid in GI tract; highly protein bound
Half life: 9-16hrs
Theraputic level: 45-125
relatively safe in overdose

Front 12

What are the clinical uses of Valproate (VPA, Depakote)?

Back 12

BP: mania (FDA approved), maintenance, depression
If mixed/rapid cycling use this instead of Li
Also used to treat aggression, impulsivity

Front 13

What are the side effects of Valproate (VPA, Depakote)?

Back 13

GI (rare pancreatitis), sedation, weight gain, alopecia, tremor, hepatotoxicity, thrombocytopenia

Front 14

What are contraindications to Valproate?

Back 14

Hepatic disease, prego (Category D - 2% spina bifida), clotting abnormalities

Front 15

What labs should you do before starting Valproate (VPA, Depakote)?

Back 15

Baseline liver function, CBC, prego
Monitor hepatic dysfunction, pancreatitis (amylase), clotting probs (stop if LFT increase 3x nL)

Front 16

Lamotrigine (Lamictal) Pharmacology

Back 16

Mech: inhibit voltage-gated Na channel, inhibit glutamate, possible affect Ca channels
Well tolerated
No lab monitoring required, don't need to check level

Front 17

What are side effects of Lamotrigine (Lamictal)?

Back 17

Rash (10% first 8wks, Stevens Johnson)
Inhibits dihydrofolate reductase -> headache, insomnia, dizziness

Front 18

How does Lamotrigine (Lamictal) interact with other drugs?

Back 18

Half life: 25 hrs
decrease to 15 hrs with carbamazepine
increase to 60 hrs with valproate
Lamotrigine increases carbamazepine neurotoxicity

Front 19

What are the uses of Lamotrigine (Lamictal)?

Back 19

Maintenance treatment; bipolar depression
dose affected by other meds (do not restart at high dose - must retitrate)

Front 20

Carbamazepine (CBZ, Tegretol)

Back 20

Mech: enhances GABA, affects Na, K channels, induces P450 (autoinduction)
Half life: 24-12 hrs (starting dose 200 mg)
Treat: mania, bipolar depression, maintenance phase of BPD

Front 21

What are side effects of Carbamazepine (CBZ, Tegretol)?

Back 21

Sedation, GI, hepatic, rash (Stevens Johnson), Agranulocytosis, ataxia, SIADH (hyponatremia), decrease effectiveness of BC

Front 22

What are contraindications of Carbamazepine (CBZ, Tegretol)?

Back 22

Hepatic disease, Neutropenia, drugs that suppress bone marrow, prego (spina bifida, craniofacial, microcephaly)

Front 23

What needs to be monitored while on Carbamazepine (CBZ, Tegretol)?

Back 23

Baseline CBC, liver function, prego
Blood levels don't correspond to response in BPD

Front 24

Oxycarbazepine (Trileptal)

Back 24

metabolite of carbamazapine 1:1.5(better tolerated, no autoinduction)
Don't monitor LFT, CBC, drug level
Risk of hyponatremia -> monitor Na
can decrease effectiveness of BC

Front 25

What are the atypical antipsychotics?

Back 25

Aripiprazole (Abilify)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
metabolized in liver, 5HT/D2 receptor antagonist, stabilize mood, less tardive kinesia

Front 26

What are the risks and what should be monitored with atypical antipsychotics?

Back 26

Risks: obesity, MD, metabolic syndrome
Monitor: fasting glucose/lipids, waist circumference, BMI, BP

Front 27

What are the clinical uses of atypical antipsychotics?

Back 27

BPD: depressive phase (Olanzapine + Fluoxetine; Quetiapine)
maintenance: aripiprazole, olanzapine
Psychotic illnesses

Front 28

What is the proper acute treatment for Bipolar Disorder?

Back 28

Mania: atypical antipsychotic, carbamazepine, divalproex, Lithium
Depression: Lamotrigine, Lithium, Quetiapine, Symbyax (fluoxetine+olanzapine), antidepressants+mood stabilizer

Front 29

What is the proper maintenance treatment for Bipolar Disorder?

Back 29

Lithium
Divalproex (not FDA approved)
Atypical antipsychotics (aripiprazloe, olanzapine)
Lamotrigine (especially to prevent bipolar depression)