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29 Cards in this Set

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Agents that do NOT work as mood stabilizers
Gabapentin (Neurontin)
Topiramate (Topamax)
other anticonvulsants not studied
Lithium Pharmacology
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
What is the proposed site of action of Lithium?
May inhibit INOSITOL MONOPHOSPHATASE -> phosphatidyl inositol sys -> modulate G proteins
May modulate PROTEIN KINASE C -> regulate gene expression
What are the side effects of Lithium?
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
What are Lithium's renal effects?
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)
What lab tests are ordered before starting Lithium?
BUN/creatinine, thyroid function, prego, EKG (if >45yo)

Start 300 mg (1-3xday) increase to theraputic level
What are the levels and sx of Lithium Toxicity?
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)
What are the clinical uses of Lithium?
mood stabilizer, augment effect of antidepressants
What are some drugs that interact with Lithium?
NSAIDs, Cox-2 inhibitors, thiazide diuretics, ACE inhibitors
Anticonvulsant pharmacology
Inhibit Na, K, Ca related activities
Increase GABA
Decrease glutamate
Valproate (VPA, Depakote) Pharmacology
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
What are the clinical uses of Valproate (VPA, Depakote)?
BP: mania (FDA approved), maintenance, depression
If mixed/rapid cycling use this instead of Li
Also used to treat aggression, impulsivity
What are the side effects of Valproate (VPA, Depakote)?
GI (rare pancreatitis), sedation, weight gain, alopecia, tremor, hepatotoxicity, thrombocytopenia
What are contraindications to Valproate?
Hepatic disease, prego (Category D - 2% spina bifida), clotting abnormalities
What labs should you do before starting Valproate (VPA, Depakote)?
Baseline liver function, CBC, prego
Monitor hepatic dysfunction, pancreatitis (amylase), clotting probs (stop if LFT increase 3x nL)
Lamotrigine (Lamictal) Pharmacology
Mech: inhibit voltage-gated Na channel, inhibit glutamate, possible affect Ca channels
Well tolerated
No lab monitoring required, don't need to check level
What are side effects of Lamotrigine (Lamictal)?
Rash (10% first 8wks, Stevens Johnson)
Inhibits dihydrofolate reductase -> headache, insomnia, dizziness
How does Lamotrigine (Lamictal) interact with other drugs?
Half life: 25 hrs
decrease to 15 hrs with carbamazepine
increase to 60 hrs with valproate
Lamotrigine increases carbamazepine neurotoxicity
What are the uses of Lamotrigine (Lamictal)?
Maintenance treatment; bipolar depression
dose affected by other meds (do not restart at high dose - must retitrate)
Carbamazepine (CBZ, Tegretol)
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
What are side effects of Carbamazepine (CBZ, Tegretol)?
Sedation, GI, hepatic, rash (Stevens Johnson), Agranulocytosis, ataxia, SIADH (hyponatremia), decrease effectiveness of BC
What are contraindications of Carbamazepine (CBZ, Tegretol)?
Hepatic disease, Neutropenia, drugs that suppress bone marrow, prego (spina bifida, craniofacial, microcephaly)
What needs to be monitored while on Carbamazepine (CBZ, Tegretol)?
Baseline CBC, liver function, prego
Blood levels don't correspond to response in BPD
Oxycarbazepine (Trileptal)
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
What are the atypical antipsychotics?
Aripiprazole (Abilify)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
metabolized in liver, 5HT/D2 receptor antagonist, stabilize mood, less tardive kinesia
What are the risks and what should be monitored with atypical antipsychotics?
Risks: obesity, MD, metabolic syndrome
Monitor: fasting glucose/lipids, waist circumference, BMI, BP
What are the clinical uses of atypical antipsychotics?
BPD: depressive phase (Olanzapine + Fluoxetine; Quetiapine)
maintenance: aripiprazole, olanzapine
Psychotic illnesses
What is the proper acute treatment for Bipolar Disorder?
Mania: atypical antipsychotic, carbamazepine, divalproex, Lithium
Depression: Lamotrigine, Lithium, Quetiapine, Symbyax (fluoxetine+olanzapine), antidepressants+mood stabilizer
What is the proper maintenance treatment for Bipolar Disorder?
Lithium
Divalproex (not FDA approved)
Atypical antipsychotics (aripiprazloe, olanzapine)
Lamotrigine (especially to prevent bipolar depression)