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71 Cards in this Set

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what is bipolar disorder?
a cyclical disorder w/ recurrent fluctuations in mood, energy, and behavior. Pts cycle between mania and depression.
what are the four types of bipolar disorder?
bipolar I: pt has major depressive episode + manic or mixed episode
bipolar II: pt has major depressive episode + hypomanic episode
cyclothymic disorder: chronic fluctuations between subsyndromal depressive and hypomanic episodes
bipolar disorder NOS
what is the lifetime prevelance rate of bipolar disorder?
about 1.5%
what is the usual age of onset of bipolar disorder?
20 (15-19 for men, 25 for women)
what is the difference in sx between men and women?
men usually present w/ manic sx initially, women usually present w/ depression
describe the disease progression
average amt of time between first and second episodes is about three years, lenght between episodes shortens as disease progesses. sx develop quickly in manic phase, gradually in depressive. episodes increase in number/severity w/ age and # of previous episodes
many bipolar pts self treat w/ what substance?
EtOH
describe the significance of genetic risk associated w/ bipolar disorder
80-90% of pts have a biologic relative w/ a mood disorder
list the possible etiologies of bipolar disorder
genetic
NT theories
sensitization/kindling theories
neuroendocrine theories
structural abnormalities
biologic rhythms hypothesis
describe the medical disorders associated w/ mania
endocrine: hyperthyroid
infections: AIDS, flu
neuro: alzheimer's parkinson's
medications associated w/ mania include:
antidepressants (TCAs are most likely, SSRIs and bupropion are least likely), psuedoephedrine, DA augmenting agents, albuterol, steroids, salmeterol, stimulants
what are the symptoms of mania?
persistently elevated, expansive, or irritable mood+:
inflated self esteem
decreased need for sleep
pressured speech
flight of ideas
easily distracted
increase in goal oriented activity
excess involvement in pleasureable activities - potential for painful consequences.
sx usually lasting at least one week
define hypomania
4 days of abnormal and persistently elevated mood w/ three mania symptoms
define mixed episodes
criteria for a major depressive and manic episode (except for duration)occur nearly every day for at least a 1 week period
define rapid cycling
> 4 major depressive, manic, hypomanic or mixed episodes in 12 months
what are the goals of treatment for bipolar disorder?
resolution of sx
prevention of future episodes
minimization of ADRs
compliance
pt education
avoidance of stressors that may precipitate episodes
What is the FDA indication for Lithium?
mania associated w/ bipolar disorder
which agent is most effective in pts having pure mania, fewer prior episodes,h/o euthymia and fam/pers h/o + response?
Lithium
how does lithium fit into tx for bipolar disorder?
mood stabilizer
onset of action for Lithium?
7-10 days
mechanism of action of lithium?
alters cation transport across cell membranes in nerve and muscle cells and influences the reuptake of NE and 5HT (has some antidepressant properties)
describe the PK of lithium
wide tissure distribution:
kidneys: decreased GFR, bad for people with kidney probs
thyroid: causes hypothyroid
bone
not metab by liver: good for hepatic disease
what are the ADRs of lithium?
GI upset, fatigue, fine hand tremor, wt gain, polyuria, polydipsia, memory impairment, concentration difficulties, diabetes insipidus, decrease in GFR, hypothyroid, cardiac dysrhyth, acne, alopecia, psoriasis, benign reversible leukocytosis
Li competes w/ ?
Na. pts should keep salt intake consistent
which drugs/factors cause an increase in Li levels
ACE-I, ARBs, diuretics, NSAIDs (not ASA)
also sodium depletion
dehydration
wt loss
what may cause a decrease in Li levels?
NaCl, caffeine, theophylline (consistent intake of Na and caff)
wt gain
counseling tips for Li
drink plenty of water, keep salt and caffeine intake consistent
titration/no titration for lithium?
slow titration
describe therapeutic drug monitoring for Li
levels checked q 12 h after last dose every 4-5 days upon initiation
levels checked 5-10 days after dose change, +/- drugs affecting clearance,changes in renal fx
desired Li conc. = 0.6-1.2mEq/L (may be higher for mania)
what factors may increase OR decrease Li levels
incorrect blood sample timing
poor pt compliance
lab error
describe lab monitoring parameters for lithium
baseline: TFTs, RFTs, CBC, electrolytes, wt, EKG, preg test
f/u: drug levels,electrolytes, R/T FTs, wt, CBC monthly for 1st three months, q 6-12 months thereafter
which drug is preferred in pts having mixed episodes, rapid cycling, or mania due to medical condition?
valproic acid
what are the FDA indications for valproic acid?
epilepsy, mania assoc w/ bipolar, migraine prophylaxis
where does vpa fit into pharm therapy for bipolar
mood stabalizer
what other properties does VPA have besides mood stabilization?
antianxiety, antipanic, antimigraine, antiaggressive, some antidepressant properties
what is the MOA of VPA?
believed to be involved in the inhibition of GABA metabolism, stimulation of GABA synth/release, or augmentation of the post synaptic inhib effect of GABA
what are the ADRs associated w/ VPA
GI upset, mild tremor, dizziness, alopecia, rash, hepatotox, pancreatitis, PCOS
sedation*
wt gain*
thrombocytopenia*
VPA has black box warnings associated with:
hepatotox and pancreatitis
what are the major drug inx associated w/ VPA?
lamotrigine - levels increase, may cause rash or SJS
warfarin - increase INR
which mood stabilizer is indicated for acute mania?
VPA - loading dose can be given
describe the lab monitoring parameters for VPA
baseline: chem profile, LFTs, CBC, wt, preg
f/u: serum levels, LFTs, wt, CBC monthly for 1st three months then q 6-12 months thereafter
amylase and lipase periodically
what are the FDA indications for carbemazepine?
epilepsy, trigem neuralg, bipolar disorder (Equetro only)
when is carbemazepine used?
pts who dont respond to LI or VPA, or cant tolerate
what is the onset of action of carbemazepine?
7-10 days
what are the ADRs associated w/ CBZ
nystagmus, ataxia, blurred vision, drowsiness, dizziness, GI upset, leukopenia, anemia, thrombocytopenia, rash, hepatotox, hyponatremia
what other properties besides mood stabilization does CBZ have?
antimanic, antidepressant, prophylactic effets comp to lithium
what types of episodes is CBZ most effective for?
mixed or rapid cycling,
also in pts w/ neuro dx, and negative fam h/o mood disorders
describe CBZs effect on hepatic enzymes
inducer: 1A2, 3A4, 2C9/10, 2D6, also has autoinduction
what are the two black box warnings associated w/ CBZ?
agranulocytosis and aplastic anemia
name one significant drug inx w/ CBZ
decrease levels of OCPs
when should CBZ be d/c'd
platelets <100,000 or WBC <3,000
lab monitoring for CBZ?
baseline:CBC, electrolytes, LFTs, preg test
f/u?
which drug(s) are tough on the kidney?
Li
which drugs are hard on the liver?
VPA (black box)
CBZ
which drugs cause sedation?
Li, VPA, CBZ
which drugs cause wt gain?
Li, VPA
not as much w/ CBZ
which drugs cause sex dysfx?
Li
not as much w/ VPA and CBZ
which APs are indicated for acute mania?
risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole (atyps)
how is acute mania most commonly treated?
requires hospitalization
mood stab + BZD +/- AP
if hallucinations: haldol
BZDs are adjunctive for short term use unless pt also has panic disorder
APs used as short term adjunct or as a mood stabilizer
which BZDs are commonly used for acute mania?
lorazepam and clonazepam
(alprazolam may worsen mania)
should be tapered and d/c once pt is stable
when should ADs be added to bipolar tx?
after mood stabilizer tx is optimized
evaluate TFTs
what are 1st line ADs for bipolar? second line?
1st: bupropion, SSRIs (not fluoxetine)
2nd: MAO-Is, venlafaxine
olanzapine/fluoxetine combo may be option for some pts
which ADs have greatest potential to precipitate mania?
TCAs
how long is course of treatment w/ AD following acute depressive episode
6-12 weeks, then taper and d/c
how are ADs used in treating bipolar disorder?
used in pts w/ bipolar depression (use w/ caution in pts w/ h/o mania following depressive episode or those w/ frequent cycling)
what are the indications of lamotrigine?
adjunctive tx for partial szr in adults w/ epilepsy, lennox gast syndrome,
*long term maintenance tx of Bipolar I disorder
lamotrigine may be most effective in pts having
depressive episodes? drug has good antidepressant properties
according to DiPiro, lamotrigine can be used to treat resistan bipolar I and II, rapid cyclers, pts w/ dysphoric bipolar or mixed episodes?
ADRs associated w/ Lamotrigine?
dizziness, HA, sedation, tremor, rash
drug inx w/ Lamotrigine?
VPA - increase Lamotrigine conc. must decrease lam. dose by 1/2 and titrate slowly
what other anticonvulsants are used for bipolar disorder?
oxcarbazepine
topiramate
gabapentin
what do you do for pts being treated for bipolar depression who switch to mania?
d/c antidepressant tx, do not taper down!