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49 Cards in this Set

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What are some of the key findings in manic episodes?
- grandiosity, decreased need for sleep, racing thoughts, speech, distractable, risky behavior
- manic episodes=marked disturbance in social/occupational situations
- DIGFAST
- distractability
- increased psychomotor agitation
- grandiosity
- flight of ideas
- activities that are dangerous
- decreased need for sleep
- talkative
- need 3/7
What is bipolar 1?
What is bipolar 2
1. presence of manic episodes w/ major depressive episodes
2. presence of hypomanic episodes w/ major depression- hypomania means pt will not have severe social and occupational impairment
What is a mixed episode?
What is rapid cycling?
1. mania and depression episodes occurring withing 24 hrs- have poorer prognosis
2. when 4 major depressive or manic episodes occur in 12 mos
BP disorder has both genetic and environmental component. Name an environmental trigger.
- is the 6th leading cause of disability in developed nations, have structural and functional brain abnormalities.
- lots of drug incompliance b/c
1. desynch of circadian or seasonal rhythm
2. hypomania/mania can be enjoyable. clouding, sedation, and wt gain with meds
Prescribing antidepressants to bipolar pts can ppt what?
In pts w/ bipolar disorder, do they mainly have depressive episodes or manic episodes?
- manic episode- in a few days pt will come back feeling really good, in unipolar depression takes longer than that
- usually will have more depressive episodes
Pts w/ bipolar disorder often have comorbid ___ problems and ____ disorders which contributes to misdx. Up to 69% of bipolar disorder is misdiagnosed. What are some methods to correctly dx bp?
1. substance abuse problems
2. personality disorders
3. careful hx, get hx from FAM, use mood disorder questionnaire
What are the nondrug tx for BPD?
1. avoidance of triggers--sleep deprivation, DA augmenting agents, alcohol intox, corticosteroids, and antidepressants (w/o mood stabilizer)
2. bilateral ECT- good for acute mania and acute depression- good for pregnant pts
3. psychoeducation- dec stress and early signs of episodes
Li- Use
1. acute manic episode - in which full therapeutic benefit seen in greater than 3 wks
2. prophylaxis-- helps reduce high relapse rate for bipolar mania and depression, prevents suicide and self injury
- gold std for bipolar disorder
- pts w/ rapid cycling or mixed states may NOT respond as well to Li monotherapy
- avoid in pts w/ unstable renal disease
Li- MOA
- lots of diff theories-- may modulate gene expression and will have neuroprotective effects
Li- PK
- renal excretion, excreted unchanged, and first order linear kinetics
- has very narrow theraputic index- reaches steady state after 5 days
- takes 3 wks to see full effects
Li- AE
- GI, intentional tremor
- increased urination, and thirst
- long term-- may have mild wt gain and acne
- can divide doses to improve GI sx
- can lead to hypothyroidism
- rare renal damage
What factors contribute to tremors of Li?
- dose-high dose coarse tremor and low dose fine tremors
- risk factors include advanced age, stress, fam hx, hihg Li concentration, and caffiene
Be careful b/c HYPERthyroidism can look like mania.
Lithium can cause _____ by concentrating in the thyroid gland and interfering w/ thyroid synthesis (higher levels of TSH and lower levels of T4)
Is this effect dose dependant?
1. hypothyroidism, can tx w/ levothyroxine
2. No not dose dependant
If pt has polyuria and polydipsia due to __, what is one way to help w/ these SE?
1. LIthium via inhibition of ADH sensitive adenylate cyclase
2. reduce dosing
Lithium toxicity occurs at levels greater than __ mEq/L. Will lead to __ sx, coordination sx, and ___ sx.
- several reports of sz, cardiac dysrhythmias, neuro impairments.
There are diff levels of toxicity-- mild, moderate, and severe.
1. 1.5
2. GI
3. cognitive
What are the risk factors for Li toxicity?
- renal impairment--decreased Li clearance
- fluid restriction can increase Li
- Drug interactions w/ meds which alter Li excretion
Li- DI
- dont used NSAIDs, ACE Inh/ ARBs
- NSAIDs-- b/c reduce RBF
- ACE inh or ARBs- dec resistance at efferent arteriole-- reduces GFR
- thiazide diuretics b/c causes no reabsorption in distal tubules-- decreases excretion of Li and increases serum levels
Li- CI
- pregnancy is relative CI esp in front trimester-- may lead to some card malformations, floppy baby synd, and neonatal hypothyroidism
Li requires monitoring of what parameters?
- Li serum concentrations
- baseline CBC
- SCr/NUM
- TSH levels
What is the kindling theory of bipolar disorder? What other disease is this seen with?
- neurons become super sensitive to firing and NEIGHBORING neurons are also recruited
- epilepsy
Valproic Acid- Class, MOA
Class: Anticonvulsant agent
MOA: enhances inhibitory effect of GABA -- which will calm areas that are over excited in the brain
Valproic Acid- Use
- good for rapid cyclers, mixed mania, and acute mania
- better for mania than depression
Valproic acid-SE
- long term-- wt gain, polycystic ovard syndrome
- hepatotoxicity, neutropenia, thrmobocytopenia
Valproic acid- CI
- pregnancy
Carbamazepine/Oxcarbazepine- Class, MOA
Class: Anticonvulsant agents
MOA: Enhances inhib action of GABA and prevents the high frequency repetitive neuronal firing
Carbamazepine/Oxcarbazepine- Use
- to tx acute mania, is a second or third line agent
- is not good for txing bipolar depression
Carbamazepine/Oxcarbazepine- SE
- aplastic anemia and agranulocytosis- black box warning
- hyponatremia
Lamotrigine- MOA, Use
- MOA: inactivates voltage sensitive Na channels and modulates or reduces release of glutamate
- Use: minimal benefit in stablizing mania but more effective than Li for preventing depression
- used as add on for tx-refractory bipolar depression
- no wt gain. sedation, blood level monitoring nor cognitive dulling
- but VERY slow initiation to minimize risk of rash
Lamotrigine- AE, DI
AE- black box rash warning--such as stevens johnson syndrome
DI: valproate decreases clearance which increases risk of rash-- moniter before and after for rash assessment
SGA-- SE
- sig wt gain w/ risk of new onset diabetes and increased TGs
Which drug is most associated w/ sig wt gain? What class does this drug belong to?
- olanzapine
- benzodiazepines- SGA
SGA- Use
- fast acting drugs-2-4 days
- adjunctive therapy
Clonazepam and lorazepam- Use, MOA
MOA: enhance GABA activity and calms the overexcited brain
Use: alleviate agitation and insomnia w/ mania and hypomania. Also improve sleep so facilitate recovery. NOT for core sx and do NOT prevent relapses
- Should NOT be used for greater than 1 mo
Clonazepam and lorazepam- Class
Benzodiazepines
Are antidepressants or mood stabilizers like Valproic Acid, Carbamezepine, SGA, and LTA more effective in tx-ing bipolar depression?
- the mood stabilizers
- also rem anti depressants are linked w/ episodes of hypomania/mania-- esp in young pts, pts w/ hx of switching antidepressants, and rapid cycling
Which antidepressants have lower risk of precipitating a hypomanic/manic episode?
When switching antidepressants what steps should you take to reduce mania?
- SSRIs and buppropion(NDRI) are better than TCAs
- TCAs are well documented to be really bad for bipolar pts

- should make sure pt is on mood stabilizing drug
What meds are used for rapid control of acute mania?
What happens if pt is psychotic and is aggressive?
- benzodiazepines and antipsychotics
- use SGAs over benzos
What agents are first line in depressive phase of bipolar disorder?
- lithium and lamotrigine, antidepressants are not used becasue can ppt attack
What is the safest class of drugs for pregnant women?
- SGAs and electroconvulsant therapy
What is one very unique mechanism of resistance for aminoglycosides?
Which aminoglycoside is resistnat to many inactivating enzymes?
- plasmid mediated production of group transferases which inactivate the drug
- Amikacin
Aminoglycosides- PK, AE
PK: not absorbed by GI tract, usually require IV or IM
AE: ototoxiicty, nephrotoxicity, NM blockade, and skin rxns
Aminoglycoside- Use, what drugs are often used synergistically?
Use- aerobic gram (-) organisms, strict anaerobes are resistant
- often used w/ beta lactam drugs synergistically
Tetracyclines- MOA
- inhibit binding of aminoacyl t RNA to the mRNA ribosomal complex
- bind to 30S subunit, are bacterioSTATIC
Tetracyclines- MOR
- efflux of drugs by plasmid coded efflux protein pump= TEST Q
- altered drug permeability/enzymatic inactivation of the drug
Tetracyclines- PK, AE, Use
PK: oral, does not absorb well into the CNS
AE: hepatotoxicitiy, teeth discoloration
Use: BROAD spectrum- both gram - and gram +
- also works of rricketsiae, chlamydiae, and mycoplasma infections
Chloramphenicol- MOA
- bind ot 50 S subunit and inhibit the peptidyl transferase- in transpeptidation
- bacterioSTATIC
Chloramphenicol- MOR
- production of plasmid coded drug inactivating enzyme-- chloramphenicol acetyltransferase
Chloramphenicol- PK(absorption)
- GI tract absorption, well distributed in body including the CSF
- hepatic inactivation
Chloramphenicol- AE
- Grey baby syndrome
- bone marrow suppression- inhibition of mitochondrail ribosomes
- aplastic anemia