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29 Cards in this Set
- Front
- Back
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oxcarb vs. cbz
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Chemical structure is similar to
carbamazepine, but has different active metabolite and no autoinduction |
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OXZ efficacy in bipolar
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Limited evidence of efficacy in bipolar disorder
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Efficacy of Lamotrigine in the
Treatment of Bipolar Disorder- acute mania mixed and depressive |
Limited evidence regarding efficacy in acute
manic or mixed episodes Effective for treatment and prevention of depressive episodes (more so for prevention than acute depressive tx) |
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lamotrigine onset of effect
titration |
6 week titration limits use in inpatient setting and
takes ~3 weeks for onset of effect |
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lamotrigine Maintenance Treatment efficacy (3)
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FDA approved for maintenance treatment of
bipolar disorder More effective in maintenance studies in preventing relapse into depressive episode vs. manic episode again NOT GREAT IN PREVENTING MANIC/MIXED- don't use asmonotherapy |
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lamotrigine metabolism
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hep glucuronidation (no CYP)
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lamotrigine ADE (4) (indicate the major one)
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CNS side effects (e.g. dizziness)
GI side effects (e.g. nausea) Diplopia RASH**** IMPORTANT! SJS! within 3-4 weeks of therapy |
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4 risk factors for lamotrigine rash
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concomitant valproate, rapid
dose titration/high initial dose, childhood, rash with other aromatic AEDs |
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Lamotrigine DIs- drugs that will change titration schedule (3)
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oral contraceptives decresae levels
inducers (phenytoin/cbz/phenobarb/primidone)- use larger starting dose (50 mg) and titrate at 2 times the usual dose VPA INCREASES levels and risk of rash- so use lower starting dose (25 mg qod and titrate using 1/2 usual dose) |
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lamotrigine monitoring (2)
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Baseline renal and hepatic function
Observe for rash no therapeutic levels est. |
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usual starting dose of lamotrigine
titration schedule |
25 mg qd
(double every 2 weeks) 25 mg/d wk1-2, 50 mg/d wk 3-4, 100 mg/d wk 5, 200 mg/d wk 6 |
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ADs in bipolar (2) when to d/c if pt is on them, when is it appropriate to use (controversial)
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Taper and discontinue any
antidepressants in hypomania, mania, mixed episodes or rapid cycling (can push towards mania) Antidepressants may be used for acute depressive episodes, only if the patient is on an adequate dose of a mood stabilizer |
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FGAs in bipolar- effective in what part
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FGAs have been shown to be effective for
the treatment of acute mania |
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major issues (2) with using FGAs to treat acute mania
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Recently updated Canadian guidelines
recommend haloperidol only as short-term treatment for acute mania due to risk of inducing depressive episode (dysphoria) also EPS |
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FGAs for maintenance?
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no
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SGAs in bipolar- onset
which ones (2) |
Rapid onset of effect in bipolar mania
Olanzapine (in combination with fluoxetine) and quetiapine have good data for efficacy in bipolar depression |
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Bipolar Disorders: General
Treatment Strategies (4) dosing, when to switch to alternative (2 cases), how long (in acute mania) before adding another agent |
When using mood stabilizers try to maximize the dose before moving to the second mood stabilizer
Switch to an alternative mood stabilizer in cases of intolerance In acute episodes, if the patient is still exhibiting symptoms after 4 weeks of treatment, addition of another mood stabilizing agent should be considered If no response in manic symptoms after 2-3 weeks of treatment, consider alternative treatment strategy |
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mood stabilizer switching (3) what should you do? hoW?
why should you not suddenly d/c |
When switching from one agent to another, a cross taper is generally ideal
No standard taper, but may consider decreasing the dose by 25% Q1-2 weeks Sudden discontinuation of mood stabilizing agents may increase the risk of relapse In cases of severe ADRs, mood stabilizers may need to be abruptly discontinued |
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bipolar continuation therapy
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After full response, mood stabilizers should
be continued for at least 3 months at the dose effective during the acute phase |
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patient pop that can consider tapering OFF of MS, and when
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First episode patients without severe symptoms or family history of bipolar disorder: may consider tapering off MS after remission has been sustained for at least 6 months
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Lifetime treatment with mood stabilizers is
generally indicated following... (2) |
2+ acute eps (mania or depressive or mixed) due to risk of recurrence
or if severe first ep, fam hx of bipolar or depressive disorder |
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generally- what is your choice for bipolar maintenance therapy
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In clinical practice, generally the mood
stabilizer that provides remission of symptoms in the acute treatment phase is continued as maintenance treatment (except FGA/ADs) |
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Choices for Maintenance Treatment After Acute Hypomanic, Manic, or Mixed Episode (4)
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Valproate
lithium SGAs (olanzapine, aripiprazole, quetiapine, ziprasidone, risperidone LAI) lamotrigine (wtf i thought she said no) |
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maintenance after depressive episode- best drugs (4)
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Lamotrigine, lithium, quetiapine, and
olanzapine |
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Is Combination Therapy Better for
Maintenance? |
i guess so
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lithium pregnancy category and why (2)
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D
Ebstein’s anomaly: displacement of tricuspid valve into rt. ventricle and rt. ventricle- but very very rare anyway. so...still kind of preferred in pregnancy hypoplasia pregnancy causes elevated levels of Li due to puking and rapid reduction of blood volume levels during delivery- so have to change dosing before/during delivery |
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VPA/CBZ pregnancy category and why
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D
-less safe than lithium neural tube defects- greatest risk in 1st trimester- folic acid might reduce risk |
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lamotrigine pregnancy category
good option for... |
C- only cuz not as much data
option in pregnant women who have depressive sx |
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Lamotrigine may not be as effective in patients
with... |
frequent, recent, or severe mania
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