Bipolar Psychopharm

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Bipolar disorder, patients who at different
times experience:

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either the up (manic) pole or the down (depressed) pole

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Mixed mood:

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depression and mania may occur simultaneously (example: talking about sad things but smiling)

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Rapid cycling:

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rapid switching of mood between mania and depression

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Hypomania:

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mania occurring in lesser degrees

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Manic Episode required (6)

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1 Period of expansive, elevated or irritable mood
2 Lasts at least one week
3 Less if hospitalization is required
4. 4 day duration for hypomanic episode
5 Rare to have only manic episodes
6 Depressive episodes are often the first presentation (esp. women); this is usually when treatment is sought

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Presentations 4

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RAPID CYCLING

MIXED EPISODE

HYPOMANIA (BAD II)

CYCLOTHYMIA

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RAPID CYCLING

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More than 4 episodes in a 12 month period

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MIXED EPISODE

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Both depressive and manic symptoms coexist

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HYPOMANIA (BAD II)

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Can be difficult to differentiate from euthymia in a chronically depressed person

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CYCLOTHYMIA

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Recurrent hypomania with sub-threshhold depressive symptoms over 2 years

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Treatment of acute manic episode 3

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lithium;
divalproex ER,
carbamezapine ER

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FDA approved for the treatment of mania (5):

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Aripiprazole (Abilify)
Olanzapine (Zyprexa),
Quetiapine (Seroquel),
risperidone, (Risperdal)
Ziprasidone (Geodon)

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FDA approved for the treatment of depression (monotherapy) 2:

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Quetiapine (Seroquel)
and Symbyax (fluoxetine and olanzapine)

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Long-term treatment of bipolar Antidepressants

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NOT a first line choice even in a depressive episode

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FDA approved for maintenance of bipolar(5)

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Aripiprazole (abilify),
lithium,
Valproate (depakote),
Lamotrigine (Lamictal),
and olanzapine (Zyprexa)

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Pharmacological maintenance of bipolar treatment is recommended

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indefinitely

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In bipolar, men show with:

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mania

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Bipolar Women show with: 2

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Depression
And they have more cycling

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Poor Prognostic Indicators of bipolar (5)

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Male
Early Age of onset
Depressive or psychotic features
Poor occupational functioning
ETOH dependance

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Good Prognostic Indicators: 4 (of bipolar)

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Advanced age of onset
Few suicidal thoughts
Few co-morbidities
Short duration of manic episodes

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What are the 2 1st line tx for mania

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Lithium
Valproate/Depakote

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Lithium 1st line agent for treatment of?

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mania

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Lithium FDA approved for children

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12 to 18

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Lithium: Monitor levels at least every

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6 months

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Lithium Normal range for levels:

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0.6 to 1.2 mEq/L (maintenance)

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Lithium Eliminated by

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renal system: check

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Lithium before starting get these 2 labs

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creatinine or BUN level

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Lithium Monitoring parameters: 5

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renal function,
thyroid function,
cardiac,
Electrolytes
Check EKG if older than 50

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Lithium If you had a ? On levels and the level was 0.8, what would you think?

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Normal continue dose

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Lithium bypasses what system?

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CYP450 so nothing to do with liver bypasses bc it’s a salt, so if you have question that says what enzyme system does it affect…it doesn’t!

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When would you draw blood levels for lithium?

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12 hrs after last dose, would not be valid before

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Lithium Takes how long to work?

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1 to 3 weeks to work

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Lithium Continue treatment for how long?

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indefinitely

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augment lithium with (4)

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Valproate,
atypicals,
lamotrigine,
ATD

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Lithium Side effects: 9

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GI symptoms,
weight gain,
acne,
tremors,
sedation,
polyuria,
polydipsia,
ataxia,
alopecia

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Lithium Long-term adverse effects: 2

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thyroid (goiter) and
kidneys

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Lithium If it’s excreted renally, what would be contraindicated?

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Diuretics
Kidney disease
Won’t get a stable blood level

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Lithium It’s considered an?

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Ion- vies for space for sodium

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Lithium Pt sweating, working in sun and losing sodium, what happens to lithium?

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It goes up

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Lithium What if he has flu, N/V, diarrhea what happens without changing dose?

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It goes up

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Lithium Why does it go up in these instances?

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It’s a very narrow therapeutic window

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MODERATE Levels Lithium Toxicity:

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(1.5 to 2.0 mEq/L)

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MODERATE Levels Lithium Toxicity:
Signs/Symptoms:

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Sluggishness
Lethargy
Tremor/muscle twitching,
nausea,
vomiting,
Diarrhea
Slurred speech,
ataxia

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SEVERE Levels Lithium Toxicity: Can cause death

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(2.0 to 3.0 mEq/L)

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SEVERE Levels Lithium Toxicity Signs & Symptoms:

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Ataxia;
coma;
seizures;
death

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Treatment of lithium toxicity:

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gastric lavage;
normal saline;
Or dialysis, in severe cases

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Pt on lithium comes in exhibiting s/s of n/v, diarrhea, tremors in hands, what do you suspect?

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Lithium toxicity

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What would you do if you suspect lithium toxicity?

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Draw blood levels to see where it is
Lower dose (Don’t stop it altogether)
It comes in 300 mg tabs so drop it one tab

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What is important to educate the pt to monitor for when taking lithium?

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Dehydration &
s/s of toxicity

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Valproate other name for? If pt cannot pay for these, do not GIVE it!

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Depakote; blood levels

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Valproate/Depakote first line for 2

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acute mania and mixed episodes;
maintenance treatment of bipolar

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Valproate/Depakote For acute mania, effects are

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within days

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Valproate/Depakote optimize effects on mood stabilization takes how long?

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May take several weeks to months

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Valproate/Depakote Side effects: 5

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nausea,
vomiting,
diarrhea,
sedation,
weight gain

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Valproate/Depakote Severe side effects: 2

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blood dyscrasias,
hepatic toxicity

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What Is Blood Dyscrasia?

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typically refers to a blood disorder where one part of the blood is not present in normal supply. The different constituents of blood like platelets, or white or red blood cells could be too high or too low in counts

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Ataxia

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is a neurological sign and symptom that consists of gross lack of coordination of muscle movements

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Pt comes in in an acute manic phase, he’s been agitated and blacking out with manic behavior, what would you put him on?

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Depakote (others avail too)

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What’s good about Depakote?

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Can increase dose quickly (1000mg start can go up to 1500 in a wk)
Can come off fast too

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What is the prob when prescribing Depakote, what do you have to monitor for?

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VPA

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What is the therapeutic range for Depakote?

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50-100

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Valproate/Depakote Mania dose:

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1200-1500mg/day. Start 1000mg

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Valproate/Depakote When do you give it?

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QHS to avoid daytime sedation

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Valproate/Depakote Monitor levels when:

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monthly for 6 months then every 6 to 12 months

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Valproate/Depakote Therapeutic blood levels

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(50-100 mg/L)

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Valproate/Depakote Monitor 3 labs

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CBC w/diff;
platelets;
liver function

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Valproate/Depakote Warning for fetal toxicities such as 2

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Neural tube defects if used during pregnancy
Cleft lip or palate

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Valproate/Depakote Make sure females are taking?

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Birth control bc of birth defects

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Valproate/Depakote Women have a risk of developing what when taking this med?

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Polycystic ovarian syndrome

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Carbamazepine (Tegretol) is an?

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Anticonvulsant

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Carbamazepine (Tegretol) is considered?

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2nd line tx for bipolar)

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Carbamazepine (Tegretol) FDA approved for

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Acute mania/mixed mania (Equetro)

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Carbamazepine (Tegretol) For acute mania, effects take

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a few weeks

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Carbamazepine (Tegretol) May take this long to stabilize mood?

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several weeks to months

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Carbamazepine (Tegretol) Side effects: 8

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nausea,
vomiting,
diarrhea,
sedation,
dizziness,
confusion,
Headache
Suppressant effect on bone marrow

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Carbamazepine (Tegretol) Monitor what lab most frequently:

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Baseline CBC and every 2 to 4 weeks for 2 months, then every 3 to 6 months during treatment!

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Carbamazepine (Tegretol) Why do we need to monitor CBC so often?

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Agranulocytosis can develop (decrease in WBC)

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Carbamazepine (Tegretol) What are s/s of agranulocytosis to teach 2?

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Signs of high fever or a cold

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Carbamazepine (Tegretol) Monitor 3 other labs

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LFT,
kidney
and thyroid function tests baseline and every 6 to 12 months

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Carbamazepine (Tegretol) Can cause 2

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fetal toxicity such as neural tube defects in pregnancy-Contraception
Steven-Johson Syndrome

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Carbamazepine (Tegretol) Can have drug-drug interaction w/?

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Birth control

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Carbamazepine (Tegretol) Can have drug-drug interaction w/ birth control so teach?

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Use backup such as depo or IUD

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Carbamazepine (Tegretol) Can you use with kids?

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yes

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Carbamazepine (Tegretol) what dose with kids?

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400-1200 mg per day

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Carbamazepine (Tegretol) blood levels

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4-12 mcg/ml

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Carbamazepine (Tegretol) what dose with adults?

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250 mg up to TID, just go slowly until you can get it in therapeutic range.

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Lamotrigine (Lamictal) indication?

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Maintenance treatment for bipolar disorder

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Lamotrigine (Lamictal) start as 1st line for bipolar

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probably not, but you may

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Lamotrigine (Lamictal) bad thing about this drug?

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Effects take a few weeks; slow titration

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Lamotrigine (Lamictal) Slow titration

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– 1st 2 weeks 25 mg/day
– 3rd week increase to 50mg/day
– 5th week increase to 100mg/day
– 6th week increase to 200mg/day (maximum)

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Lamotrigine (Lamictal) Common side effects 7

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headache, nausea,
vomiting, dizziness, benign rash, diplopia (double vision)

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Lamotrigine (Lamictal) used to?

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good for depression aspect of bipolar not 1st line use

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Lamotrigine (Lamictal) Use with caution with valproate because

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it can double lamotrigine blood levels

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Lamotrigine (Lamictal) Can also cause a benign

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rash (~10%)

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Lamotrigine (Lamictal) can cause this with a greater risk in peds

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Stevens-Johnson Syndrome: a potentially
fatal rash that destroys tissue

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Stevens-Johnson Syndrome: a potentially
fatal rash preceded by

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URI (rare serious
rash-greater risk in pediatrics) or cold so they will have sniffles

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Lamotrigine (Lamictal) if SJS occurs what do you do?

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Stop medication immediately

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Lamotrigine (Lamictal) monitor blood levels?

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No

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Topiramate (Topamax) titration?

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Is slow as well

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Topiramate (Topamax) May be more effective for

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rapid cycling &
mixed episodes as adjunctive treatment

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Topiramate (Topamax) Used for

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psychotropic induce weight loss; Binge-eating disorders; HA; seizures

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Topiramate (Topamax) has no clear

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mood stabilizing properties alone

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Topiramate (Topamax) Side effects:

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sedation, dizziness, ataxia,
nausea, weight loss, appetite loss

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Topiramate (Topamax) Side effects many of these

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cannot be improved

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If you have a pt that has gained a lot of wt on psychotropic meds, which med can you put them on to help with the wt loss?

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Topiramate (Topamax)

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What 3 drugs do you monitor blood levels?

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Lithium, Depakote, and Tegretol

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Nonadherence of medications is common during?

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Mania

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Topiramate (Topamax) Range:

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50-300 mg (start low at 25 and go up from there- slow titration)

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Managing side effects with bipolar meds monitor 6

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monitor liver, blood, kidneys, drug-drug interactions, BC, baseline weight

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Medication Adherence Strategies

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• Teaching, teaching, teaching (not healthy for their brain or personal lives to suffer so severely!)
• Monitor for depressive symptoms and treat
• Simplify complex medication regimens
• Family involvement in treatment, planning, and monitoring S/S of relapse
• Psychosocial interventions
• Non-adherence is common during mania

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BPD-
1st line according to Stahl-

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Lithium, Depakote, Tegretol, Trileptal, Lamictal

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2nd line-

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Topomax, Benzo, Neurontin

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for huge weight gain

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Can add Topamax to Zyprexia

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Once you have handled the mania (impulsivity, aggression, hyperverbal, grandiosity)  apathetic "blah" 

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ATD (low dose Zoloft

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can be used together

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Lithium & depakote

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BPD- usually results in

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polypharmacy