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48 Cards in this Set
- Front
- Back
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Types of Bipolar Disorders outlined in DSM-IV?
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Bipolar I
Bipolar II cyclothymia (milder form of bipolar) Bipolar disorder not otherwise specified |
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Bipolar I
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Bipolar I
Similar to the classic concept of manic-depressive disorder: - manic or mixed episodes, alternating with major depression - mania is severe, and is the hallmark of Bipolar I - During mania, person will act amazingly happy or high, irritable, restless, have grandiose behavior, and likely will have psychotic features such as hallucinations, delusions or paranoia. There is a decreased need for sleep, and racing thoughts. - depressive episodes can last for several weeks |
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Bipolar II
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Bipolar II
- "hypomania" and depression - hypomania (or "euphoric mania") does not have psychotic symptoms and does not require hospitalization - other sx such as talking fast, needing less sleep and engaging in risky behavior - Bipolar II usually has less severe features than Bipolar I - Although sx are milder, they are difficult to treat - Bipolar II has about twice the incidence of Bipolar I, and is more common in women - Difficult to diagnose, since the high and low durations vary from weeks to months, and pt's usually only seek trtmt during depressive stage |
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T or F:
Bipolar is often comorbid with many other mental disorders. |
True.
Bipolar is often comorbid with many other mental disorders, such as ADHD, substance abuse and anxiety disorders. Bipolar also has a high rate of suicide. |
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diagnostic criteria for a manic episode
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Criteria include a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or if any hospitalization is necessary), AND 3 or more of the following sx:
- inflated self-esteem or grandiosity - decreased need for sleep - more talkative than usual or pressure to keep talking - flight of ideas or subjective experience that thoughts are racing - distractability - increase in goal-directed activity (either social, at work, at school, or sexually) or psychomotor agitation - excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. buying sprees, sexual indiscretions, gambling) |
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True or False:
It is more difficult to use first-generation antipsychotics in schizophrenia than in bipolar. |
False.
It is more difficult to use first-generation antipsychotics in Bipolar Disorder, because bipolar patients are more susceptible to extrapyramidal symptoms (EPS) than those with schizophrenia. |
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All the atypical antipsychotics now have approval for ______________.
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mania
Two of them have indications for mania AND depression: - Abilify (aripiprazole) - Seroquel (quetiapine) Lamotrigine can be useful in the treatment of the depressive stage, but is not very beneficial in mania. Lithium is beneficial for depression and mania. |
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True or False:
It is a good idea to treat bipolar patients with antidepressants. |
False (mostly).
Antidepressants carry a risk of causing cycling. However, they may be used as adjunctive treatment in patients with refractory depression, but the clinician will need to monitor for mania. |
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PREGNANCY:
valproate |
Category D - known fetal risk!
valproate exposure in pregnancy is associated with increased risk of fetal anomalies, including neural tube defects, fetal valproate syndrome, long term adverse cognitive effects. It should be avoided, especially during the first trimester. |
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PREGNANCY:
carbamazepine |
Category D!
associated with fetal carbamazepine syndrome should be avoided in pregnancy, if possible, especially during the 1st trimester CBZ has limited efficacy in treating bipolar, but is occasionally used |
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PREGNANCY:
lithium |
Category D!
associated with an increased in congenital cardiac malformations |
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PREGNANCY:
lamotrigine |
Category C
often considered a safer option for bipolar patients (compared to others) |
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PREGNANCY:
benzodiazepines |
benzo use shortly before delivery is associated with floppy infant syndrome
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If an antidepressant is used during pregancy, ______________ should avoided.
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paroxetine
Category D should be avoided during pregnancy due to the risk of cardiac defects, particularly in the 1st trimester other SSRI's and SNRI's should be considered to have some degree of risk as well |
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valproate / valproic acid / divalproex
- Dosing - Serum Levels - Warnings/Contraindications/Adverse Effects - Monitoring |
Initial Dosing:
125 - 250 mg BID Maintenance: 15 - 45 mg/kg/day Serum Levels: keep between 50 - 125 mcg/mL BBW: - Hepatic Failure; LFT's must be checked prior to start, frequently during the first 6 months, and periodically thereafter - teratogenicity, including neural tube defects (such as spina bifida) - pancreatitis, potentially fatal Adverse Effects: GI upset, alopecia (treat with selenium and zinc), sedation, tremor, weight gain, thrombocytopenia Monitoring: LFT's, CBC, platelets |
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What are the primary bipolar mania agents?
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valproate / valproic acid / divalproex
lamotrigine lithium |
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Depakene
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valproic acid
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Stavzor
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valproic acid
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Depakote
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divalproex
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lamotrigine
- dosing - warnings/contraindications/adverse effects |
Wk 1-2: 50 mg/day
Wk 3-4: 100 mg/day Wk 5: 200 mg/day Wk 6: can increase by 100 mg every 1-2 weeks, max 400 mg/day Divide BID, unless XR BBW: - serious skin reactions, including SJS and TEN; increased risk with high starting doses, rapid increases, or co-administration of valproic acid, which increases lamotrigine levels > 2-fold - to decrease risk of rash follow titration schedule - Lamictal Starter Kit and and Lamictal ODT Patient Titration Kits provide the recommended titration schedule for the 1st 5 weeks Side Effects: diplopia, sedation, ataxia, headache |
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lithium
- dosing - serum levels - warnings/contraindications/adverse effects - monitoring |
cannot use with renal impairment: lithium is 100% renally cleared - and if not eliminated, toxicity will result
start at 900 mg/day, divided then 900 - 1200 mg/day, divided titrate slowly to avoid AE's take with food (post-meal) to decrease nausea, or split dosing if tremor/thirst/confusion, try QHS dosing SERUM LEVELS: 0.58 - 1.2 mEq/L (trough) acute mania may need up to 1.5 mEq/L initially Adverse Effects: GI upset (take with food, can change to ER forms if GI upset is intolerable) cognitive effects, cogwheel rigidity, fine hand tremor, weight gain polyuria/polydipsia, hypothyroidism - must monitor, avoid co-admin with other serotonergic agents TOXICITY: > 1.5 mEq/L (coarse hand tremor, vomiting, persistent diarrhea, confusion, ataxia) > 3 mEq/L (CNS depression, arrhythmia, seizures, irreversible brain damage, coma) MONITORING: basic metabolic panel, renal function, thyroid function |
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valproic acid drug interactions
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valproic acid
can increase the levels of amitriptyline, carbamazepine, lamotrigine, lorazepam, nortriptyline, paroxetine, phenobarbital, warfarin, zidovudine use special caution with combination of valproate and lamotrigine, due to risk of serious rash (combo is used in children, requires lower doses with slow titration and parent counseling) salicylates may displace valproic acid from protein-binding site, leading to toxicity and valproate can displace phenytoin from albumin, resulting in phenytoin toxicity carbapenems can decrease valproate levels, leading to seizures |
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valproic acid counseling points
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do not use if you have liver disease, may cause liver failure in rare cases; tell doc if you have severe fatigue, vomiting or loss of appetite
rare cases of severe pancreatitis, tell doc if you have N/V, abdominal pain, or loss of appetite do not stop taking med even if you feel fine do not crush/chew/break capsules, because they may hurt the mouth and throat; Depakene caps contain liquid which will cause irritation Pregnancy Category D! Malformations to head, heart, nervous system; drug passes into breast milk take each dose with a full glass of water, take with food to avoid stomach upset doctor may require blood tests during treatment |
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lithium drug interactions
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these will increase lithium levels:
decreased salt intake, NSAIDs, ACEI's, ARB's, dehydration (and caution with diuretics), metronidazole these will decrease lithium levels: increased salt intake, caffeine, theophylline these will increase serotonin syndrome risk if given with lithium: SSRI's, SNRI's, triptans, linezolid, and other serotonergic drugs increased neurotoxicity risk (ataxia, tremors, nausea) with: verapamil, diltiazem, phenytoin, carbamazepine |
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lithium counseling points
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take with food
call your doc if you experience N/V/D, slurred speech, extreme drowsiness, or weakness may cause dizziness/drowsiness, use caution when driving until you know how this affects you; if you experience dizziness or drowsiness, avoid these activities lithium is FDA pregnancy category D drink 8 - 12 glasses of water every day! Avoid dehydration. Call doc if you lose a significant amount of water from sweating, diarrhea, vomiting, etc. do not change the amount of salt you consume your doctor may require blood tests during therapy do not stop taking this med, even if you feel better |
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lamotrigine drug interactions
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valproate, divalproex and strong inducers (including carbamazepine and others) increase lamotrigine levels significantly and increase rash risk
there are different (lower) titration schedules when using these drugs concurrently |
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lamotrigine counseling
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may cause mild or severe rash; there is no way to tell if a mild rash will develop into a more severe reaction; a serious rash is more likely to happen w/in the first 2 - 8 weeks, but it can happen at any time; children 2 - 16 have higher risk; risk is higher if you also take valproate or divalproex, start with a higher dose, or increase dose faster than prescribed
dose must be increased slowly; may take weeks or months to reach the best dose very rare cases of worsening mental thoughts (depression, anxiety, suicidal ideation) do not stop this med suddenly! can very rarely cause aseptic meningitis; get medical treatment immediately if you develop a severe headache, fever, stiff neck, nausea less serious side effects: dizziness, sleepiness, blurred vision, nausea, upset stomach or diarrhea, headache, feeling uncoordinated, weight loss tell doc if you have difficulty sleeping or get unusual dreams |
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Abilify
- class/generic - dosing - contraindications/warnings/adverse effects - monitoring |
aripiprazole (Abilify)
atypical antipsychotic approved for mania and depression and mixed symptoms, maintenance, +/- lamotrigine or valproate 15 - 30 mg QAM Adverse Effects: akathisia (esp. in younger patients), restlessness, insomnia, constipation, fatigue, blurred vision Atypical antipsychotics can cause metabolic issues, including dyslipidemia, weight gain, diabetes Risk of Neuroleptic Malignant Syndrome Risk of Tardive Dyskinesia Risk of leukopenia, neutropenia, agranulocytosis All can cause orthostasis/dizziness |
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Symbyax
- class/generic - dosing - contraindications/warnings/adverse effects - monitoring |
olanzapine/fluoxetine (Symbyax)
approved for bipolar depression, 2nd line option due to metabolic effects from olanzapine usually started at 6 mg / 25 mg capsule QHS (fluoxetine is activating, but olanzapine is more sedating), can increase cautiously CONTRAINDICATED with: pimozide, thioridazine (caution with other QT prolonging drugs/conditions) Adverse Effects (of olanzapine): cognitive dysfunction, dry mouth, fatigue, sedation, increased appetite/weight, peripheral edema, tremor, blurred vision, less CVD risk than many other antipsychotics Atypical antipsychotics can cause metabolic issues, including dyslipidemia, weight gain, diabetes Risk of Neuroleptic Malignant Syndrome Risk of Tardive Dyskinesia Risk of leukopenia, neutropenia, agranulocytosis All can cause orthostasis/dizziness |
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Seroquel XR
- class/generic - dosing - contraindications/warnings/adverse effects - monitoring |
quetiapine extended-release (Seroquel XR)
atypical antipsychotic approved for mania, maintenance with lithium or divalproex, and for bipolar depression Bipolar mania/maintenance: 400 - 800 mg QHS Bipolar depression: 300 mg QHS Adverse Effects: sedation, dry mouth, constipation, dizziness, increased appetite, weight gain, nausea Atypical antipsychotics can cause metabolic issues, including dyslipidemia, weight gain, diabetes Risk of Neuroleptic Malignant Syndrome Risk of Tardive Dyskinesia Risk of leukopenia, neutropenia, agranulocytosis All can cause orthostasis/dizziness |
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Risperdal
- class/generic - dosing - contraindications/warnings/adverse effects - monitoring |
risperidone (Risperdal)
atypical antipsychotic approved alone or with lithium or valproate for acute mania or mixed episodes start at 2 - 3 mg/day, can increase to 6 mg/day in children, start 0.5 mg/day tablets, oral solution, M-tabs (ODT) Adverse Effects: sedation, increased appetite, fatigue, insomnia, parkinsonism, akathisia, nausea, some QT risk Atypical antipsychotics can cause metabolic issues, including dyslipidemia, weight gain, diabetes Risk of Neuroleptic Malignant Syndrome Risk of Tardive Dyskinesia Risk of leukopenia, neutropenia, agranulocytosis All can cause orthostasis/dizziness |
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Geodon
- class/generic - dosing - contraindications/warnings/adverse effects - monitoring |
ziprasidone (Geodon)
atypical antipsychotic approved with lithium or valproate for maintenance, or alone for manic/mixed episodes start at 40 mg BID, can increase to 80 mg BID Adverse Effects: QT risk, sedation, EPS, dizziness, akathisia, abnormal vision, asthenia, nausea Atypical antipsychotics can cause metabolic issues, including dyslipidemia, weight gain, diabetes Risk of Neuroleptic Malignant Syndrome Risk of Tardive Dyskinesia Risk of leukopenia, neutropenia, agranulocytosis All can cause orthostasis/dizziness |
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Saphris
- class/generic - dosing - contraindications/warnings/adverse effects - monitoring |
asenapine (Saphris)
atypical antipsychotic approved for acute manic or mixed episodes 5 - 20 mg sublingual only: must dissolve under tongue, no food/drink for 10 minutes after taking Adverse Effects: QT risk, numbs mouth, sedation, dizziness, weight gain (less than risperidone & olanzapine) Atypical antipsychotics can cause metabolic issues, including dyslipidemia, weight gain, diabetes Risk of Neuroleptic Malignant Syndrome Risk of Tardive Dyskinesia Risk of leukopenia, neutropenia, agranulocytosis All can cause orthostasis/dizziness |
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Zyprexa
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olanzapine
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akathisia
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feeling of inner restlessness
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Neuroleptic Malignant Syndrome
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life-threatening neurological disorder associated with some antipsychotics
rigidity, muscle cramps, tremor, fever, delirium, elevated CPK, unstable blood pressure thought to be caused by dopaminergic blockade, similar to Parkinson's mechanism, but acute treatment may include bromocriptine (ergot alkaloid with potent dopaminergic activity), apomorphine (dopamine agonist, also used in Parkinson's), dantrolene (muscle relaxer) |
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Parlodel
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bromocriptine
ergot alkaloid with potent dopaminergic activity used to treat Neuroleptic Malignant Syndrome and Parkinson's, also used to treat hyperprolactinemia and infertility |
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Cycloset
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bromocriptine
ergot alkaloid with potent dopaminergic activity used to treat Neuroleptic Malignant Syndrome and Parkinson's, also used to treat hyperprolactinemia and infertility |
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Dantrium
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dantrolene
muscle relaxant used to treat Neuroleptic Malignant Syndrome |
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Apokyn
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apomorphine
dopamine agonist used to treat "off" episodes in Parkinson's, and to treat Neuroleptic Malignant Syndrome |
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Describe lithium clearance.
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100% renal clearance, no hepatic metabolism
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When a pt on lithium prepares meals, they should be careful to keep this component of their diet constant:
a. Calcium b. Potassium c. Sodium d. Magnesium e. None of the above |
c. Sodium
decreased sodium intake can increase lithium levels |
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Considering only cardiovascular risk, which of the following antipsychotics would be the safest option?
a. Saphris b. Risperdal c. Geodon d. Melloril e. Zyprexa |
e. Zyprexa (olanzapine)
considered to have less CVD risk than other antipsychotics Generics were: a. Saphris (asenapine, increased QT risk) b. Risperdal (risperidone, some QT risk) c. Geodon (ziprasidone, QT risk) d. Melloril (thioridazine, high risk, assoc w/ sudden death) e. olanzapine (Zyprexa) |
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A patient is using valproate. Black box warnings for this medication include:
a. hepatotoxicity b. teratogenicity c. pancreatitis d. A and B only e. all of the above |
E
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A patient has been diagnosed with Bipolar II. Which of the following statement/s concerning Bipolar II are correct?
a. the mania symptoms are generally worse than in Bipolar I b. the depressive symptoms are generally worse than in Bipolar I c. Bipolar II is much less common than Bipolar I d. Bipolar II is much more common in men e. none of the above |
E
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A patient received a prescription for asenapine (Saphris). Choose the correct statement concerning asenapine:
a. formulations of asenapine include an oral solution and tablets b. asenapine can make the mouth numb c. asenapine has little QT risk and can safely be used with cardiovascular conditions d. A and B e. All of the above |
B
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In the past few years, drugs typically used for schizophrenia have been approved for bipolar disorder. Which of the following antipsychotics have indications for bipolar disorder, according to the FDA?
a. aripiprazole and tiagabine b. thioridazine and topiramate c. risperidone and quetiapine extended-release d. lamotrigine and levetiracetam e. all of the above |
C
risperidone & quetiapine extended-release |
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A physician wants to use an atypical antipsychotic for a patient with early Parkinson's Disease. Her medications include ropinirole, metformin, glipizide, and a daily aspirin. He chooses quetiapine extended-release. Which of the following benefits would likely be experienced with the use of this agent?
a. little risk of movement disorders b. little risk of metabolic issues, such as elevated blood sugar and lipids c. little risk of sedation, orthostasis or dizziness d. no risk of stroke or worsened mental state e. no risk of increased appetite or weight gain |
A
little risk of movement disorders |
