Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
58 Cards in this Set
- Front
- Back
|
What is the difference between bipolar I, bipolar II, and a hypomanic episode?
|
hypomanic episode is the same thing, but at least 4 days & can't include psychosis
Bipolar I = at least 1 manic episode Bipolar II = at least 1 hypomanic episode & 1 depressive episode |
|
|
What is the treatment of mania?
|
Mood stabilizers: lithium, valproic acid, carbmazepine, atypical antipsychotics
|
|
|
What is the first line treatment for mania and what is is best for?
|
lithium
valproic acid (divalproex) olanzapine (antitypical antipsychotic) |
|
|
What is lithium best used for?
|
great for "pure" euphoric mania with no complicating factors
|
|
|
What are the concerns about using lithium?
|
due to 1) side effects
2) low therapeutic index 3) belief that need to keep serum levels below 1mEq/L (can be inadequate dosing for some patients), 4) need for other therapies to treat psychosis, agitation |
|
|
What is divalproex more useful than lithium in treating?
|
as effective as lithium, more effective for cases of dysphoria or mixed manic states
|
|
|
What atypical antipsychotics are approved for acute mania?
|
(ALL approved for acute mania)
Olanzapine, Risperidone, Quetiapine, Ziprasidone, Aripiprazole mood stabilizers and antipsychotics |
|
|
What are the advantages of using atypical antipsychotics as opposed to lithium?
|
do NOT require serum monitoring
can use in pregnancy, as have low risk teratogenesis |
|
|
What are the side effects of atypical antipsychotics?
|
can have serious metabolic side effects (weight gain, hyperlipidemia, ↑risk diabetes)
|
|
|
What are the uses of olanzapine?
|
has antidepressant activities, mania, psychosis
|
|
|
Besides lithium, valproic acid and divalproex, what other Rx can you use in mania?
|
Lamotrigine (anticonvulsant used for maintenance)
carbmazepine |
|
|
What can antidepressants undesirably do in bipolar treatment?
|
have the propensity to induce mania and/or accelerate cycling frequency (TCAs are the worst for this!)
|
|
|
When is it okay to prescribe an antidepressant to a bipolar patient?
|
if aggressive mood stabilizers does not relieve bipolar depression → short half-life antidepressants for brief periods is indicated
|
|
|
What adjunctive treatments are used in bipolar management? What symptoms are they used to manage?
|
recommend using atypical antipsychotics or benzodiazepines with a mood stabilizer such as Lithium or divalproex
Benzos help with sleep and agitation, antipsychotics do this and also address psychotic symptoms, choice depends on presentation use to manage psychosis, extreme agitation, sleep disturbance associated with acute mania |
|
|
What should you do with treatment-resistant mania?
|
use combination therapy
add a second mood stabilizer, add a benzo, add a typical/atypical antipsychotic ECT for treatment of acute mania or depression if treatment-refractory |
|
|
What reproductive issues should you consider in the treatment of bipolar disorder?
|
Lithium, divalproex, carbamzepine associated with increased risk of birth defects
atypical antipsychotics have not been associated with specific teratogenic effects (but are also not proven safe during therapy) however, NOT treating mania can have a bad effect on the pregnancy, delivery, and bonding |
|
|
What precautions do you need to use in the 1st trimester while treating bipolar disorder?
|
avoid divalproex and carbamazepine (↑ risk NTDs. if on med, take folate supplementation!)
weigh the continued use of lithium (↑ risk Ebstein's anomaly at a low rate) |
|
|
What is the efficacy of Lithium? What is it used to treat? How about in kids?
|
70-80% efficacy after 1-2wks for mania, prophylaxis of depression in bipolar, but better for mania prophylaxis. Also Rx bipolar and & disruptive behavior in kids.
Narrow therapeutic index |
|
|
What are the Side effects/Risks of using Lithium? What can be done about these?
|
SE – resting tremor, nausea, diarrhea, gait disturbance (ataxia), cognitive changes or loss of consciousness, polyuria, acne, psoriasis, weight gain, Ebstein’s anomaly (so maybe stop for just 1st trimester of pregnancy & use ECT or Olanzapine instead).
renal failure, hypothyroidism 10-20% (Li antagonism—assess TSH, especially in rapid cyclers & Rx resistance). Some people experience no SE. "LITHIUM: Leukocytes Increased (leukocytosis), Tremors (& ataxia), Hypothyroidism, Increased Urine (& renal failure), Moms beware (teratogenic)" Renal clearance impaired by diuretics, NSAID’s, ACE-Is, angiotensin II receptor blockers (Losartan, etc.) to ↓ polyuria: thiazides (also increase Li dose). to ↓ resting tremor: consolidate dose at bedtime, beta blockers order ECG in pts who >40 yo & have CV dz. |
|
|
What is Olanzapine (Zyprexa)? What is it used to treat? What is its mechanism of action?
|
Atypical antipsychotic. also used in peds where it causes lots of weight gain.
also approved for mania (effective w/ or w/o psychosis) Also shows antidepressant activity that is being explored Dirty Drug with affinity for D1,2,3,4. 5HT2,3,6. alpha1, musc1, and hist1. blocks 5HT2 (it's an atypical antipsycho) = 2xD2affinity Positive and negative antipsycho efficacy equal to risperidone at hi doses |
|
|
What receptor can olanzapine enhance cognition?
|
possibly thru 5HT6-cholinergic interaction
|
|
|
What are the side effects/benefits of olanzapine?
|
Well tolerated acutely with sedation, orthostasis
SE – wt gain (can be 0-70#), hyperlipidemia, glucose intolerance? not associated w/ teratogenisis & so perhaps good for bipolar in 1st trim. of pregnancy (when Li is contraindicated) No tardive dyskinesia, reduced EPS—causes parkinsonism in the elderly No blood monitoring needed |
|
|
What is ECT ElectroConvulsive Therapy effective for? When should you use it?
|
most effective treatment for major depression. may be especially indicated for severe mania. good alternative Rx for both mania & depression in pregnancy to avoid drug teratogenicity
|
|
|
What are BZDs useful for?
|
Useful for acute management of agitation and mania synergistic with neuroleptics—can lower doses of both. Difficult to know if effects are directly on mania or thru sedation, but who cares?
|
|
|
Which BZD should be avoided in bipolar disorder? What does it cause?
|
Alprazolam can induce mania so avoid this BZD in bipolar.
|
|
|
What are the side effects of BZD?
|
intoxication, delirium, disinhibition
|
|
|
What CYP enzymes is Valium metabolized by?
|
Valium – CYP3A4 and CYP2C19
|
|
|
What is the "LOT" (Lorazepam, Oxazepam, Temazepam) combination used for?
|
bipolar depression management
BZDs w/ glucuronide conjugation metabolism, & so levels increased with glucuronidation inhibition |
|
|
What is the "MAT" (Midazolam, Alprazolam, Triazolam) combination used for?
|
bipolar depression management
BZDs inhibited by CYP3A4, so levels increased by CYP3A4 inhibition & lowered by CYP3A4 induction |
|
|
How are BZDs used in the treatment of alcohol withdrawal?
|
can be used to treat acute alcohol withdrawal to limit seizure and anxiety.
|
|
|
How can we manage polyuria/polydispsia associated with lithium Rx?
|
HS dosing, lower dose, use a diuretic
|
|
|
How can we manage the hypothyroid associated with lithium Rx?
|
exogenous thyroid supplementation
|
|
|
How can we manage the GI distress associated with lithium Rx?
|
lower dose or change formulation
|
|
|
How can we manage the tremor associated with lithium Rx?
|
HS dosing, β-blocker
|
|
|
What are the uses of lithium?
|
acute mania
bipolar prophylaxis |
|
|
What are the benefits of using lithium?
|
may be especially good at reducing suicide
|
|
|
What are the signs of lithium toxicity? What can exasperate this?
|
nausea, diarrhea, tremor, unsteady gait, mental status changes
drugs that alter renal clearance of Li: thiazide diuretics, NSAIDS |
|
|
What are the side effects of lithium?
|
Hypothyroidism, GI distress, fine resting tremor, polyuria (rare LT effects - polyuria, nephrogenic diabetes insipidus, renal insufficiency, renal failure), Ebstein's anomaly, birth defects
|
|
|
What do you need to monitor when Rx with lithium?
|
electrolytes, CBS, thyroid, pregnancy, ECG (over 40 y/o or with heart disease), serum Cr
|
|
|
Tell me about the kidneys and lithium?
|
renal clearance of lithium is impaired by diuretics, NSAID's, ACE-Is, angiotensin II receptor blockers
|
|
|
What is the use of valproic acid?
|
acute mania
bipolar depression augments Li-prophalaxis mixed mania anti-seizure absence myclonic GTC |
|
|
What is the response rate to valproic acid? efficacy?
|
24-63%
similar efficacy to Li for acute mania |
|
|
What is valproic acid better for than lithium?
|
mixed states
dysphoric mania substance abuse rapid cycling secondary mania |
|
|
Contrast the half life of valproic acid and lithium?
|
faster onset than lithium because shorter half life
|
|
|
What medications does valproic acid interact with?
|
albumin-bound
ASA, dicumarol, CBZ, lamotrigine, EtOH |
|
|
What are the side effects of valproic acid?
|
Gi distress, sedation, tremor, weight gain, hair loss, polycystic ovaries, neural tube defects, hepatotoxicity
|
|
|
What should you monitor when Rx with valproic acid?
|
CBC, LFT (will tolerate 2-3x normal), electrolytes (can become hyponatremic)
|
|
|
What is carbamazepine used to treat?
|
mania
may be better than Li for mixed states, dysphoric mania, SA, rapid cycling, secondary mania |
|
|
What drug interactions occur with carbamazepine?
|
Metabolized by P450—toxicity with some drugs (erythro), reduces levels of other drugs including itself (autoinduction)
|
|
|
What side-effects/serious rxns occur with carbamazepine?
|
SE: nystagmus, dizziness, OH, sedation, GI distress
Serious rxns: rash, blood dyscrasias (leukopenia), hepatic toxicity (rare) |
|
|
What should you monitor when Rx with carbamazepine?
|
serum CBZ, CBC, electrolytes, renal and LFT
|
|
|
What is the use of olanzapine? What is it approved for?
|
acute mania, mixed mania, cognitive function, psychosis
approved for maintenance treatment also shows antidepressent activity |
|
|
What is olanzapine used in combo with? To treat what?
|
fluoxetine for bipolar depression
|
|
|
What do you need to monitor when Rx with olanzapine?
|
No blood levels to check, no teratogenicity
|
|
|
What are the side effects/benefits of using olanzapine?
|
SE: WEIGHT GAIN, sedation, dry mouth, orthostatic hypotension, increased risk for hi TG/chol/glucose
not associated w/ teratogenisis & so perhaps good for bipolar in 1st trim. of pregnancy (when Li is contraindicated) causes parkinsonism in the elderly |
|
|
What is Lamotrigine used to treat? What is it not good for? What is its side effects? How do we avoid those?
|
Tx-resistant bipolar
maintenance therapy in bipolar disorder can treat bipolar depression but not acute mania very good at preventing depressive relapses associated with Stevens-Johnson syndrome (rash) slow dose reduces risk of rash |
|
|
What is Gabapentin used for? But?
|
Tx-resistant bipolar
But...Worse than placebo in large controlled add-on study, good for anxiety |
|
|
What is ECT used to treat? Where is it most effective?
|
acute mania
depression maintenance Tx bitemporal |
