Pharm III (Exam 1) - Mood Stabilizers

high rate of _____________ vs placebo for many mood stabilizers but not for _______________

suicide, lithium

Lithium indication

bipolar

________ is Well absorbed, peak levels occur

•1.5 - 2 hours (____) and

•4 - 4.5 hours (____)

lithium, IR, CR

lithium half life is around ________hrs and is directly related to ________ since it is 95% renally excreted

24, GFR

lithium renal adjustments are needed when CrCl is below _____mL/min and is contraindicated when CrCl is below ________mL/min

60, 30

lithium (like Na) is filtered by the _______________ and 70-80% is reabsorbed in the __________________________

glomerulus, proximal renal tubules

reabsorption of lithium and _________ is competitive

Na

unlike Na, lithium is not further absorbed in the ______________ and the excretion is not facilitated by _____________ diuretics

distal tubules, thiazide

Lithium contraindications

CV, renal, dehydration, hyponatremia, diuretics (not absolute)

lithium toxicity has ____ and _____ Sx that get progresively worse as the levels rise

GI, CNS

NSAIDs and COX2 inhibitors _______________ lithium levels

increase

preferred NSAID for use with Lithium

Sulindac (Clinoril)

ACE/ARBs and CCBs ___________ the levels of lithium

increase

thiazides _____________ the levels of lithium

increase

loops, mannitol, spironolactone, and triamterene can _____________________ the levels of lithium

increase or decrease

methylxanthines (caffeine, theophylline) can ______________ the levels of lithium

decrease

when stopping lithium, decrease over several ____________________ esp w bipolar

weeks to months

lithium is a __________ drug so levels must be obtained ____________ the next dose

NTI, before

target level for lithium depends on the ____________(acute mania, acute depression, maintenance)

indication

Tx of lithium toxicity

lower or stop dose, saline diuretics, dialysis

If patient has a level > 1.5 mEq/L but NO symptoms of toxicity, ___________ level to ensure it was drawn as a trough

re evaluate

avoid lithium in the ________ trimester of pregnancy due to __________ malformations that can occur in infants

first, cardiac

lithium availibility

oral

lithium in ___________________ can cause cardiac arrhythmias, hypoglycemia, diabetes insipidus, thyroid function abnormalities, floppy infant syndrome, neonatal lithium toxicity

2nd-3rd trimester

Anticonvulsant mood stabilizers are available as _______ dosage forms and select medications may also be available as _____________ products

oral, injectable

Valproic Acid BBWs

hepatic failure, pancreatitis

valproic acid is an enzyme _____________

inhibitor

valproic acid can increase the toxicity of ____________

lamotrigine

drugs that lower the concentration of valproic acid

contraceptives, carbapenems, rifampin

valproic acid dosing can be ______________ or ____________

weight based, fixed

there is a poor correlation between serum levels of ____________ and anti manic effects

valproic acid

___________ pts have a decreased elimination of valproic acid so we need to start lower and go slower

elderly

do not use ______________ if planning to become pregnant

valproic acid

________________ can cause congenital malformations and should only be used in pregnancy to manage bipolar disorder if no other effective option exists

valproate

________ auto-induces its own metabolism and that of ________ substrates

CBZ, CYP3A4

REQUIRED for CBZ: Test for _________*1502 in patients at increased risk for developing SCARs, particularly Asian ancestry; if positive, avoid therapy; some guidelines recommend ALL patients be tested

HLA-B

Test for _______*3101 in pts on lithium - if positive, may increase risk of hypersensitivity; guidelines not well-established

HLA-A

CBZ/Oxcarb ADEs

sedation, SIADH, bone marrow suppression, agranulocytosis/aplastic anemia

CBZ/Oxcarb BBW

agranulocytosis/aplastic anemia

Oxcarb may be __________ sedating and have _________ bone marrow toxicity than CBZ

less, less

CBZ/Oxcarb are very potent inducers of ______________

CYP3A4

CBZ/Oxcarb reduced the efficacy of _____________ and select _______________

oral contraceptives, antipsychotics

contraindicated for use with CBZ/Oxcarb due to additive myelosuppressive effects

Clozapine (Clozaril)

CBZ/Oxcarb increases the concentrations of _________________ and the use of both together is contraindicated

Lurasidone (Latuda)

Antipsychotics which may be given but require higher doses when given with ___________: quetiapine, aripiprazole, iloperidone, cariprazine, brexpiprazole

CBZ

once pt is on CBZ therapy for 2-3mo, recheck levels to ensure still in ____________ range as auto induction may lead to __________ levels

therapeutic, decreased

______ can cause congenital malformations and should only be used in pregnancy to manage bipolar disorder if no other effective option exists

CBZ

Associated with SIADH in the elderly

CBZ

•Narrow therapeutic index drug

•Therapeutic drug levels are not routinely monitored for bipolar disorder

•Obtain if symptoms of toxicity arise, suspected non-adherence, new drug interactions, pregnancy, or to establish a patient-specific "efficacy level"

CBZ

Lamotrigine BBW

rash

70% of Topiramate dose is eliminated in ______ as unchanged drug

urine

Topiramate Renal dose adjustment when CrCl is below ___mL/min - reduce dose to ____% of normal dose and titrate more slowly

70, 50

Risk for causing birth defects (cleft lip and palate)

topiramate

Topiramate (Trokendi XR formulation) contraindication

Recent alcohol use (within 6 hours prior to and 6 hours after administration)

Topiramate ADEs

CNS, weight loss, anorexia

oral contraceptives may have _______________ effectiveness when taken w topiramate

decreased

valproic acid and topiramate combo may increase ________________ effects

hepatotoxic

GABA analog ADE

somnolence

GABA analog drug interactions

CNS depressants

Pts should not ________________ taking GABA analogs

abruptly stop

pregabalin controlled class

V

most sedating

CBZ, topiramate

rash most likely

CBZ, lamotrigine

most weight gain

gabapentin, valproic acid

most weight loss

topiramate

Inducers (induce metabolism of other drugs)

CBZ

Inhibitors (inhibit metabolism of other drugs)

valproate

OC failure due to mood stabilizer therapy

increases risk of pregnancy

CBZ, topiramate

Mood stabilizer failure due to oral contraceptive

increases risk of bipolar symptoms

lamotrigine, valproic acid

best for use in pregnancy

lamotrigine