Bipolar Disorder - Dr. G Study Guide

What are the symptoms of bipolar mania?

Distractibility

Impulsivity

Grandiosity

Flight of ideas

Activities

Sleep - decreased need

Talkativeness

What is the difference between bipolar 1 and bipolar 2 disorders

Bipolar 1: have both mania and depression

Bipolar 2: have hypomania and depression

What is the issue with diagnosis of MDD instead of BP2 disorders in terms of treatments?

If bipolar is treated with antidepressants alone, then patient will switch to mania

Why is bipolar 2 disorder often misdiagnosed as major depression?

Same clinical presentation

True or False: There are more women than man with bipolar disorders

False --> 1:1 ratio

What is the average age of onset of bipolar disorders?

20 ish

What is the danger of a misdiagnosis of ADHD instead of bipolar disorder?

ADHD is treated with stimulants which can worsen bipolar mania

The symptoms experienced during bipolar depression and major depression are the same (D/A+SIGECAPS). What is the main difference with treatments?

Depression: antidepressants

BPD: 2nd generation antipsychotic + mood stabilized

What is your recommendation for a bipolar patient with manic symptoms on Prozac 20 mg QAM?

Discontinue Prozac → will cause mania

What baseline labs are needed for lithium therapy?

BUN and SCR

Urine Specific gravity

CBC with differential

Serum Sodium

Thyroid Function test

Pregnancy Test

Why test BUN and SCR for Lithium therapy?

to assess renal function; lithium is eliminated by kidneys

Why test Urine Specific Gravity for Lithium therapy?

lithium can decrease kidney's ability to concentrate urine

Why test CBC with differential for Lithium therapy?

leukocytosis

Why test Serum sodium for Lithium therapy?

hyponatremia

Why test Thyroid function for Lithium therapy?

rule out hyperthyroidism (can cause mania). Lithium causes hypothyroidism

Why test pregnancy for Lithium therapy?

lithium increases risk of fetal cardiovascular malformation

What is the usual therapeutic lithium level range?

0.6-1.2 mEq/L

How many hours post-dose would you educate your patient on lithium to go get labs for their lithium levels? Why?

10 - 12 hours post dose. Trough levels - No peak

What common DDIs can cause higher and possible toxic lithium levels?

NSAIDs, Thiazides diuretics, ACE inhibitors

What are the symptoms of lithium toxicity?

confused, ataxia, slurred speech

What can be recommended for a patient with lithium toxicity?

Hold lithium doses for 1 day and reevaluate

Lithium has a delay in onset of action (2-3 weeks). What medications are usually prescribed for acute mania before lithium's onset of action?

Sedating antipsychotic (i.e. Zyrexa). BZD to calm the patient down (do not use long term)

Which atypical antipsychotics are FDA-approved for bipolar depression?

Cariprazine (Vraylar)

Lurasidone (Latuda)

Olanzapine-fluoexetine combo (Symbyax)

Olanzapine monotherapy

Quetiapine (Seroquel)

What indications is Caplyta® (lumaterperone) approved for? What are 2 common ADRs?

Bipolar I and II depression as monotherapy or adjunctive.

Sedation and weight gain

Patients with ClCr <_______ ml/min shuold not be on lithium therapy

30

Explain the effects of a 2-gm sodium restriction diet for your patient on lithium. Explain the mechanism of action for this effect.

More reabsorption of Na and Li → higher Li concentration → increase ADRs or toxicity

Which anticonvulsants are prescribed for the treatment of bipolar disorder?

Carbamazepine (Tegretol)

Valproic Acid (Depakote)

Lamotrigine (Lamictal)

What is the advantage of Depakote® vs. Depakene®?

Depakote has enteric coat that is designed to be released in the smell intestine to reduce GI side effects

What is the problem with using antacids with Depakote®?

Antacid decreases stomach pH. Enteric coating is dissolved --> GI SE. Defeats purpose of enteric coating

What is the problem with using CBZ or VPA during pregnancy?

Neural tube defects (spina bifida).

VPA: higher risk of ASD

You have a patient with a new Rx for carbamazepine (CBZ). She is also on oral contraceptives. What do you need to inform the patient and her provider?

CBZ = inducer --> reduce efficacy of contraceptive

"Lamotrigine is FDA-approved for the treatment of maintenance treatment of bipolar I disorder to delay the time to occurrence of mood episodes in patients treated for acute mood episodes with standard therapy." Is lamotrigine effective for acute bipolar mania?

No. Lamotrigine is used for bipolar depression (NOT mania)

What is an important patient education point for patients starting on lamotrigine?

Monitor for rash. Risk of SJS

What is the dosing precaution with the use of lamotrigine (Lamictal®) for patients on valproic acid (Depakene®) or divalproex sodium (Depakote®). Why?

Valproic Acid inhibits Lamotrigine metabolism → Start at HALF dose of Lamotrigine

What is the best mood stabilizer for a pregnant patient with Bipolar 2 disorder?

Lamotrigine (Lamictal)

Which antipsychotic is FDA-approved for bipolar mania and depression?

Vraylar (Cariprazine)

Which mood stabilizer is neuroprotective and being studied for Parkingson and Alzheimer disease?

Lithium