Pharm Bipolar disorder

What are the DSMV criteria for mania

Greater than 1 week of abnormal and persistently elevated, expansive, or irritable mood

At least 3 of the following (4 if mood is only irritable): inflated self-esteem, decreased need for sleep, talking excessively, racing thoughts, distractability, psychomotor agitation, risk-taking activities

DSMV criteria for hypomania

Period of mood must last at least 4 days without any psychotic features

Much less debilitating than true mania

DSMV criteria for major depressive disorder

5 or more symptoms for at least 2 weeks that is a change from previous functioning:

depressed mood/anhedonia, reduction in interest or pleasure, weight loss/gain, insomnia or hypersomnia, fatigue, agitation, recurrent thoughts of death or suicidal ideation

Describe the SIGECAPS mnemonic

For depressive symptoms:

S - sleep disturbance, I - interest, G - guilt, E - energy, C - decreased concentration, A - appetite, P - psychomotor agitation/retardation, S - suicidal ideation

Mood-Stabilizers for BPD

Carbamazepine: acute mania, maintenance med

Divalproex sodium DR/ER: mania and mixed episodes

Lamotrigine: maintenance in bipolar depression

First Gen antipsychotics for BPD

Chlorpromazine, Haloperidol, Fluphenazine

MOA and S.E. of second gen (atypical) antipsychotics

MOA: Dopamine Antagonists

S.E.: weight gain, DM, sedation, seizures

Second gen (atypical) antipsychotic examples and indications

Aripiprazole: bipolar mania, monotherapy

Olanzapine: bipolar mania, maintenance, monotherapy or adjunct

Quetiapine (Seroquel): bipolar mania/depression monotherapy or adjunct

Asenapine: bipolar mania, maintenance, monotherapy or adjunct

Risperidone: bipolar mania, monotherapy or adjunct

Ziprasidone (Geodon): bipolar mania, monotherapy

(In bold are most commonly used)

General Tx for acute mania and hypomania

D/C offending agents: antidepressants (no SSRIs used as monotherapy, triggers mania), EtOH, caffeine, nicotine

Medications: Lithium, anticonvulsants, antipsychotics, benzodiazepines

Features of severe mania

Suicidal or homicidal ideation, aggression, psychotic features, poor judgement, usually requires hospitalization

Tx for hypomania or mild-moderate mania

1st line: lithium, valproate, or atypical antipsychotic

2nd line: carbamazepine, oxcarbazepine, or typical antipsychotic

Tx for severe mania

1st line: lithium or valproate PLUS an antipsychotic

Lithium MOA, labs to monitor

MOA: mood stabilizer

Labs: HCG, BMP, TSH, UA, CBC, and lithium levels

Lithium has a narrow TI (1.2-2.5)

Lithium S.E., drug interactions, C.I.

S.E.: N/V/D, polydipsia and polyuria, HA, hypernatremia, nephrogenic diabetes insipidus

Drugs that increase lithium levels: thiazide diuretics, NSAIDs, COX-2 inhibitors, CCBs, ACE/ARB, Metronidazole

Drugs that decrease lithium levels: theophylline, caffeine, acetazolamide, loop and k sparing diuretics, CCBs

C.I.: renal insufficiency, hyponatremia, dehydration, CV disease, pregnancy (ebstein’s anomaly)

LITH mnemonic

L - leukocytosis

I - insipidus

T - tremor/teratogenic

H - hypothyroidism

Divalproex MOA, labs to monitor, S.E.

MOA: blocks voltage-gated sodium channels and increases GABA availability in the brain

Labs: HCG, LFTs and CBC (platelets)

S.E.: fine hand tremors, diarrhea, constipation, sedation, thrombocytopenia

What are the three BBWs for Divalproex

Hepatotoxicity (avoid in pts with liver disease, highest risk within 6 months), Teratogenicity (neural tube defects), Pancreatitis

Lamotrigine MOA, indications, S.E., drug interactions, BBW

MOA: inhibits release of glutamate (excitatory AA) and inhibits voltage-gated sodium

Indications: maintenance therapy

S.E.: rash, dizziness, nausea, HA

Drug interactions: valproic acid (Divalproex active component), carbamazepine, phenytoin, phenobarbital (antiepileptics), oral estrogen decreases lamotrigine levels (need to titrate up)

BBW: Severe skin rxns (SJS/TEN)

Carbamazepine MOA, S.E., CYP450, BBW

MOA: sodium channel blockade, has broad spectrum of uses

S.E.: fatigue, blurred vision, hyponatremia (SIADH), aplastic anemia

CYP450: auto-inducer, increases metabolism of the enzyme

BBW: aplastic anemia, agranulocytosis, skin reactions in pts with HLA B1502 allele

Tx of bipolar disorder in pregnancy

-Obtain HCG prior to therapy initiation

-Lamotrigine is drug of choice in pregnancy for mood stabilization

AVOID lithium, valproic acid/Divalproex, carbamazepine,