Bipolar

List the acute goals of therapy for the acute treatment of bipolar disorder

Immediate treatment in response to current mania or depressive episodes 

Mania

abnormally elevated or irritable mood and energy, symptoms last at least 1 week (if hospitalized duration doesn't matter)

→ Inflated self-esteem

→ Decreased need for sleep

→ More talkative

→ Distracted

→ Racing thoughts 

→ increase in goal-directed activity

→ Excessive involvement in activities that have a high potential for painful consequences

Hypomania

 4 consecutive days 

→ Inflated self esteem

→ Decreased need for sleep

→ More talkative

→ Distracted

→ Racing thoughts 

→ increase in goal-directed activity

→ Excessive involvement in activities that have a high potential for painful consequences

*Not severe enough to cause impairment in social functioning or necessitate hospitalziation

Mixed states

symptoms of mania and depression at the same time or in rapid sequence 

Bipolar 1

At least one lifetime manic episode.  

Bipolar 2

Hypomanic episode and major depressive episode

List the maintenance goals of therapy for the treatment of bipolar disorder

 prevention after stabilization of acute mania or depressive episodes

Medication algorithm for acute mania

Which SGAs should you avoid for acute mania

Lurasidone, Lumateperone, iloperidone, brexipiprazole

Which SGAs is preffered for acute mania

Quetiapine

Medication algorithm for acute bipolar depression

Which SGAs are preffered for acute bipolar depression

Quetipaine, cariprazine, lumaterperone, lurasidone, olanzapine

Can lamotrigine be used for mania?

No

Can antidepressants be be used as monotherapty for bipolar?

No becuase it risks switching to mania

What are mixed episodes?

Aspects of both mania and depression present

What meds are preffered for mixed episodes

Second gen antipsychotics

What medications should you consider for bipolar with rapid cycling?

Antipsychotic , VPA

What medications should you avoid for bipolar with rapid cycling?

Antidepressants, lithium

What medications should you consider for bipolar with high suicide risk?

Lithium, ECT (electro convulsive therapy )

What medications should you consider for bipolar with psychosis?

Antipsychotic, ECT

What medications should you consider for bipolar with anxiety ?

Antipsychotic, VPA

Describe the purpose of maintenance treatment for bipolar disorder, and how medications are selected or used for this purpose

• Goal: prevent relapse 

→ meds used for acute symptoms should be continued as maintenance 

→ combo therapy is better than mono therpay

Transient side effects of lithium

N/V, GI upset

Diarrhea

Fine hand tremor

Somnolence

Ataxia

Cognitive impairment

Long term side effects of Lithium

Weight gain

Tremor

Polyuria and polydipsia

Increased WBC

Hypothyroidism

Hypercalcemia & hyperparathyroidism

Renal failure (rare)

Cardiac abnormalities

Provide recommendations for managing or minimizing lithium ADEs.

Slow titration, Lower Dose, ER formulation, Split daily dosing

Describe when lithium levels should be checked following initiation of lithium or dosage change to ensure steady state trough levels are obtained.

•Draw levels 12 hours post dose (trough levels)

•First level should be drawn within 5-7 day (steady state)

Mild/Early Lithium toxicity symptoms

Develops gradually over several days

drowsiness

confusion

course hand tremor

ataxia

dysarthria / slurred speech

reappearance or worsening of GI symptoms

How to manage Mild/Early Lithium toxicity

Hold dose, check blood level, monitor vitals/symptoms

Determine cause of elevated level and educate patient

Adjust lithium dose if interacting medication cannot be stopped

Moderate-Severe lithium toxicity symptoms

Gradual or sudden onset

Muscle tremor

Hyperreflexia

Seizures

Cardiovascular collapse

Coma

Death

How to manage moderate/ Severe lithium toxicity

Hold doses

Li Level

Hydration

Gastric Lavage

Supportive Therapy

ECG

Labs

Hemodialysis

Identify common drug interactions that occur with lithium, and the impact of these interactions on lithium levels (i.e. elevated or reduced).

•Diurectics, ACE inhibitors, ARBs, NSAIDs increase lithium concentrations

dehydration can also increase lithium levels

Recommend baseline and follow-up laboratory values to evaluate the safety and efficacy of lithium in the management of bipolar disorder.

SCr / BUN / eGFR

Thyroid function

CBC

Electrolytes

Pregnancy test

Weight or BMI

ECG if CVD or risk factors

List important education points for a patient newly starting on lithium therapy for bipolar disorder

Do not alter dose or stop lithium without contacting HCP—inconsistent medication taking, or rapid discontinuation increase risk for relapse

Birth control recommended while taking lithium—contact HCP if pregnant or considering

Maintain adequate fluid intake to avoid dehydration, contact HCP if diarrhea or vomiting or acutely ill

Avoid OTC NSAIDS—acetaminophen is an OTC pain/fever med that won’t interact with lithium

Importance of consistent f/u with prescriber and lab monitoring

Lithium Half life

24 hours

steady state after 3-5 half lives

How to titrate lithium for acute mania

every 5-7 days based on levels and symptoms

Estimate time to benefit on manic symptoms following initiation of a medication to treat bipolar disorder

Initial response: 1-2 weeks

Max beenfit: 3-4 weeks

Estimate time to benefit on depressive symptoms following initiation of a medication to treat bipolar disorder

Initial response: 2 weeks

Mac beenfit: 6-8 weeks

Describe how medications should be discontinued in a manner that reduces risk for relapse and withdrawal in a patient receiving treatment for bipolar disorder

•Engage in discussion of risks

•Taper slowly, 4 week or longer

•educate patient on monitoring for relapse & importance of re starting meds