Lithium and Bipolar- Joshi

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What is bipolar disorder?

  • just recognize

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  • chronic cyclic mood disorder characterized by recurrent fluctuations in mood, energy, and behavior

  • includes hypomania, mania, major depression, and mixed episodes

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What symptoms characterize mania?

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  • extreme mood elevation: euphoria, extremely optimistic

  • mood abnormality: irritability, distractibility, agitation

  • behavioral changes: increased energy, hypersexuality

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16 Terms

1
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What is bipolar disorder?

  • just recognize

  • chronic cyclic mood disorder characterized by recurrent fluctuations in mood, energy, and behavior

  • includes hypomania, mania, major depression, and mixed episodes

2
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What symptoms characterize mania?

  • extreme mood elevation: euphoria, extremely optimistic

  • mood abnormality: irritability, distractibility, agitation

  • behavioral changes: increased energy, hypersexuality

3
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Major depression is a depressed mood daily for a minimum of __ weeks.

2

4
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Etiology of bipolar disorder?

  • UNKNOWN!!!

  • genetics—> CACNA1C, ANK3

  • NT dysregulation

5
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Secondary causes of bipolar disorder?

  • medical conditions

    • CNS disorders, infections, electrolyte/metabolic abnormalities, hormones

  • drugs

    • alcohol, drug withdrawals, antidepressants, hallucinogens, weed, DA drugs

  • environmental triggers

    • traumatic brain injury, stressful childhood events, etc.

6
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What are the 2 types of bipolar disorder?

  • how many manic/depressive episodes in each?

  • Bipolar I: 1 or more manic episodes ± depressive episodes

  • Bipolar II: 1 or more episodes of hypomania + depression ± manic and mixed episodes

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7
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List the drugs used for bipolar disorder:

  • LITHIUM

  • antiepileptics: LAMOTRIGINE, valproic acid, carbamazepine

  • antipsychotics: LURASIDONE, olanzapine, aripiprazole, chlorpromazine

  • antianxiety: BZDs

8
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Lithium can be used in…

a. bipolar I

b. bipolar II

c. both

c.

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MOA of lithium:

  • not 100% known but…

  • inhibits inositol monophosphates = inhibits hydrolysis of IP1 and IP2

  • inhibits glycogen synthase kinase-3 (GSK-3) = reduces phosphorylation of b-catenin, modulates energy metabolism, provides neuroprotection/plasticity

  • inhibits depolarization-evoked release of DA and NE

  • inhibits bisphosphate 3’ nucleotidase (BPNT-1)

KNOW THE BOLDED 3

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Lithium mimics and replaces what electrolyte in the body?

Na+

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How is lithium eliminated?

unchanged in the urine (~95%)

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ADRs of lithium:

  • GI (n/v/d, bloating)

  • CNS (confusion, lethargy, fatigue, HA, memory impairment, tremor, muscle weakness)

  • increase WBCs

  • nephrogenic diabetes insipidus (decreases ADH)

  • polyuria, polydipsia, xerostomia

  • hypothyroidism

  • derm ADRs

note: GI and CNS MOST COMMON

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Can lithium be used in pregnancy? category? why/why not?

  • C/I IN PREGNANCY

  • category D

  • associated w/ down syndrome, club foot, fetal goiter, abnormalities

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C/I of lithium:

  • Pregnancy

  • sick sinus syndrome

  • renal disease

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D/I with lithium

  • diuretics (may increase reabsorption)

  • NSAIDs, ACEis, ARBs (lithium retention)

  • insulin/sulfonylureas (lithium enhances hypoglycemia)

  • succinylcholine, pancuronium (associated with paralysis with lithium)

  • antipsychotics (risk of serotonin syndrome)

  • CCB, phenytoin, carbamazepine (neurotoxicity)

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Why must lithium be monitored closely?

  • with what levels does toxicity occur?

  • NARROW THERAPEUTIC WINDOW

  • requires therapeutic monitoring

  • >1.5 mEq/L—> MILD/MOD TOXICITY

  • >3.0 mEq/L—> SEVERE TOXICITY