🎭👩🏻‍⚕️ therapeutics bipolar disorder

- inflated self-esteem/grandiosity

- decreased need for sleep

- more talkative than usual or pressure to keep talking

- flight of ideas/ subjective experience that thoughts are racing

- distractability as reported or observed

- increase in goal-directed activity or psychomotor agitation

- excessive involvement in activities that have a high potential for painful consequences

symptoms of mania in bipolar disorder?

manic episode/mania

abnormally, persistently elevated, expansive, or irritable mood and abnormally goal-directed behavior for at least 1 week or any amount of time if hospitalized.

bipolar 2 disorder

- need at least one hypomanic episode

- no mania present

- at least one major depressive episode

- no psychotic features

- lasts at least 4 consecutive days

bipolar 1 disorder

- at least one manic episode

- depression or hypomania not needed for diagnosis

- maybe psychotic features

bipolar 2

no mania present in this bipolar type

bipolar 1

hypomania or depression may or may not be present in this bipolar type

you can't tell the difference until you known the patient has bipolar disorder

what symptoms differentiate bipolar depression from major depression?

Sleep problems

Interest deficit

Guilt/worthlessness

Energy deficit

Concentration deficit

Appetite dysregulation

Psychomotor retardation/agitation

Suicidality

Depression - SIDECAPS

Distractibility

Indiscretion

Grandiosity

Flight of ideas

Activity increase

Sleep deficit

Talkativeness

Mania - DIGFAST

- antidepressants

- stimulants (cocaine, methylphenidate, amphetamine)

- sympathomimetics (pseudoephedrine, ephedrine)

- dopamine agonists (pramipexole, ropinirole, bromocriptine)

- carbidopa-levodopa

- corticosteroids

- androgens

- thyroid supplements

- drugs of abuse

drugs that can induce mania?

- antihypertensives (beta-blockers, clonidine)

- CNS depressants (ethanol, barbiturates, BZDs)

- hormonal agents (anabolic steroids, corticosteroids, progestin/estrogen contraceptives, tamoxifen

- drugs of abuse

drugs that can induce depression

- mood stabilizers

- antipsychotics

first-line drugs for manic phase of bipolar disorder?

- antidepressants

- benzodiazepines

first-line drugs for depressive phase of bipolar disorder?

lithium

anti-convulsants

atypical antipyschotics

mood stabilizers used to treat mania in bipolar disorder?

lithium

- one of the first-line choice for mood stabilizers in bipolar disorder

- first line for mania and major depressive in BPD

- only bipolar agent that can decrease suicidality and bc of this can treat bipolar depression

- once pt is stabilized use single-dose regimens

lithium

• interacts with:

- ACEis

- ARBs

- diuretics (except diuretics)

- NSAIDs

• can cause alopecia and acne

- Acne & alopecia

- Benign Leukocytosis

- Cardiac rhythm changes, (non-urgent)

- Diabetes insipidus+dizziness

- Ebstein’s anomaly, excessive thirst, urination

- Fine motor tremor

- GI upset (diarrhea and upset when big dose given

- Hypothyroidism (can disrupt thyroid glands which can mimic depression)

- Impaired cognition

- Nephrotoxicity

ADVERSE lithium effects

ABCDEFGHIN

• Acute mania: 0.6 - 1.2 mEq/L

• Maintenance 0.6 - 1.0 mEq/L

• Toxicity 1.5-2.5 mEq/L

• Severe toxicity: >2.5 mEq/L

important ranges of lithium levels?

- 5 days after initiation or dosage change

- draw level 12 hours after last dose

- 1-2 week

- once stabilized 1-3 months

how often to check lithium to avoid toxicity?

- lithium levels

- renal function

- electrolytes

- thyroid function

- CBC w/differential

- EKG

- skin checks

- tremors

- hydration and sodium intake

- OTC drug used (NSAIDs)

- preggo?

lab values to check when on lithium

valproic acid

- 1st line for mania in BPD

- 1:1 conversion for all except ER to DR (1.2mg: 1.0mg)

- dose should be inc by 20% when DR to ER

- contraindicated in hepatic disease

- caution for liver

- teratogenic

true

true or false: valproic acid is teratogenic

valproic acid DDIs

- lamotigine

- CMPZ

- phenobarbital/primidone

- topiramate

- Vomiting &nausea

- Alopecia

- Liver toxicity

- Pancreatitis, PCOS

, (low) Platelets

- Rash

-Obesity

(weight gain)

- (Hyper)

Ammonemia

- Teratogenicity, Tremors, Transaminitis, Thrombo-cytopenia

- Exhaustion

(sedation) &Encephalopathy

valproate ADEs? (VALPROATE)

Nothing, it will eventually pass the more they take it. Advise patient to take it at night

if pt has valproate levels >75 mg/L (75-100mg/mL) and are at risk for ataxia, sedation, lethargy, and tiredness, what to do ?

consider lowering dose if they are constantly at or above 100mg/L

if valproate levels with >100 mg/L and they experience tremors and thrombocytopenia?

• Acute mania: 50 - 125 mcg/mL

• Maintenance 50 - 100 mcg/mL

• Toxicity >125 mcg/mL

important dosing ranges for VPA?

- 3 days after start or dose change

- draw after 12 hours for DR or 24 for ER after last dose

- check 1-2x a week when adding other meds

- once stabilized, every 3-6 months

when to check to avoid toxicity in valproate?

- VPA level

- LFTs

- CBC w/differential

- ammonia

- amylase/lipase

- skin checks

- body wt and waist line

- preggo?

- check monthly for 2 months than every 3-6 months (like lithium)

lab values to check when on valproate?

carbamazepine

used for acute mania and mixed episodes for BPD

- like VPA, only indicated for mania and not depression

- tolerability issues

- many DDIs

- unpredictable PK profile

• Maintenance 4 - 12 mcg/mL

• Toxicity >15 mcg/mL

- take 4 days after initiating or dose change

- draw 12 hours after last dose

- levels gonna be higher for 1st 30 days, then will be lower

carbamazepine important dosing ranges?

Carbamazepine

BPD agent indicated to treat acute mania and mixed episodes of maintenance of BPD that severely induces cyp1A2 and CYP3A4 with many other DDIs?

carbamazepine

- check HLAB1502

- SJS

- agranulocytosis

- hyponatremia

- BBW: SJS with pts with HLAB1502 allele. also aplastic anemia and agranulocytosis

- hepatoxicity

- antiretrovirals

- psychiatric drugs induced by 3a4

- antipsychotics

- contraceptives

- other drugs in its class

carbamazepine DDIs?

- eye exams

- skin checks

- LFTs

- teratogenic so no preggo

- sodium

- cbc w/differential

- HLAB1502 and HLA3101

- check every 2 weeks for first 2 months then every 3 months

lab values to monitor while on CBZ?

valproic acid

takes 3 days to reach steady state with levels around:

• 80 mcg/mL

• 50-125 mcg/mL (acute mania)

• 50-100 mcg/mL (maintenance

carbamazepine

takes 4 days to reach steady state with levels around:

• 8 mcg/mL

• 4-12 mcg/mL (acute mania,

maintenance)

lithium

takes 5 days to reach steady state with levels around:

• 0.8 mEq/L

• 0.6 - 1.2 mEq/L (acute mania)

• 0.6 -1.0 mEq/L (maintenance

oxcarbazepine

- like carbamazepine it is not first line but can be used to treat mania in BPD

- aripiprazole

- asenapine

- cariprazine

- olanzapine

- quetiapine

- risperidone

- ziprasidone

atypical antipsychotics proven to be equally effective in treating mania in BPD and can be first line?

- lithium

- atypical antipyschotica

- lamotrigine

mood stabilizers used to treat bipolar depression in BPD?

true

true or false: there is a greater risk of mania-induction with anti-depressant monotherapy when treating bipolar depression

mania

lurasidone and lumateperone are FDA-approved for bipolar depression but not for?

- Seroquel (quetiapine)

- Olanzapine/fluoxetine

- Latuda. Lithium, Lamotrigine, Lumateperone

- Vraylar (cariprazine)

drugs to treat bipolar depression? (SOL4V IT)

yes

cariprazine and quetiapine (like VPA and lithium) have FDA indications for both bipolar mania and depression. yes or no

lamotrigine

- isn't typically chosen as a first line agent bc it req's titration schedule, not good for treating acute mania or depression

- tolerated in preggo

- inc risk for SJS/TEN with higher doses

lamotrigine dosing schedule

- 25mg QD weeks 1-2

- 50 mg QD week 3-4

- 100mg QD week 5

- 200mg QD week 6 and beyond

- lower the dose to taper up to since VPA will inhibit its metabolism (only up to 100mg week 6)

when taking lamotrigine with VPA?

- inc the dose to taper up to since VPA will induce its metabolism (up to 400 mg week 6)

when taking lamotrigine with CBZ?

lamotrigine

drug used to treat BPD depression and has bbw for life-threatening rashes like sjs

- can cause dipolpia, ataxia, and somnolence

- avoid in 1st - ebstein's anomaly in fetus

- can use in 2nd and 3rd

- clearance inc's when preggo

when can take lithium if preggo?

NO. teratogenic. birth defects

can u use CBZ or VPA in preggo?

1-6 mcg/mL

target range of lamotrigine in preggo ppl for BPD depression?

6 months of initial treatment

when are pts at high risk for relapse while treating for BPD?

FALSE: requires an extensive dosing schedule. Will work too late

true or false: lamotrigine is approved for treatment of acute mania