Therapeutics 3

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mmccaf9260
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18395
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Therapeutics 3
Updated:
2010-05-08 22:46:32
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Therapeutics
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Description:
Biopolar and Affective Disorders
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  1. Define Biopolar -1
    manic disorder(s) or mixed episode(s) plus major depressive episode
  2. Define Bipolar-2
    major depressive(s) episode(s) plus hypomanic episode(s): never presenting with a full manic or mixed episode.
  3. Define cyclothymia
    recurring hypomanic symptoms plus depressive symptoms: episodes are insufficient to meet DMS-4 criteria for major depressive and manic symptoms
  4. What percentage of the population is affected by bipolar?
    3.7%
  5. What does an onset of a first manie epised after the age of 40 indicate?
    substance abuse or other g eneral medical condition
  6. is bilopar recurrent?
    yes, in >90% of cases
  7. What differential diagnosises do you need to rule out before diagnosising Bipolar?
    enodcrine or metabolic disorders, hyperthyroidism, infections(encephalitis), temporal lobe epilespy, medications (alcohol, steroids, xanthines) and sleep deprivation
  8. Hospitalization needed for major depressive episode?
    yes
  9. Do manic episodes need to be hospitalized?
    yes
  10. Do hypomatic episodes need to be hospitalized?
    No
  11. When starting a new medication, how often should you be seen?
    Every two weeks
  12. How often should severely ill patients be seen?
    weekly, instead to every two weeks for lesser ill patients
  13. How often should a stable patient be seen?
    every month for the first 3 months then every 2 to 3 months
  14. Reasons for non-adherence to meds?
    side effects (tremor, thrist, frequent urination, sedation, obesity, froggy feeling), missed the highs, dislike the though of mood control by meds, felt well while on a manic high, denial
  15. Name some mood stabilizers
    Lithium, valproic acid, carbamazepine, gabapentin, lamotrigine, topiramate, oxcarbamazepine
  16. Drugs to treat classic mania/mixed mania
    lithium, valproic acid, carbamazepine, oxcarbamazepine, SGAPs
  17. Drugs to treat depression as a subtype of bipolar disorder
    lamotrigine, lithium, quetiapine
  18. Drugs to treat rapid cycling
    valproic acid, lamotrigine, SGAPs
  19. Drugs to treat Bipolar-1
    Lamotrigine, Lithium
  20. Maintenace drugs for bipolar disorder
    Lithium, Lamotrigine, SGAPs
  21. Is Lithium effective in unipolar depression?
    no
  22. How effective is Lithium in aborting manic/hypomanic episodes?
    60-80% typically, may take about 7 days
  23. Name some pre-lithium work-up labs
    CBC, electrolytes, renal function, TFT, urinalysis, ECG, BHCG
  24. Serum concentation for acute mania of lithium dosing
    0.8-1.2 mEq/L
  25. Serum concentration for maintenance of lithium dosing
    0.6-1.0 mEq/L
  26. Benefit of QDay dosing of Lithium
    minimize potential renal damage
  27. Dosing of Lithium
    • initial: 600-900 mg/d
    • Maintenance: 900-2400 mg/d
  28. Name the drug to initiate to reduce muscle weakness or tremor
    Propranolol, or you can reduce the dose of Lithium
  29. What is an option for CNS toxicity such as confusion or agitation with Lithium?
    reduce dose
  30. What is an option for GI distress with Lithium?
    reduce dose or switch to ER form
  31. How would you reduce the SE of polyuria/polydispia related to Lithium?
    reduce dose, manage intake, dose hs
  32. Diabetes insipidus-like syndrome can be seen in patients with large fluid intake who are taking Lithium. How would you treat this SE?
    Manage fluid and use HCTZ or amiloride
  33. Hypothyroidism can be a non-dose related SE of Lithium. How would you treat this?
    D/C lithium or administer levothyroxine
  34. Would you D/C lithium if the patient developed a rash?
    No, treat symptomatically
  35. How do ACE and ARBS interact with Lithium?
    They increase Li concentrations
  36. Can a patient take NSAIDs while on Li?
    Avoid, can increase Li concentrations
  37. Are diuretics C/I with Lithium?
    diuretics-thiazides increase Li concentrations by 40-50%. Furosemide and amiloride have little effect
  38. 1.5-2.0 mEq/L is what level of Li toxicity?
    Mild- drowsiness, poor concentration, unsteady gait, hand tremors and diarrhea
  39. 2.0-3.0 mEq/L is what level of Li toxicity?
    moderate- speech difficulties, muscle weakness, confusion, sedation, and possible death
  40. Concentrations of >3.0 mEq/L are what level of Li toxicity?
    severe- convulsions, increased deep tendon reflexes, CV collapse, death
  41. How often do you monitor Li levels?
    weekly for first month until stable, then monthly for three months, then every six months
  42. Valproic acid is considered first line for...?
    rapid cyclers and patients with dysphoric mood
  43. When should you use a delayed-release valproic acid?
    To minimize GI side effects
  44. Do valproic capsules or EC tablets absorb faster?
    capsules...and liquid..duh
  45. Monitoring and target level for valproic acid?
    • monitor levels between: 50-125 mcg/ml
    • target level: 75 mcg/ml
  46. Loading dose needed for valproic acid?
    yes (hint- add a zero to a patient weight in lbs)
  47. Name some SE of valproic acid
    • Hepatotoxicity (rare- monitor LFTs) a concern for children
    • weight gain
    • GI distress
    • sedation
    • Pancreatitis (rare)
    • hyperammonemia (rare) tx with L-carnitine
    • C/I in pregnancy
  48. Usual dose range for Carbamazepine?
    • initially 200 mg bid
    • increase every 3-4 days to a range of 600-1600 mg/day in divided doses
  49. Name some SE of carbamazepine
    ataxia, dizziness, ha, blurred vision, hyponatremia, dry mouth, constipation, rash, hematological effects
  50. Lamotrigine is indicated for...?
    tx of bipolar-1
  51. How does CBZ, phenytoin and phenobarbital affect lamotrigine?
    decreased 1/2 life to about 15 hours
  52. How does birth control affect lamotrigine?
    decreases lamotrigine concentrations by as much as 50%
  53. Name some SGAPs
    • risperidone
    • ziprasidone
    • olanzapine
    • quetiapine
    • clozapine
    • aripiprazole
  54. What is risperdone used for?
    monotherapy or combo with VPA or Li tx of acute mania or mixed episodes of Bipolar Disorder
  55. What is ziprasidone indicated for?
    acute mania and mixed episodes with/without psychosis
  56. Olanzapine indicated for?
    acute mania and maintenance monotherapy and in comb tx
  57. Quetiapine indicated for?
    short term treatment of acute manic episodes associated with BP-1 as monotherapy or adjunct to li or vpa
  58. Clozapine indicated for?
    tx of refractory mania as monotherapy or as an add-on to therapy (not FDA approved tho)
  59. Aripiprazole indicated for?
    tx of actue bipolar mania including manic and mixed episodes assocated with BP disorder and maintenace

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