Bipolar disorder

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Author:
timothy.pdlt
ID:
212109
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Bipolar disorder
Updated:
2013-04-09 08:31:52
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bipolar disorder
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Description:
therapeutics, side-effects, drug interactions
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  1. GoT of bipolar disorder Tx
    • decrease severity, frequency, and duration of episodes
    • promote regular sleep and activity
    • decrease negative s/s of episodes
    • decrease functional impairment
  2. DSM classification of bipolar disorder
    • 1. bipolar disorder I
    • a. M=F
    • b. 1+ manic or mixed episodes (usually with major depressive disorder)

    • 2. bipolar disorder II
    • a. F>M
    • b. 1+ MDE and 1+ hypomanic episodes

    • 3. cyclothymic disorder
    • a. 2 years of repeated hypomanic and depressive s/s

    4. bipolar disorder not otherwise specified
  3. S/S of bipolar disorder
    • acute mania±psychoses
    • bipolar depression (2x compared to mania)
  4. Summary of bipolar disorder Tx
  5. Acute Tx of mania/mixed episode of bipolar disorder
    • first line: Li or VPA ± SGA ± BDZ
    • second line: CBZ, OXC, Li+VPA
    • *(avoid CBZ+OLZ)
    • third line: haloperidol, Li+CBZ, CLZ

    • for mixed: VPA>Li, OLZ>Li
    • refractory: 2MS+SGA, CLZ, ECT

    • *d/c antidepressant (taper is possible)
  6. Acute treatment of bipolar depression
    • first line: Li, LTG, QTP, OLZ+SSRI, Li/VPA+SSRI/bupropion
    • second line: QTP+SSRI, adjunctive modafinil

    • *avoid ARI monotherapy
    • *avoid antidepressant monotherapy
  7. Indications for bipolar disorder maintenance Tx
    • >2 major episodes
    • 1 severe episodes
    • rapid onset of S/S
    • frequent attacks (>1/yr)
    • family history
  8. Maintenance Tx of bipolar disorder
    first line: Li, VPA, LTG, OLZ

    • growing evidence for:
    • 1. QTP as a monotherapy/adjunct for manic/depressive prophylaxis
    • 2. RIS, ARI, ZIP for manic prophylaxis
  9. Mood stabilizers' doses and onset of action
  10. Acute s/e of lithium
    • cognitive dysfunction
    • lethargy
    • hand tremor (tolerated)
    • GI upset (tolerated)
    • polydipsia
    • polyuria
  11. Chronic s/e of lithium
    • cardiac effects (T-wave depression)
    • diabetes insipidus
    • glomerular dysfunction
    • hypothyroidism (not dose-related)
    • weight gain
    • leukocytosis (benign, reversible)
    • acne
    • psoriasis
  12. Serum range of lithium
    through (after 8-12hours)= 0.8-1.1mmol/L (0.4-0.7mmol/L in elderly)
  13. Lithium toxicity s/s
    • mild: cognitive dysfunction, fine tremor, GI s/s, weakness, fatigue
    • moderate: confusion, lethargy, ataxia, dysarthria, nystagmus, vomiting, coarse tremor
    • severe: seizure, myoclonus, brain damage, coma
  14. Monitoring parameters for lithium
    • electrolytes (dehydration= increased lithium levels)
    • CBC: increased WBC
    • SrCr/BUN
    • TSH/T4
    • weight
    • pregnancy test
    • urinalysis: lithium inhibits ADH-->SIADH
  15. Serum range of VPA
    300-700uM
  16. S/E of VPA
    • sedation
    • ataxia
    • N/V
    • epigastric cramping
    • fine hand tremor
    • throbocytopenia
    • increase LFTs
    • pancreatitis
    • weight gain
    • alopecia
    • polycystic ovarian syndrome (amenorrhea, anovulation)
  17. Monitoring parameters for VPA
    • CBC: increased WBC, decreased platelets
    • weight
    • pregnancy test
    • DI (inhibit metabolism)
  18. Serum range of CBZ
    17-50uM

    *avoid combining with VPA or OLZ
  19. Rare S/E of CBZ
    • hepatotoxicity
    • hyponatremia
    • agranulocytosis (severe leukopenia)
    • aplastic anemia
    • rash: SJS, toxic epidermal necrolysis
  20. DI of CBZ
    erythromycin, fluoxetine, fluvoxamine, cimetidine, ketoconazole= decrease CBZ Cl

    CBZ induction: anticonvulsants, antidepressants, BDZs, warfarin, OCs
  21. LTG doses for bipolar disorder Tx
    LTG 25mg/d-->200mg/d

    • *use lower doses with VPA
    • *use higher doses with CBZ
    • *slow increase dose by 25mg/d q2weeks= decrease risk of rash
  22. S/E of LTG
    rash (10%) within 6-8weeks
  23. Risk factors of LTG-induced rash
    • high dose
    • fast tiration
    • concurrent VPA
    • children
  24. Role of SGA in bipolar disorder
    • 1. acute mania
    • a. effective as adjuncts to lithium/VPA OR as monotherapy
    • b. clozapine in refractory/rapid cyclers
    • 2. bipolar depression
    • a. OLZ and QTP= LTG
    • 3. bipolar maintenance
    • a. limited data for OLZ or QTP
  25. How pharmacist can help with bipolar disorder?
    • adherence
    • regular sleep
    • education about medications and bipolar disorder
    • monitoring efficacy and s/e
    • early recognition of s/s
    • act as resources

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