thera final bipolar

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coal
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272893
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thera final bipolar
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2014-05-02 18:02:08
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thera final bipolar
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  1. main criteria for major depressive episode
    • 1) abnormal depressed mood
    • 2) abnormal loss of all interest and pleasure
    • 3) if < 18 yo, abnormal irritable mood

    at least 1 of the above that occurs most of the day, nearly every day for at least 2 weeks
  2. second part of major depressive episode criteria
    5 of the following with at least 1 being depressed mood or loss of interest/pleasure

    • depressed mood
    • marked loss of interest/pleasure
    • appetite or weight disturbance
    • sleep disturbances
    • activity disturbances
    • abnormal fatigue
    • abnormal feelings of worthlessness or guilt
    • abnormal concentration
    • abnormal morbid thoughts of death
  3. criteria for manic episode (same for hypomanic)
    3 or more of the following

    • inflated self esteem
    • decreased need for sleep
    • more talkative
    • flight of ideas
    • distractibility
    • increase in goal-directed activity
    • excessive involvement in activities that have a high potential for painful consequences
  4. treatment of choice in acute mania
    • lithium
    • with AP or Benzo to reach steady state (1 wk)
  5. lithium maintenance dose
    0.6 - 1.2 mEq/L
  6. monitoring for lithium
    renal function
  7. lithium AE
    • early
    •   polydipsia
    •   polyuria
    •   confusion
    •   decreased concentraton

    • late
    •   DI
    •   hypothyroidism
    •   hypokalemia
  8. lithium advantages
    • gold standard
    • use for > 50 years
    • effective in mania and hypomania
    • cheap
  9. lithium disadvantages
    • narrow therapeutic window
    • slow onset
    • not as effective in mixed or rapid cycling bipolar disorder
  10. valproic acid maintenance levels
    50-125 mcg/mL
  11. valproic acid AE
    • GI
    • tremor
    • sedation

    • less frequent
    •   wt gain
    •   lethargy
  12. valproic acid advantages
    • quick onset
    • titrated quickly
    • effective in mixed states or rapid cycling
    • effective in some lithium refractory pts
  13. valproic acid disadvantages
    • monitoring
    • inhibitor of cytochrome enzyme (2D6)
    • expensive
  14. carbamazepine maintenance levels
    4-12 mcg/mL
  15. carbamazepine AE
    • drowsiness/dizziness
    • fatigue
    • clumsiness/confusion
    • hyponatremia
    • blurred vision
  16. carbamazepine advantages
    • effective in bipolar subtypes
    • cheap
  17. carbamazepine disadvantages
    • DI - CYP 450 enzymes
    • monitoring
  18. what if a pt is getting valproic acid and lamotrigine
    decrease dose by 50% of lamotrigine
  19. lamotrigine advantages
    • effective in depressive episode
    • no blood level monitoring
    • decreases relapse
    • ODT formulation available
  20. lamotrigine disadvantages
    • rash
    • long titration period
    • 2nd agent needed for acute mania
  21. 1st line for acute manic or mixed episodes
    • lithium + AP (Seroquel)
    •   VPA + AP
  22. 1st line for less severe acute treatment
    • lithium
    • VPA (preferred of lithium in mixed)
  23. 1st line for treatment of acute depressive episodes
    • lithium
    • quetiapine
    • lamotrigine
  24. 1st line for treatment of acute depressive episodes (more severe)
    lithium + antidepressant
  25. 1st line acute treatment of rapid cycling
    • taper antidepressant if possible
    • lithium VPA
  26. 1st line maintenance therapy
    • lithium
    • lamotrigine
    • olanzapine
    • aripiprazole

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