Card Set Information
Bipolar Disorder PHPR521
What is the definition of bipolar disorder?
a disorder of mood or affect defined by the presence of at least 1 manic episode at some point in the pts life
What is the definition of mania?
an abnormally and persistently elevated, expansive, or irritable mood that lasts at least 1 wk and causes marked impairment in functioning
What is the definition of hypomania?
an abnormally and persistently, elevated, expanxive, or irritable mood that lasts at least 4d but does not cause marked impairment in functioning
What is the definition of mixed episode?
criteria for both a major depressive episode and manic episode occur nearly every day for at least 1 wk
What is the definition of bipolar Type I?
manic episode +/- major depressive or mixed episode
What is the definition of bipolar Type II?
major depressive episode +/- hypomanic episode
What is the definition of dysthymic disorder?
chronic subsyndromal depressive episodes
What is the definition of cyclothymic disorder?
chronic fluctuations b/w subsyndromal depressive and hypomanic episodes (2y for adults; 1y for children and adolescents)
What is the definition of bipolar disorder not otherwise specified?
mood states do not meet criteria for any specific bipolar disorder
What is the definition of rapid cycling?
4 major depressive or manic episodes (manic, mixed, or hypomanic) in 12mo
When does bipolar usually show up?
usually b/w 15 and 30
average age = 21
after 60 is rare and usually medically induced
What type of bipolar episode is usually first for women?
What type of bipolar episode is usually first for men?
Which sex is more likely to have mixed, depressive, or rapid cycling?
What types of bipolar is CBZ useful for ?
mixed states, rapid cycling....but second line due to poorly tolerated SE and DI
What is the most common serum concentration of CBZ?
What are the advantages of CBZ?
effective for broad spectrum of bipolar pts
ER capsules available
relatively cheap for standard dosage forms (cheaper than Depakote)
What are the disadvantages of CBZ?
CNS SE not well tolerated (but can develop tolerance and dose-dependent)
rashes - rarely severe
What are some DI of CBZ?
antibiotics (esp. erythro)
Induces it's own metabolism so check levels after couple wks
Decreased neurotransmitter turnover, increased substance P, Na+ channel blockade, et al
aplastic anemia - very rare
hepatitis - very rare
What antipsychotics are approved for bipolar acute mania?
Which antipsychotics are good for mixed states?
Which antipsychotic is approved for treatment of bipolar
quetiapine (the only first line alternative for this)
Which antipsychotic is approved for
treatment of bipolar?
Which antipsychotic is associated with frequent akathisia?
What are the concerns of using FGA's for adjunct treatment of bipolar?
tardive dyskinesia (greater than in SCZ)
What are the advantages of antipsychotics in bipolar disorder?
FGA's have fast onset on some behaviors (within a week)
helpful in partial responders and manic pts with psychotic features
some available as immediate release injectables
Which antipsychotics are available as immediate release injectables?
olanzapine, ziprasidone, aripiprazole
What are the disadvantages of antipsychotics in treatment of bipolar disorder?
bipolar pts at higher risk of FGA SE than other pts (esp. TD)
some SGAs are VERY expensive
use lowest effective doses to avoid SE
anti-convulsant ("novel mood stabilizer")
of stabilized patients only
1st line for bipolar depression
aseptic meningitis - rare
rash (Stevens-Johnson) - tritrate SLOWLY and do not use with VPA
anti-convulsant ("novel mood stabilizer")
fewer DI and better tolerance than CBZ
hyponatremia - mainly in elderly
induces metabolism of oral contraceptives
Protein Kinase C inhibitor ("novel mood stabilizer")
experimental ONLY for BD acute mania
What does Switch mean in bipolar depression?
time from depression to mania may be shortened by antidepressants
What is first line therapy for bipolar depression?
any of the above + antidepressant (esp. SSRI or bupropion)
AVOID antidepressant monotherapy - combine with a mood stabilizer or AAP
What is second line treatment for bipolar depression?
quetiapine + CBZ or Li
add CBZ to existing regimen
Li or VPA + lamotrigine
olanzapine + fluoxetine
Li or VPA + olanzapine
AVOID venlafaxine, it seems to have higher risk of Switch than other ADs
Quetiapine is approved for what type of depression?
bipolar depression ONLY (not major depression)
What drugs are used for bipolar disorder?
CCB (for HTN comorbidity)
How long does it take to see a response from mood stabilizers in bipolar pts?
What is the efficacy of mood stabilizers in bipolar pts?
better for mania than depression
better for acute episodes than for prophylaxis
Why should Li, VPA, and CBZ be avoided during pregnancy?
they are all known teratogens
Which drug is the DOC for classic, euphoric mania?
Li, but 20-30% may not respond to tx
What is the problem with taking pts off of Li or pts who are intermittently compliant?
10% may experience withdrawal-induced refractoriness, but this is
Why is Li the "kineticist's dreamdrug"?
How is Li excreted?
96% in urine
4% in sweat
80% is reabsorbed at the proximal tubule
Cl = 0.2 x CrCl
What are the target plasma concentrations of Li?
0.8-1.2 meq/L for acute mania
0.6-1.0 meq/L for maintenance tx
When must a sample be drawn to ensure Li has reached steady state?
4-5d after initiation of tx and 12h after last dose
What are the advantages of Li?
yrs of experience
best mood stabilizer for manic or depressive (lamotrigine or quetiapine?) episodes
What are the disadvantages of Li?
toxic in OD
requires therapeutic monitoring
What are the SE of Li?
t-wave inversion resembling hypokalemia
What are the acute toxic effects of Li?
irritability or agitation
What are the chronic toxic effects of Li?
goitrogenic hypothyroidism (levothyroxin - but reversibility is questionable)
Renal tubular necrosis (stop Li)
diabetes insipidus syndrome (stop Li)
If Li levels are 0.4-0.8 and pt has insomnia, what should be done?
increase dose, they are not controlled (Li is sedating)
What labs should be drawn prior to Li institution?
CBC w/ differential
What DI should you worry about with Li?
NSAIDs - decrease clearance of Li (ASA and sulindac ok)
diuretics - increase clearance of Li (thiazides, not loops)
ACEI and ARBs increase Li concentrations
significant changes in salt intake
What is first line tx for bipolar according to CANMAT?
What are the advantages of VPA (Depakote)?
efficacy includes rapid cyclers, mixed states and presence of EEG abnormalities
safer than Li
DR form is generic
What are the disadvantages of VPA (Depakote)?
expensive (except DR)
not as effective for depressive episodes
hepatotoxic (all were in kids on multiple antiepileptics)
What are the SE of VPA (Depakote)?
hyperammonemia (usually benign - monitor for hepatic and CNS toxicity)
increased appetite or anorexia
NVD (use enteric coated, give w/food, or add H
ataxia (modify dose)
drowsiness/sedation (modify dose
tremor (modify dose or add BBL)
alopecia (hair loss - tolerance possible, reversible; try Zn and Se supplements)
thrombocytopenia (modify dose)
elevated liver enzymes (usually benign, educate pt on signs of liver failure, modify dose, d/c if >2x normal)
hepatotoxicity (rare - d/c drug)
pancreatitis (rare - d/c drug)