Term
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Definition
mood-stablizing agent
Indications:
mania associated with bipolar disorder (first line)
MoA: alters cation transport, influences NE & 5-HT reuptake
Dose: 900-2400 mg/day in 3-4 divided doses OR 900-1800 mg/day q12 hrs (ER)
Serum Monitoring:
Acute Mania - 0.6-1.2 mEq/L
Maintenance - 0.8-1 mEq/L
Elderly - 0.6-0.8 mEq/L
Lab Monitoring:
Baseline: thyroid fcn, renal fcn, CBC, electrolytes, weight, EKG, pregnancy test
Follow up: renal & thyroid fcn, weight, CBC monthly for 1st 3 months then every 6-12 months
ADRs:
GI, somnolence, fatigue, WEIGHT GAIN, polyuria/polydipsia, NEPHROGENIC DIABETES INSIPIDUS, HYPOTHYROIDISM, TREMOR (decrease dose, switch to ER, and/or add a beta blocker)
Pregancy Cat. D - Epstein's Anomaly (1st trimester - displaced tricuspid valve allows blood flow back into right atrium) |
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Term
| valproate (Depakote, Depakote ER, Depakote Sprinkle, Depacon, Depakene) |
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Definition
Indication: mania associated w/ bipolar (1st line); DRUG OF CHOICE: rapid cycling or mixed episodes;
MoA: increases availability of GABA;
Dose: Initial - 500-750 mg/day in divided doses, MAX dose = 60 mg/kg/day
Serum Monitoring:
Min. conc. = 60-70 mcg/ml, Upper limit: 125 mcg/ml
Monitoring Parameters:
Baseline - Chem-7, LFTs, CBC, weight, pregnancy test; Follow up - serum drug levels, LFTs, weight, CBC, amylase, lipase
ADRs:
somnolence, dizziness, TREMOR, MILD THROMBOCYTOPENIA, WEIGHT GAIN, mild hepatotoxicity (BLACK BOX WARNING), ALOPECIA, PANCREATITIS (Black Box Warning);
Toxicity:
occurs >200 mcg/mL, symptoms - visual hallucinations, deep sleep, coma, motor restlessness, new onset tremor
Drug Interactions:
Lamotrigine - decreases levels, drug may increase lamotrigine levels;
Warfarin - increases INR
Pregnancy class D |
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Term
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Definition
FDA indication: maintenance therapy w/ bipolar disorder (mainly bipolar II)
Dosing:
Initial: 25 mg/day for 2 wks, increase to 50 mg/day for 2 wks, then increase to 100 mg/day for 1 wk
Max dose: 500 mg/day
Cut dosing schedule in half if also on VPA --> increased risk of SJS |
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Term
| carbamazepine (Tegretol, Tegretol XR, Equetro) |
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Definition
Equetro only - acute manic & mixed episodes w/ Bipolar I;
DRUG of CHOICE: given to pts who fail Li and/or VPA
Dose:
Initial: 200 mg BID, increased in 200 mg increments based on symptoms
Serum Monitoring (every 6-12 months):
Optimal - 8-12 mcg/ml
>15 mcg/ml = ataxia, seizures, coma
PK:
Induces 1A2, 3A4, 2C9/10, 2D6
Autoinduction occurs
Monitoring Paramaters:
Baseline - CBC, electrolytes, LFTs, EKG
Follow up - LFTs, CBC every 3-6 months
ADRs:
blurry or double vision, confusion, N/V, diarrhea, dyspepsia, leukopenia, hepatotoxicity, hyponatremia w/ SIADH, BLACK BOX WARNINGs: agranulocytosis, aplastic anemia
Drug Interactions:
CYP3A4 inhbitors --> increase levels
VPA inhibits degradation of drug
Drug induces metabolism of VPA
Neurotoxicity with drug & Li
Pregnancy Cat. D |
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Term
| risperidone (Rispderdal, Risperdal Consta) |
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Definition
SGA used to tx:
schizophrenia
acute manic/mixed episodes of bipolar (adults & children)
irritability/aggression associated with autism
DEPOT INJECTION:
adjunctive or monotherapy for maintenance of bipolar |
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Term
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Definition
FDA indications:
schizophrenia
acute manic/mixed episodes
maintenance tx of bipolar
acute agitation
depressive episodes when used with fluoxetine |
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Term
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Definition
FDA indications:
schizophrenia
acute manic/mixed episodes
depressive episodes
adjunctive agent for maintenance of bipolar |
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Term
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Definition
FDA indications:
schizophrenia
acute manic/mixed episoded of bipolar
acute agitation |
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Term
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Definition
FDA indications:
schizophrenia
maintenance therapy of bipolar
manic/mixed episodes of bipolar (CHILDReN & ADULTS)
acute agitation
adjunctive for major depressive disorder |
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Term
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Definition
| hx of manic or mixed episodes, major depressive episodes are typical but NOT REQUIRED |
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Term
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Definition
| one or more episodes of hypomania & a hx of depressive episodes |
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Term
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Definition
| for at least 2 yrs, with NO symptom-free period of > 2 months, presence of numerous periods of hypomania & depressive symptoms |
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Term
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Definition
| manic symptoms present but pt does not meet criteria for bipolar I, bipolar II, or cyclothymic disorder |
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Term
| Medical Disorders associated with Mania |
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Definition
| hyper/hypothyroidism, CNS disorders, infections |
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Term
| Medications associated with Mania |
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Definition
| alcohol intoxication, antidepressants, steroids, weight loss agents, St. John's wort, xanthines |
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Term
| Signs & Symptoms of Bipolar Disorder |
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Definition
| characterized by dramatic changes in behavior: euphoric highs ("mania") to depressive lows; Onset: dramatic mood swings and/or extreme alterations in energy levels & behaviors; NOT ALL PTS experience it the same |
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Term
| DSM-IV-TR Criteria for Major Depressive Episode of Bipolar Disorder |
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Definition
5 or more of following symptoms present nearly every day for > 2 wks; at least 1 of symptoms is depressed mood or loss of interest:
depressed, sad mood
decreased interest & pleasure in normal activities
decreased weight loss, appetite
insomnia
psychomotor retardation or agitation
fatigue, loss of energy
feelings of guilt or worthlessness
suicidal thoughts or attempts |
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Term
| DSM-IV-TR Criteria for Manic Episodes of Bipolar Disorder |
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Definition
3 of following symptoms >1 wk period of abnormally & persistently elevated, expansive or irritable mood:
inflated self-esteem, grandiosity
decreased need for sleep
pressured speech
flight of ideas
distractible
increase in goal-directed activity
excessive involvement in pleasurable activities |
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Term
| DSM-IV-TR Criteria for Hypomanic Episode of Bipolar Disorder |
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Definition
At least 4 days of elevated, expansive or irritable mood; associated with at least 3 of following:
inflated self esteem
decreased need for sleep
pressured speech
racing thoughts
increase in goal-directed activity
excessive involvment in pleasurable activities |
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Term
| DSM-IV-TR Criteria for Mixed Episode for Bipolar Disorder |
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Definition
| criteria met for both manic & depressive episodes nearly every day during a one week time frame |
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Term
| DSM-IV-TR Criteria for Rapid Cycling in Bipolar Disorder |
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Definition
| >4 major depressive or manic epidodes in 12 months |
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Term
| Goals of Bipolar Treatment |
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Definition
| resolve or shorten duration of acute manic, hypomanic, or depressive episode; prevent future episodes; *MAXIMIZE COMPLIANCE with THERAPY*; minimize adverse effects; treat comorbid substance use & abuse; avoidance of stressors that may precipitates acute episode |
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Term
| Drugs that increase Li levels |
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Definition
| NSAIDs, ACE-Is/ARBs, diuretics |
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Term
| drugs that decrease Li levels |
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Definition
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Term
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Definition
| 1.5 mEq/L-2 mEq/L; impaired memory & concentration; fine hand tremor; N/V; fatigue; muscle weakness |
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Term
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Definition
| 2 mEq/L - 2.5 mEq/L; worsening tremor; altered mental status; increased deep tendon reflexes |
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Term
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Definition
| >2.5 mEq/L; seizures; coma; respiratory depression; arrhythmias; CV collapse; death |
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Term
| oxcarbazepine (Trileptal) |
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Definition
NOT FDA indicated but still used for bipolar disorder;
2nd-line tx for acute mania & depression associated w/ bipolar disorder
SEs: hyponatremia w/ SIADH |
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Term
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Definition
drug that failed to improve symptoms of acute mania in trials
NOT RECOMMENDED for monotherapy of acute mania |
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Term
| Drugs for Tx of Acute Manic/Mixed Episodes |
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Definition
| risperidone (Risperdal), olanzapine (Zyprexa), quietapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), asenapine (Saphris) |
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Term
| Drugs for Maintenance of Bipolar Disorder |
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Definition
| risperidone consta (Risperdal Consta), olanzapine (Zyprexa), quietapine (Seroquel), aripiprazole (Abilify) |
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Term
| Drugs for Tx of Depressive Episodes |
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Definition
| olanzapine w/ fluoxetine; quietapine (Seroquel) |
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Term
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Definition
| drugs that should not be added until pt's primary medication dosing has decreased or eleminated symptoms of mania or hypomania |
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Term
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Definition
limited evidence for use in bipolar;
if added, must be used with an antimanic agent to prevent bipolar switch |
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Term
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Definition
| antidepressants found to be effective for tx of bipolar depression but due to safety concerns, other therapies should be considered first |
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Term
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Definition
| antidepressants effective for treating bipolar depression despite their SE disadvantages |
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Term
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Definition
| lorazepam & clonazepam are preferred agents, useful as adjunctive tx for acute mania; should be tapered & D/C'd once pt is stable |
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Term
| Tx for Severe Manic or Mixed Episodes |
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Definition
1) Lithium + antipsychotic OR
2) valproate + antipsychotic
3) Antidepressants tapered & D/C'd if possible
4) Psychosocial therapy |
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Term
| Tx for Less Ill Manic Pts (Mild/Moderate) |
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Definition
1) Lithium monotherapy OR
2) valproate monotherapy
3) SGAs (IM injection) - olanzapine or risperidone
4) Antidepressants tapered & D/C'd if possible
5) Psychosocial therapy |
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Term
| First Line Tx Failure in Pts w/ Acute Mania |
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Definition
1) If pt fails 1st line med, add another 1st line med
2) add carbamazepine OR oxcarbazepine OR
3) add antipsychotic
4) clozapine may be effective in refractory illness |
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Term
| First line Tx for Bipolar Depressive Episodes |
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Definition
1) Lithium OR
2) lamotrigine OR
3) divalproex
4) Antidepressant tx only used in severe depression with a mood stabilizzer
5) preferred antidepressants: venlafaxine, SSRIs |
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Term
| First line Tx Failure for Pts with Depressive Episodes in Bipolar pts |
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Definition
1) ADD lamotrigine OR
2) Add paroxetine OR
3) switch SSRI or venlafaxine |
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Term
| Treatment Guidelines for Maintenance Tx of Bipolar Disorder |
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Definition
1) Lithium
2) Valproate
3) Alternative - lamotrigine OR carbamazapine OR oxcarbazepine
4) antipsychotics - should be D/C'd |
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Term
| Tx Guidelines for Rapid Cycling |
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Definition
1) identify & tx medical conditions that may contribute to problem
2) Taper & D/C antidepressants
3) Initial Tx: lithium OR valproate
4) Alternative: lamotrigine OR carbamazepine
5) Combo therapy often required: manic patient - add 2nd mood stablizer; depressed pt - add 2nd mood stabilizer , stop antidepressant
6) Add SGA if needed |
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Term
| Tips for Pts with Bipolar Disorder |
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Definition
1) seek tx as soon as you notice episodes
2) avoid drug & alcohol use
3) maintain regular sleep patterns
4) take all meds & stay on meds even when feeling well
5) seek advice prior to taking any OTC meds
6) Establish support system |
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