Bipolar

Question 1

What is bipolar disorder?

Answer 1

• Fluctuatoins in mood from an extremely sad or hopelss state to an abnormally elevated, overexcited or irritable mood called mania

Question 2

What is bipolar I?

Answer 2

• at least one episode of mania
• Maina is associated with at least one of the following: impairment in social or work functions, psychosis/delusions, or hospitalization

Question 3

What is bipolar II?

Answer 3

• at least one episode of hypomania (lasting > 4 days) and at least one depressive episode
• This DOES NOT affect social/work, DOES NOT cause psychosis, NO hospitalization

Question 4

What are some of the symptoms of mania as described in the DSM-5 Diagnostic criteria?

important slide

Answer 4

• Inflated self esteem
• Needs less sleep
• More talkative than normal
• Jumping from topic to topic
• Easily distracted
• Increased in goal-directed activity
• High risk pleasurable activities (Gambling, buying sprees…)

Question 5

what are some of the drug treatment options that are used for bipolar?

Goal is to stabilize the mood WITHOUT inducing a depressive or manic state

Answer 5

• Mood Stabilizers (Lithium) & Antiepileptics (Valproate, Lamotrigine, Carbamazepine) treat BOTH mania and depression
• Antipsychotics can help stabilize the mood when mania occurs
• Antidepressants can induce mania when given alone (should be used with Mood Stabilizers)

Question 6

What is the acute treatment for a manic episode?

Answer 6

• Antipsychotic (olanazpine, risperidone), lithuim or valproate

Antipsychotic + Lithium or Valproate for severe episodes

Question 7

What is the Acute treatment for a depressive episode?

Answer 7

• Antipsychotic (quetiapine, lurasidone).
• Lithium, Valproate or Lamotrigine can be added

Question 8

What medications should be used as maintenance after a manic/depressive episode?

Answer 8

• What helped the acute episode = helps prevent relapse
• i.e.; lithium, antiepileptics, 2nd gen antipsych

Antidepressants NEED a medguide = ALL have increased suicide risk

Question 9

What are the antepileptic drugs that are commonly used to help with bipolar disorders?

Answer 9

• Lamotrigine (Lamictal) [needs slow tiration to prevent rashes & NOT for acute maina]
• Valproate (Valproic Acid, Divalproex)
• Carbamazepine

Question 10

What are some of the 2nd generation antipsychotics that are commonly used to help with Bipolar disorders?

Answer 10

• Aripiprazole (Abilify)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)
• Ziprasidone (Geoden)

Question 11

What is the MOA for lithium (lithobid)?

Answer 11

• Works to influence the reuptake of serotonin and/or noepi or by moderating glutamate levels in the brain (high levels could cause mania)

Question 12

What are some warings for lithium?

Answer 12

• Serotonin syndrome

Question 13

What are some within therapeutic range side effects for lithium? What is the therapeutic range?

Answer 13

• GI upset (N/D), cognitive effects, cogwheel rigidity, tremor, thirst, polyuria/polydipsia, weight gain, hypothyroidism
• 0.6 - 1.2

Question 14

What are some toxicity side effects for lithium?

Answer 14

• > 1.5 mEq/L: ataxia, coarse hand tremor, vomiting
• > 2.5 mEq/L: CNS depression, arrhythmias, seizures, coma

Question 15

What are some of the ways that lithium levels in the body can increase (leading to toxicity)?

Answer 15

• Decreased NaCl intake or sodium loss (with ACEi or ARBs)
• NSAIDs (aspirin and sulindac is safer)

Question 16

What are some of the ways that lithium levels in the body can decrease (worsen the effect)?

Answer 16

• Increase n NaCl intake, caffiene, theophylline

Question 17

What are some of the drugs that could increase the risk of serotonin syndrome if lithium is taken?

Answer 17

• SSRIs, SNRIs, Triptans, Linezolids…

Question 18

What are some things to monitor with lithium?

Answer 18

• Lithium levels, renal function (BUN or SCr), thyroid function (TSH/T4)

Question 19

What are some additional notes for lithium?

Answer 19

• Renally cleared
• Avoid in pregnancy

Question 20

Which drugs should be avoided in those that are pregnant or trying to become pregnant for someone that has bipolar?

Answer 20

• Valproate - can cause fetal issues [AVOID especally during 1st tri]
• Carbamazepine - can cause fetal carbamazepine syndrome
• Lithuim - increase cardiac malformations

Question 21

Which drug is considered the Safer options when treating Bipolar disorder in pregnant patients?

Answer 21

• Lamotrigine - is the safer option compared to other mood stabilizers
• Lurasidone - has most favorable safety profile in pregancy [limited due to it being approved for bipolar depression]

Question 22

What is the resource to where the diagnostic criteria is found for bipoar disorder?

Answer 22

• DSM-5 or Diagnostic and Statistical Manual of Mental Disorders 5th edition

Question 23

What is the convertion between the lithum formulations?

Answer 23

• 5 ml lithum citrate syrup = 8 mEq lithium ion
• 8 mEq lithium ion = 300 mg lithium carbonate tabs/caps

Question 24

Patient Case Scenario

A patient is taking 450 mg lithium carbonate BID, but reports difficulty swallowing the capsules. How many milliters of lithium citrate syrup should be given for each dose? (Round to the nearest TENTH)

Answer 24

• 7.5 ml of lithium citrate syrup per dose