From ANCC Review
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| Bipolar disorder acute phase goals | control symptoms of agitation, aggression and impulsivity. return to usual levels of psychosocial functioning. if depressed, avoid precipitation of manic episode.
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| Bipolar disorder acute phase Tx: severe mania and some mixed episodes | initiate lithium or valproate in combination with an antipsychotic
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| Bipolar disorder acute phase Tx: for less severely ill: | may use monotherapy with lithium, valproate or an atypical antipsychotic
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| Bipolar disorder acute phase Tx: if symptoms are inadequately controlled after 10-14 days | add another first line medication
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| baseline labs for lithium | BUN, Creatinine, thyroid, EKG, CBC w Diff, BMP, glucose, urine specific gravity, pregnancy test
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| baseline labs for valproate | assess for hepatic, hematological and bleeding abnormalities and pregnancy
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| Bipolar disorder stabilization and maintenance phase goals | prevent relapse and recurrence, reduce subthreshold symptoms, reduce suicide risk, reduce cycling frequency or milder degrees of mood instability, improve overall function
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| Bipolar disorder stabilization and maintenance phase Tx | maintenance medication is recommended following a manic or depressive episode. Monitor lithium or valproic levels, hematologic and hepatic functioning at least every 6 months
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| Valproic acid makes this condition worse | PCOS
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| Treatment of bipolar disorder in children and adolescents | current approach is to tx acute mania or severe aggressive behavior with atypical antipsychotic or combination with mood stabilizer.
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| This is not approved for pre-pubertal children | lithium
but studies show useful for severe aggression
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| When treated with mood stabilizing agents, children tend to | gain weight compared to adults (lithium, anticonvulsants, atypical antipsychotics)
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| Atypical antipsychotics are useful in tx bipolar disorder in children and adolescents because | they have a more rapid onset of action than lithium and mood stabilizers
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| Lithium is indicated for | acute euphoric mania and mood stabilization
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| Lithium is excreted in | the kidneys - must r/o renal impairment
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| Lithium dosage for the acute phase | 900-2400mg/day (adult) in divided doses
SR dose 900-1800mg/day
1200-1800mg/day (child) in divided doses
start at 300mg 2-3x/day and adjust
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| Maintenance dosage of lithium | adolescent or adults 900-1200mg /day
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| lithium has a __ half life and __ therapeutic index | long half life
narrow therapeutic index
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| Response to lithium in acute mania may take | 7-14 days
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| Maintenance with lithium lasts | 18 months to 2 years then taper gradually
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| Due to the narrow therapeutic index, lithium requires | frequent physical exams and labs.
Check twice a week when starting, weekly with dose change
Check dose 3-4 days after dose increases and every 3-6 months after achieving maintenance dose
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| When should blood draws for lithium occur | 8-12 hours after last dose
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| Lithium Blood Levels - Acute Episodes | 0.6-1.2mEq/L
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| Lithium Blood Levels - Maintenance Episodes | 0.4-1.0mEq/L
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| Common adverse effects of lithium | tremor, weight gain, sedation, stomach upset, polyuria, thirst, edema of lower legs, hypothyroid, acne
LITHIUM
Leukocytosis, Insipidus, Tremor, Hypothyroid, Increased Urine, Mom's beware
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| Signs of lithium toxicity | nausea, vomiting, diarrhea, drowsiness, tremor, muscle weakness, giddiness, ataxia, vertical nystagmus, tinnitus, diabetes insipidus, multiorgan toxicity.
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| Lithium toxicity is a medical emergency, do the following: | discontinue immediately, emesis or lavage, check labs and EKG, dialysis may be required.
Emesis is not usually recommended due to aspiration.
Lithium will not bind to activated charcoal
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| lithium affects the kidneys at this time | Each time it peaks, ok to dose once a day
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| Lithium instructions to patients | avoid dehydration!!!
excessive salt or excessive fluid intake
take with meals to reduce GI upset
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| Excess sodium = Low sodium = | excess sodium = decreased lithium levels, low sodium = toxic lithium levels
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| These are associated with increased lithium levels | NSAIDS, thiazide, diuretics, use potassium sparing diuretics, ACE inhibitors, low sodium dehydration, renal disease
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| These are associated with decreased lithium levels | caffeine, theophylline = decreased response
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| These may reduce tremor associated with lithium | propranolol 20-30mg tid and reduced caffeine.
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| EKG should be checked for | ST segment changes, T wave flattening, arrythmias, conduction disturbances
Done baseline and annually
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| Lithium is in this class | Mood Stabilizer
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| Anticonvulsant mood stabilizers have therapeutic effects on reducing mania after | days, but mood stabilization takes weeks to months
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| Common transient adverse effects of anticonvulsants | N/V/D and sedation
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| Common maintained adverse effects of anticonvulsants | weight gain, tremor, increased risk for thrombocytopenia, risk for agranulocytosis
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| for weight gain with anticonvulsants | monitor weight and BMI, encourage diet and exercise
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| these anticonvulsants have the lowest risk for weight gain | lamotrigine and topirimate
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| to combat tremor with an anticonvulsant | consider low dose beta blocker
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| for increased risk of thrombocytopenia with an anticonvulsant | monitor PT and platelets
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| for risk of agranulocytosis with an anticonvulsant | monitor WBC
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| This anticonvulsant is known for causing issues with WBC | Carbamazepine
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| valproate/divalproex depakene/depakote is useful for | acute mania, mixed and euphoric mania. Less effective for maintenance and bipolar depression
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| Dosing for valproate | 1200-2500mg/day (adult)
up to 20mg/kg/day for child/adolescent
can use loading dose - 2mg/kg in divided doses
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| side effects for valproate | weight gain, alopecia, nausea, diarrhea, tremor, thrombocytopenia, spina bifida- if pregnant, pancreatitis, elevated LFTs, PCOD
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| Labs for monitoring valproate | LFTs - monthly and in the first 6 months then q6 months
amylase
HCG
CBC w Diff
PT/PTT baseline and q 6 mo
depakote level 2 weeks after starting then q3-6 mo
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| Depakote level should be | 50-125
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| Depakote has a black box warning for | pancreatitis
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| valproate is contraindicated in | liver disease
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| if acute mental status change, check | ammonia level
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| carbamazepine (Tegretol) dosing | 400-1200mg/day (adult)
20-30mg/kg/day (child/adolescent)
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| carbamazepine (Tegretol) good for | augmenting agent for acute mania
rapid cycling
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| Tegretol is an enzyme | inducer
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| carbamazepine (Tegretol) side effects | aplastic anemia, liver problems, thrombocyctosis, hyponatremia
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| if at risk for aplastic anemia/agranulocytosis | monitor WBC q 2 weeks x 2 months then q3 months
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| someone on tegretol is at risk for this serious side effect | stevens johnson's syndrome
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| labs for carbamazepine (Tegretol) | LFTs, CBC w diff, renal function, EKG, HCG
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| Blood levels for tegretol range | 6-12
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| gabapentin (Neurontin) dosage | 900-3600mg/day
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| this is not used for mood stabilization anymore | gabapentin - well tolerated but questionably effective.
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| Neurontin is good for | anti-anxiety, pain control effects, fibromyalgia and anti - craving
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| Side effects of neurontin | sedation, ataxia, decreased coordination
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| lamotrigine (Lamictal) dosage | 100-400mg/day
start at 25mg/day
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| lamictal is indicated for | bipolar maintenance, useful for bipolar depression
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| major risk with lamictal | Steven Johnson Syndrome. Start low and go slow
Children/adolescents have higher risk of rash than adults
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| this increases risk of rash associated with lamictal | valproate
exceeding dose recommended
exceeding dose escalation
abrupt withdrawal
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| side effects of lamictal | insomnia, headache, dizziness
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| if a pt misses more than 5 days of lamictal, | need to restart and titrate
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| topiramate (Topamax) dosage | 50-300mg/day
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| use for topamax | adjunct in bipolar disorder. Not effective as first line
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| topamax may cause | weight loss
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| side effects of topamax | short term memory loss, cognitive slowing, paresthesias, nephrolithiasis
DOPAMAX - Cognitive slowing
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| topamax is contraindicated if | chronic nephrolithiasis or glaucoma
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| oxcarbazepine (Trileptal) dosage | 300-1200mg/day
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| side effects of oxcarbazepine (Trileptal) | hyponatremia, somnolence
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| oxcarbazepine (Tegretol) interferes with this medication | birth control
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| Other anticonvulsants | Keppra, Gabitril, Zonegran, Equetro
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