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Define Biopolar -1
manic disorder(s) or mixed episode(s) plus major depressive episode
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Define Bipolar-2
major depressive(s) episode(s) plus hypomanic episode(s): never presenting with a full manic or mixed episode.
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Define cyclothymia
recurring hypomanic symptoms plus depressive symptoms: episodes are insufficient to meet DMS-4 criteria for major depressive and manic symptoms
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What percentage of the population is affected by bipolar?
3.7%
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What does an onset of a first manie epised after the age of 40 indicate?
substance abuse or other g eneral medical condition
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is bilopar recurrent?
yes, in >90% of cases
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What differential diagnosises do you need to rule out before diagnosising Bipolar?
enodcrine or metabolic disorders, hyperthyroidism, infections(encephalitis), temporal lobe epilespy, medications (alcohol, steroids, xanthines) and sleep deprivation
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Hospitalization needed for major depressive episode?
yes
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Do manic episodes need to be hospitalized?
yes
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Do hypomatic episodes need to be hospitalized?
No
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When starting a new medication, how often should you be seen?
Every two weeks
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How often should severely ill patients be seen?
weekly, instead to every two weeks for lesser ill patients
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How often should a stable patient be seen?
every month for the first 3 months then every 2 to 3 months
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Reasons for non-adherence to meds?
side effects (tremor, thrist, frequent urination, sedation, obesity, froggy feeling), missed the highs, dislike the though of mood control by meds, felt well while on a manic high, denial
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Name some mood stabilizers
Lithium, valproic acid, carbamazepine, gabapentin, lamotrigine, topiramate, oxcarbamazepine
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Drugs to treat classic mania/mixed mania
lithium, valproic acid, carbamazepine, oxcarbamazepine, SGAPs
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Drugs to treat depression as a subtype of bipolar disorder
lamotrigine, lithium, quetiapine
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Drugs to treat rapid cycling
valproic acid, lamotrigine, SGAPs
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Drugs to treat Bipolar-1
Lamotrigine, Lithium
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Maintenace drugs for bipolar disorder
Lithium, Lamotrigine, SGAPs
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Is Lithium effective in unipolar depression?
no
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How effective is Lithium in aborting manic/hypomanic episodes?
60-80% typically, may take about 7 days
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Name some pre-lithium work-up labs
CBC, electrolytes, renal function, TFT, urinalysis, ECG, BHCG
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Serum concentation for acute mania of lithium dosing
0.8-1.2 mEq/L
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Serum concentration for maintenance of lithium dosing
0.6-1.0 mEq/L
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Benefit of QDay dosing of Lithium
minimize potential renal damage
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Dosing of Lithium
- initial: 600-900 mg/d
- Maintenance: 900-2400 mg/d
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Name the drug to initiate to reduce muscle weakness or tremor
Propranolol, or you can reduce the dose of Lithium
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What is an option for CNS toxicity such as confusion or agitation with Lithium?
reduce dose
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What is an option for GI distress with Lithium?
reduce dose or switch to ER form
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How would you reduce the SE of polyuria/polydispia related to Lithium?
reduce dose, manage intake, dose hs
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Diabetes insipidus-like syndrome can be seen in patients with large fluid intake who are taking Lithium. How would you treat this SE?
Manage fluid and use HCTZ or amiloride
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Hypothyroidism can be a non-dose related SE of Lithium. How would you treat this?
D/C lithium or administer levothyroxine
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Would you D/C lithium if the patient developed a rash?
No, treat symptomatically
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How do ACE and ARBS interact with Lithium?
They increase Li concentrations
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Can a patient take NSAIDs while on Li?
Avoid, can increase Li concentrations
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Are diuretics C/I with Lithium?
diuretics-thiazides increase Li concentrations by 40-50%. Furosemide and amiloride have little effect
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1.5-2.0 mEq/L is what level of Li toxicity?
Mild- drowsiness, poor concentration, unsteady gait, hand tremors and diarrhea
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2.0-3.0 mEq/L is what level of Li toxicity?
moderate- speech difficulties, muscle weakness, confusion, sedation, and possible death
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Concentrations of >3.0 mEq/L are what level of Li toxicity?
severe- convulsions, increased deep tendon reflexes, CV collapse, death
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How often do you monitor Li levels?
weekly for first month until stable, then monthly for three months, then every six months
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Valproic acid is considered first line for...?
rapid cyclers and patients with dysphoric mood
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When should you use a delayed-release valproic acid?
To minimize GI side effects
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Do valproic capsules or EC tablets absorb faster?
capsules...and liquid..duh
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Monitoring and target level for valproic acid?
- monitor levels between: 50-125 mcg/ml
- target level: 75 mcg/ml
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Loading dose needed for valproic acid?
yes (hint- add a zero to a patient weight in lbs)
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Name some SE of valproic acid
- Hepatotoxicity (rare- monitor LFTs) a concern for children
- weight gain
- GI distress
- sedation
- Pancreatitis (rare)
- hyperammonemia (rare) tx with L-carnitine
- C/I in pregnancy
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Usual dose range for Carbamazepine?
- initially 200 mg bid
- increase every 3-4 days to a range of 600-1600 mg/day in divided doses
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Name some SE of carbamazepine
ataxia, dizziness, ha, blurred vision, hyponatremia, dry mouth, constipation, rash, hematological effects
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Lamotrigine is indicated for...?
tx of bipolar-1
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How does CBZ, phenytoin and phenobarbital affect lamotrigine?
decreased 1/2 life to about 15 hours
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How does birth control affect lamotrigine?
decreases lamotrigine concentrations by as much as 50%
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Name some SGAPs
- risperidone
- ziprasidone
- olanzapine
- quetiapine
- clozapine
- aripiprazole
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What is risperdone used for?
monotherapy or combo with VPA or Li tx of acute mania or mixed episodes of Bipolar Disorder
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What is ziprasidone indicated for?
acute mania and mixed episodes with/without psychosis
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Olanzapine indicated for?
acute mania and maintenance monotherapy and in comb tx
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Quetiapine indicated for?
short term treatment of acute manic episodes associated with BP-1 as monotherapy or adjunct to li or vpa
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Clozapine indicated for?
tx of refractory mania as monotherapy or as an add-on to therapy (not FDA approved tho)
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Aripiprazole indicated for?
tx of actue bipolar mania including manic and mixed episodes assocated with BP disorder and maintenace
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