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Lithium
- Classical mood stabilizer
- CI: significant, renal impairment, thyroid disorders, cardiac effects
- Pregnancy category D (greatest in 1st trimester)
- Inverse relationship w/Na+
- - Summertime- stay well hydrated
- Dose higher in acute episode than maintenance
- Therapeutic window: 0.5 - 1.5
- - 3-5 days after 1st dose (10-12 H post dose)
- DIs: caffeine decreases Li levels
- - Diuretics, NSAIDs, ACE/ARB increases Li levels
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Lithium Toxicity
- D/C or hold medication
- Gastric Lavage
- Supportive Care
- Severe Toxicity: Hemodialysis
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divalproex sodium
- Depakote
- Classical mood stabilizer
- Mixed episodes
- Increased LFTs (3x UNL), NH4
- CI: severe liver damage, hematologic abnormalities (caution)
- Pregnancy category D (DNU in 1st trimester)
- Sedation, GI upset, hand tremors (switch to ER- increase dose by 8-20%)
- Weight gain, thrombocytopenia
- Therapeutic window: 50-100 mg/L
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lamotrigine
- Lamictal
- Approved for Bipolar I, but works best in Bipolar II / Depression
- SJS (titrate slowly- greatest in 1st 3 weeks)
- - MonoTx- 25 mg/day
- - Inducer (carbamazepine) 50mg/day
- - Inhibitor (Depakote) 25 mg QOD
- Pregnancy category C
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carbamazepine
- Tegretol, Carbatrol
- Alternative Tx
- CI: bone marrow suppression
- Pregnancy Category D
- 3A4 Auto inducer (adjust dose in 3 weeks)
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DNU
- Keppra (levetiracetam)
- Neurontin (gabapentin)
- Topamax (topiramate)
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Severe Sx / Episode
Lithium / Depakote + SGA
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Mild Sx / Episode
Li / Depakote / SGA
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Adjunct
- BZDs
- - Acute Agitation, Irritation, Mania, Anxiety, Panic, Insomnia
- - Klonopin (clonazepam)
- - Ativan (lorazepam)
- SGA
- - Behavioral issues- agitation, irritation
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Manic/mixed episodes
- 2nd Line
- - Keep Mood stabilizer
- - Add another mood stabilizer or switch SGA
- Antidepressants should be tapered down
- Breakthrough Sx: Optimize therapy, add antipsychotic if needed
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Bipolar II
- Do not maintain on antidepressant as monotherapy (induce mania)
- - TCAs have greatest risk
- - SSRI generally used
- 1st Line- Li or Lamictal as monotherapy
- - Severe- Li + SSRI
- - BP II w/psychotic features- add SGA
- 2nd line- keep on previous agent and add Lamictal / Paxil / Welbutrin
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Rapid Cyclers
- Combination Tx
- - Lithium or Depakote
- Alternative: Lamotrigine
- Inducers of Rapid Cycling
- - Medical conditions (hypothyroidism)
- - Substance abuse
- - Antidepressant use
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Typical (FGA)
- Adjunct/acute symptoms
- Haldol- IM formulation
- More susceptible to EPS
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Atypical (SGA)
- Preferred over FGA, more effective in combination w/a mood stabilizer
- May use in bipolar depression
- - quetiapine and fluoxetine/olanzapine (Symbyax)
- Geodon (ziprasidone)
- Abilify (aripiprazole)
- Latuda (lurasidone)
- Risperdal (risperidone)
- Saphris (asenapine)
- Seroquel (quetiapine)
- Zyprexa (olanzapine)
- Vraylar (cariprazine)
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