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Lithium
antimanic classification
- naturally occuring salt, it is an alkali metal (from the ground) can cause a metallic taste in your mouth
- potentially dangerous, toxicity a major problem, needs frequent monitoring- thyroid, htn
- most effective and widely used anti manic agen
- also used in prevention of recurrence of biplar disorder
- used since 1960's
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lithium discovery
- found in coca cola, 7 up back in the day.
- 1949 american psychiatrist John Cade found it to stabilize mania
- accidental discovery
- he believed there was a link between uric acid and mental illness and he used lithium urate and found that those hyper people turned calmer
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Lithium
- alters NT in the CNS, it interderes with the Ionic pump mechanism in the brain
- although ist exact mode of action is unknown, it affects NE and 5HT, dec levels available at the synapse
- no sedative effects
- because lithium is an ion it can be measured in the blood
- narrow therapeutic index:
- - levels desire- acute phase 1.0-1.5
- maintenance 0.6-1.2
- levels closely linked to hydration and sodium intake
- body see lithium as salt
- thirsty alot
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lithium how to take and how it works
- takes 1-10 days to work (dec symptoms), 1-3 weeks for therapeutic levels
- pts should take for two yrs
- it missed a dose can take up to 2 hours after sched time or skip it
- blood levels should be taken prior to treatment, after each dosage inc and evry 2-3 month and when there is a behavior chx (re-emergence of symptoms)
- note: draw blood in AM prior to next dose and wait for the lab results prior to administering next dosel
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lithium side effects
- n&v, diarrehea, anoerexia, abd pain
- tremors, slow cognition, forgetfulness
- polydypsia, polyuria (kidney)
- weight gain
- take after meals, smaller doss, more frequently, slow release= lower peaks- helps to decre side effects (can get encentric coated lithobid)
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lithium toxicity
- very toxic
- n&v diarrehea
- slurred speech, thirst (early symptoms)
- over sedation, confusion
- ataxia, muscle weakness, coarse tremors
- seizures, coma
- death can occur form respiratory complications
- > 2 mEq/L consider toxic
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lithium contraindications
- need adequate salt and fluid intake- DO NOT TAKE DIURETICS (no low/no salt diet). Li and Na compete. dec Na causes reaborption of Li, incr Li levels
- contraindicated with impaired renal function. CHF, Sodium restricted diets (interferes with ionic pmp in intracellular in body as well as the brain particularyly with sodium chloride)
- organic brain syndrome, pregnancy d/c med. lactation, encourage family planning
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lithium caution
- caution with increased sweating, with fluid and electrolyte losses thru fever, diarrehea, vomiting, excessive sweating etc. it can ince the concentration of lithium, if pt has GI virus should call md to see if should hold lithium
- NSAIDS, medical illness, tetracyclic, tegretol, marijuana, uses incre the lithium levels
- LiCO3 enhances effects of other meds cautions
- fasting crash dieting can lead to toxicity bc alter Na, electrolytes, and fluid balance
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Lithium long term
- long term potential side effects. kidney changes (excreted by the kidney), thyroid dysfucntion
- need to monitor thyroid and kidney function
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mood stabilizing agents- anticonvulsants
- valproic acie (depakote)
- tegretol (carnamazine)
- trileptal (oyxcarbazepine)
- lamotrigine (lamictal)
- gabapentin (neurotin)
- topiramate (topamax)
- clonazepan (klonopin)
- regular and sustained release forms
- most often need to take for life
- cant come off these cause mood will be messed up
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mood stabilizing agent- anticonvulsants
- actions in the tx of bipolar is unclear
- SE= NV, drowiness, dizzyness, blood dyscrasias (low wbc, suppress bone marrow), prolonged bleeding time with VPA, risk of severe rash with lamotrigine (steven johnson syndrome) and toxic epidermal necrolysis, decreasd efficacy of BC with topiramide
- these are not antidepressants- effective? can they work, carry out life responsibilities?
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anticonvulsants- depakote (valproic acid)
- cns excitation (inhibits glutamate)
- used- rapid cycling, conmonitant seizure D/O, hx of brain damage, schizoaffective d/o
- better tolerated than lithium more effective treating maniavs depression and is used for preventative therapy (maintenance)
- normal levels- 500-100
- se: drowiness, dizziness, hypotension, bradycardia, nausea, constipation, incr bleeding time, check LFT, CBC
- adverse effects: weight gain, gi upset, sedation hair loss, liver toxcity, ataxia, check for mild leukopenia, WBC > 3,000, prolonged bleeding time, thrombocytopenia, and platlets induce pancreaitis
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Verapramil- mood stabilizer Ca channel blocker
- cardiac contraindication
- do not d/c abrupt
- rise slowly from sitting/lying to prevent sudden drop in bp
- report following symptoms to md:
- - irregular heart beat, chest pain
- - sob, pronounce dizziness
- - swelling of hands and feet
- - profound mood swings
- - severe and persistent h/a
- do not use in pt with left ventricular dysfunction, heart block, hypotension or CHF
- watch- cardiac hx, HR, HA
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other medications for mania
- antidepressants may trigger bipolar cycle acceralation
- symbyax- a combo of prozac and zyprexa- treat depressive episodes w/o triggering mania
- during manic phase, ect may also be used for illnesses that do not respond to pharmacologic interventions including mania, severe suicidality
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Mania with psychotic features
- antipsychotics block dopamine in the brain, dec DA concentration in CNS, tranquilizing effect
- high incidence of antichol se
- antipsychotics: abilify, saphris, zyprexa
- - do not discontinue drug abruptly
- - use sunblock lotion when outdoors
- - rise slowly from sitting or lying
- - avoid alcohol and over the counter medications
- - continue to take the meidcation, even if feeling well and as though it is not needed, sumptoms may return if med is discontinued
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antipsychotics
- cause orthostatic hypotension- goes away 3-4 weeks, hyperglycemia
- report the following symptoms to physician:
- - sore throat, fever, malaise- dec wbc
- - unusual bleeding easy bruising skin rash- dec plat
- - persitent n/v- gi, pancreas
- - severe ha. rapid hr
- - difficulty urinating or excessive urinating
- - muscle twitching tremors
- - darkly colored urine, pale stools- liver
- - yellow skin eye,
- - excessive thirst or hunger
- - muscular incoordination of weakness
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tx modalities for bipolar disorder
- the recovery model (continous process)
- Learning how to live a safe, dignified full and self determined life in the face of the enduring disability which may at times be associated with serious mental illness
- client identifies goals
- client and clinician develop tx plan
- client and clinician work on strag to help the individual manage the bipolar
- clinician serves as support person to help the individual achieve the previously identified gials
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tx modalities for bipolar disorder
- some strag may be
- become an expert on the disorder
- take meds as prescribed
- become aware of earliest symptoms
- develop a plan for emergencies
- identify and reduce source of stress, know when to seek help
- develop a personal support system
- although there is no cure for bipolar, recovery is possible in the sense of learning to prevent and minimize symptoms and to successfully cope with the effects of the illness on mood, career social life
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