pharmacotheray exam 3 bipolar

  1. what are the suptypes of bipolar?
    • BIPOLARI-manic or mixed episode +/- major depressive episode
    • BIPOLARII- hypomanic episode + major depresseive episode (more common in women)
    • CYCLOTHYMIA--fluctuations between subsyndromal depressive and hypomanic episodes
  2. what is DSMIV criteria for manic episodes
    • more than 1 week period of abnormal and persistent elevated mood associated with atleast three:
    • inflated self esteem (grandiosity)
    • decreased need for sleep
    • increased talking (pressure of speech)
    • racing thoughts (flight of ideas)
    • distractible (poor attention)
    • increased activity (either socially, at work or sexually) or increased motor ativity or agitation
    • excessive involvement in activities that are pleasrueable but have a high risk of serious consequences --buying sprees, poor judgment in business venture
  3. what are symptoms of a manic episode?
    • decresae sleep**KEY**
    • euphoria
    • irritability
    • expansiveness
    • others--psychotic symptoms
    • manifestations--pressure speech
    • hypererbosity
    • physical hyperactivity and agitation
    • decresaed need for sleep
    • hypersexuality
    • extravagance
    • impraired judgment
  4. what is presentation of manic episode
    • usually escalates quickly over several days
    • changes in sleep cycyle often first clue to episode
    • seasonal changes, stressors, sleep deprivation, antidepresssants can precipitate episode
    • attention span is usually very short resultuing in flight of ideas
    • severe stages o fepisode may resembe schizo with bizarre behavior hallucinations and delusions
  5. atypical fatures of bipolar
    • hypersomnia
    • hyperphagia
    • leaden paralysis
  6. what is hypomania?
    what is mixed episode?
    what is rapid cycling?
    • HYPOMANIA--similar to manic episode, however needs only to be present for 4 days and does not impair functioning
    • MIXED EPISODE--simultanesou occurence of mania and depressive symptoms for nearly ever day for atleast 1 week period (unresponsive to monotherapy)
    • RAPID CYCLING-->= 4 major depressive or manic episodes (manic mixed or hypomanic) in 12 months associated frequcntly with clinicl or subclinical hypothyroidism
  7. what are factors that affect compliance
    • human nature
    • side effects
    • substance abuse
    • missing highs
    • lack of insight
    • complex medication schedules
    • lack of psychosocial support
  8. what are the agents used to treat bipolar
    • LITHIUM--actue and prophylatcic treatment of bipolar dz
    • DIVALPROEX SODIUM--approved for treatment of acute mania
    • CARBAMAZEPINE--acute manic and mixed episodes
    • OLANZAPINE, RISPERIDON, QUETIAPINE, ARIIPRAZOLE, ZIPRASIDONE, ASENAPINE---approved for treatment of actue manic or mixed episodes
    • Olanzapine/fluoxetine, quetiapine--fda approved for depressive episodes assoiated with bipolar dz
    • lamotrigine, olanazpine, aripiprazole, fda approved for maintenance treatment of bipolar I
  9. what drugs treat acute mania
    • lihium
    • valproic acid
    • atypical antipsychotics
    • carbamazepine
    • ADJUNCTIVE--benzos
  10. treatment for acute bipolar depression
    • lamotrigine
    • lithium
    • valproic acid
    • atypical antisychotics
    • carbamazepine
    • ANTIDEPRESSANTS--use cautiously
  11. what are lithium pharmacokinetic
    • rapidly and completely absorbed
    • widely distributed--distributes to muscle bone and thyroid and approximates
    • no protein binding
    • excreted renally with no metabolism
    • t1/2 20 hours
    • enters and leaves the CNS slowly
    • narrow therapeutic index
  12. what is lithium treat
    • classic euphoric mania
    • good predictors of response--fam history of lithium response, few prevoius episodes
    • POOR RESPONSe--rapid cycling disorder, numerous previous episodes ofmania, dysphoric mania, psychotic mania
  13. what is dosing00intial/maintenance and plasma concentrations
    • INITIAL--600mg/day prophylaxis, 900-1200 mg/day acute mania
    • MAINTENANCE--titrate by 300-600 mg/day q 2-3 days, target dose usually 900-2400 me/day to reach desired plasma concentrations
    • acute mania--0.8-1.5 meq/L
    • maintenance 0.6-1.2meq/L
  14. what are intial lithium adverse effects
    • abdominal discomfort/nausea
    • metallic taste
    • fine tremor
    • muscle weakness
    • lethargy
    • polydipsia/polyuria
    • headache
    • confusion
  15. what are long term lithium adverse effects
    • polydipsia/plyuria
    • goiter/hypothryoidism
    • benign reversible leukocytosis
    • fatigue/lethargy
    • weight gain
    • ekg changes
    • dermatologic effects
  16. when serum concentration monitor lithium
    • once to twice weekly to start
    • once desired concentration attained monitor every 1-2 weeks for 2 months or until concentrations stabilized
    • four to five days to reach steady state
    • maintenance concnetrations monitorying ever 3-6 months
  17. what symptoms fall under lithium intoxication at 1.2-1.5 meq/l
    • imparied concentration
    • lethargy/fatigue
    • irritability
    • muscle weakenss
    • nausea/vomiting/diarrhea
    • worsening tremor
  18. what symptoms fall under lithium intoxicatino at 1.6-2.5meq/l
    • disorientation
    • confusion
    • drowsiness
    • coarse rtremor
    • vomiting
    • ataxia
    • muscle fasciculation
  19. what symptoms fall under lithium intoxication at levels >2.5meq/l
    • imparied consciousness
    • coma
    • arrhtyhmias
    • eps
    • seizures
    • deliurium
    • hypotensin
    • death
  20. what is treatment for lithium intoxication
    • reduce dose/discontinue
    • gastric lavage
    • hydration
    • incresa sodium intake
    • dialysis
  21. what are lithium drug interactions
    • diuretics--primarly thiazide type, reduce clearance by 25-30%
    • ace inhibitors--some incresd lithium levels
    • xanthings--increas lithium excretion
    • NSAIDS caseu reabsorption of NA and LI
  22. what are good things to take valporate for
    • effective in patients less responsive to lithium--rapid cycling patterns, mixed mania
    • LOADING DOSE--20mg/kg for rapid stabilization--normal dose being at 5-10mg/kg/day
    • dose titrated based on respose and adverse effects--plasma concentrations 50-125mcg/ml
  23. adverse effects of valporate
    • GI upset
    • sedation
    • tremor
    • weight gain
    • hair loss
    • increased liver function
    • LESS COMMON--impaired platelet function, thrombocytopenia, polycystic ovary disease
    • RARE--irreversible hepatic failure, pancreatitis
  24. what do you use carbamazepine for
    • mixed states
    • rapid cycling
    • neurologia dz
    • TEHRAPUETIC RANGE--4-12 mcg/ml
    • CYPA3A4 substrate
    • induced multiple isoenzymes
    • response seen in 1-2 weeks
  25. ADVERSE EFFECTS carbamazepine
    • neurotoxic--sedation, dizziness, sipolopia, ataxia
    • headache
    • gastrointestinal
    • leukopenia
    • thromocytopenia
    • increased LFTs
    • rashhyponatreamia
    • RARE--agranulocytosis/aplasitc anemia
    • SJS
    • hepatic failure
  26. contraindications for carbamazepin
    • hypersensitivity to TCAs
    • concomitant use of MAOIs
    • history of bone marrow depleation
  27. what do you use olanzapine for
    • acute mania
    • 10mg/day initially, adjust 5-20 mg/day based on clinical response
    • adverse reactions--somnolence, drymouth, dizziness, and weight gain
  28. what are metabolisms you need tobe aware of of atyical antipsychoitcs
    • olanzapine--cyp1a2 and glucuronidation
    • asenapine cyp1a2 and glucuronidation
    • risperidonecyp2d6
    • quetiapine cyp3a4
    • aripiprazole cyp 2d6 nad cyp3a4
    • ziprasidone primarily non cyp 450 metabolism
  29. what is treatment for maintanenceof bipolar
    • lamotrigine, lithium, olanzapine, aripipraozle, and valporate decrase relapse rate in most studies
    • after remission of acute episode continue mood stabilizer wile discontinuing adjunctive treatments treat breakthrough episodes of hypomania or depression wiht short term adjunctive medications
  30. what is lamotrigene for
    • bipolar depression--delays time to occurence of mood episodes, greater effect on depressive episodes, drug interations, enzyme inhibiors increase levels
    • adverse effects--headache, dizziness, ataxia, diplopia, drowsiness, tremor, nausea, rash--higher dose for faster tiration, SJS
  31. whats dosing for lamotrigene
    • need to adjust based on concommit drugs--25, 50, 100.
    • valproate 25 qod, 25 q day, 25-50 qday
    • carbamazepine 50, 100, 100
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pharmacotheray exam 3 bipolar
bipolar disease