What are the general goals of treatment for bipolar disorder?
- Reduce frequency, severity & duration of mood episodes
- Prevent suicide
- Maximize adherence with therapy
- Minimize adverse effects i.e. employ medications w the most acceptable tolerability & fewest DDIs
What are the goals of treatment for an acute episode of bipolar disorder?
Eliminate mood episode with remission of symptoms
What are the goals of treatment in the continuing phase of bipolar Tx?
- Reduce frequency, duration & severity of recurring mood episodes
- Reduce suicidal ideation or attempts
- Regain psychosocial functioning
- Avoidance of stressors or substances that may precipitate an acute mood episode
What are the non-pharm Tx options?
- Psychoeducation about the disorder, treatment and monitoring for the patient and caregiver
- Psychotherapy – to help individual, group and family members
- Stress reduction techniques, relaxation therapy etc
- Sleep hygiene – regular bedtime and wake schedule, avoid alcohol or caffeine prior to bedtime
- Nutrition – balanced nutrition (normal requirements for general health)
- Exercise (normal requirements for general health)
How should initial treatment of an acute bipolar episode be done?
- Short course of PRN BZD – to help the patient relax and sleep
- Onset of effectiveness: within hours
- Taper off when condition improved and mood stabiliser has been optimised
- Start mood stabilizer
What are the mood stabilizer options for manic episodes?
- Antipsychotics
(2nd gen: Olanzapine, Quetiapine, Risperidone, Aripiprazole|1st gen: Haloperidol) - Lithium (should only be initiated by specialists)
- Valproate (least preferred, should only be initiated by specialists)
What are the mood stabilizer options for depressive episodes?
- Lithium (should only be initiated by specialists)
- Antipsychotics (2nd gen only) – Quetiapine, Olanzapine + Fluoxetine
- Lamotrigine (does not treat mania, can result in rash)
At what serum concentrations is lithium considered toxic?
Mild= 1.5-2.0
Moderate= 2.0-2.5
Severe >3.0
What are the symptoms of lithium toxicity?
GI: N/V/D (gets worse with increasing toxicity levels)
CNS:
* Mild: Lethargy, confusion, coarse hand tremors, drowsiness, lightheadedness
* Moderate: Slurred speech, ↑confusion, ataxia, blurred vision, profound lethargy, tinnitus, apathy
* Seriously impaired consciousness, ↑deep tendon reflexes, stupor, coma, seizures, death
What are the DDIs predisposing to lithium toxicity?
- Sodium depletion
- Thiazides
- ACEi/ARBs
- NSAIDs
- Dehydration
- Neurotoxicity may occur when Li+ is combined w CBZ, diltiazem, losartan, methyldopa, metronidazole, phenytoin, verapamil
What are the monitoring parameters for lithium?
- TDM: 0.6-1.0 mmol/L (highest 1.2mmol/L)
- FBC: baseline and Q6-12/12
- Renal panel & electrolytes: baseline and Q6-12/12
- TFT: baseline and Q6-12/12
- Metabolic parameters: baseline and Q6-12/12
What are the monitoring parameters for valproate for bipolar?
- TDM: 50-125 mg/L
- FBC: baseline and Q6-12/12
- LFTs: baseline and Q6-12/12
- Metabolic parameters: baseline and Q6-12/12
What are the monitoring parameters for carbamazepine for bipolar?
- TDM: >7mg/L for bipolar (limited evidence), 4-12mg/L for epilepsy
- FBC: baseline and Q6-12/12
- LFTs: baseline and Q6-12/12
- Renal panel & electrolytes: baseline and Q6-12/12
What are the monitoring parameters for lamotrigine for bipolar?
- baseline FBC
- LFTs: baseline and Q6-12/12
- baseline renal panel and electrolytes
What are the monitoring parameters for 2nd gen APs for bipolar?
- Metabolic parameters: baseline and Q6-12/12
How long is an adequate trial for manic episode medications?
2-4/52
When should carbamazepine be used for bipolar mania?
Used when following lines of defence are all ineffective
→ Mania has not responded within 2-4/52 w an established (1st line) mood stabilizer
→ Augment with a second first line agent (ie add on)
→ Switch to a 2nd gen AP e.g. Olanzapine
How should bipolar disorder with rapid cycling be handled?
- Avoid antidepressants/stimulants in rapid cycling or Hx of antidepressant-induced mania
- Evaluate and treat underlying hypothyroidism, hormonal imbalance, substance abuse
- For antidepressant-induced rapid cycling – avoid and taper off antidepressant and other agents that inc NE or DA activity (e.g. CNS stimulants, sympathomimetics, caffeine)
- Optimize mood stabilizer treatment – Valproate, Lithium, Lamotrigine
What are the considerations in treating bipolar during pregnancy?
- Pregnancy should be planned in consultation w psychiatrist and OBGYN to weight risks vs benefits – e.g. whether to gradually taper medications, avoid a drug in 1st trimester or throughout pregnancy, risks of mood episodes after stopping
- ?Safer options: Quetiapine, Olanzapine, Risperidone, 1st gen APs – monitor for SEs
- Avoid valproate – risk of neural tube defects
- Lithium – small risk of Ebstein anomaly, but likely need dose adjustments
- Carbamazepine also implicated with teratogenicity
- Consider ECT for severe mania, mixed episode, depression or psychosis
What are the considerations for treating bipolar disorder during breast-feeding?
Weight risks vs benefits – all mood stabilizers are secreted into breastmilk
What are the possible options for bipolar pts with cardiac disease?
Consider Valproate – monitor ↑BP, ↑HR, peripheral edema
What are the possible options for bipolar pts with renal impairment?
Lithium
What are the possible options for bipolar patients with renal impairment?
Consider Valproate – monitor serum levels closely
What are the possible options for pediatric patients with bipolar disorder?
Lithium, Valproate
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Neuropharmacology - Antiepileptics44
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Neuropharmacology - Anti-migraine16
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Neuroanatomy14
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Schizophrenia7
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Schizophrenia - Treatment32
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Depression7
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Depression - Treatment29
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Bipolar4
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Bipolar - Treatment27
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Anxiety9
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Anxiety - Treatment8
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Sleep Disorders4
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Sleep Disorders - Treatment15
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Parkinson's3
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Parkinson's - Treatment20
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Dementia15
