BIPOLAR DISORDER MANAGEMENT BY:AMIRUL IZWAN BIN MANSOR

MODE OF THERAPY

1)PHARMACOTHERAPHY LITHIUM ANTICONVULSANT ATYPICAL ANTIPSYCOTIC

LITHIUM MOOD STABILIZER DOC FOR ACUTE MANIA AND PROPHYLAXIS FOR MANIC AND DEPRESSIVE BIPOLAR DISORDER. MOA: unknown but has shown it may alter neuronal sodium transport ONSET OF ACTION: 7-14 DAY

LITHIUM EXCRETION = 95% ATTENTION!!! : IT HAS LOW THERAPEUTIC INDEX. DAILY DOSE = 400-1200MG LEVEL: 0.7 – 1.2 (TOXIC > 1.5, LETHAL >2.0)

L EUKOCYTOSIS (BENIGN) I NSIPIDUS ( NEPHROGENIC DIABETES) * SIDE EFFECT L EUKOCYTOSIS (BENIGN) I NSIPIDUS ( NEPHROGENIC DIABETES) * T REMOR,TERATOGENIC (EBSTEIN ANOMALY)* H YPOTYROID *, HYDRATION > DRY MOUTH , THIRST, HYPERPARATHYROIDISM I SHAL (DIARRHEA), INCREASE URINE , (POLYUREA) U NCONTROL VOLUNTARY MOVEMENT , (ATAXIA) M ETALLIC TASTE, NAUSEA, VOMITING. *LONG TERM EFFECT

BEFORE U GIVE PATIENT LITHIUM….CHECK……

1- Pregnancy test 2- Thyroid function test 3- KFT 4- CBC

MONITOR????? SERUM LEVEL OF LITHIUM 2. TYROID FUNCTION TEST - 2-3 TIMES PER WEEK INITIALLY AFTER GIVING LITHIUM TO PATIENT - EVERY 3 MONTH ONCE THERAPEUTIC LEVEL HAS REACHED 2. TYROID FUNCTION TEST -EVERY 3 M INITIALLY, THEN EVERY 6 M. 3. KIDNEY FUNCTION TEST -EVERY 3 M 4. OTHERS: -ECG, SERUM NA, CALCIUM, PTH

WHAT MAY AFFECT LITHIUM LEVEL????? INCREASE DECREASE NSAIDS DIURETICS ACEI,ARB LOW SODIUM INTAKE DEHYDRATION THEOPHYLLINE CAFFEINE ANTACID

ANTICONVULSANT CARBAMAZEPINE VALPROIC ACID

CARBAMAZEPINE (tegretol) USE: MIXED EPISODE AND RAPID-CYCLING BIPOLAR DISORDER MOA: act by blocking sodium channels and inhibiting action potentials, GABA receptor agonist. Onset of action is 5-7 days DAILY DOSE: UP TO 1200MG DAILY IN 3 OR 4 DIVIDED DOSE. OTHER USAGE: TRIGEMINAL NEURALGIA, EPILEPSY,DIABETIC NEUROPHATY. MAY DECREASE EFFICIENCY OF COCP….

SIDE EFFECT C NS (DIZZINESS, DROWSINEES, CONFUSION) A TAXIA R ASH (STEVEN’S JOHNSON SYNDROME) B LUR VISION A PLASTIC ANEMIA M IGRAINE A GRANULOCYTOSIS (ESP NEUTROPHIL) Z zzzzzz PROBLEM E LEVATION LIVER ENZYME P LATELET DECREASE I RREGULAR HEARTBEAT N AUSEA AND VOMITING

CHECK!!!! CBC LFT

VALPROIC ACID(depakine) Use: mixed manic episodes and rapid cycling bipolar disorder Mechanism : unknown but it has been shown to increase central nervous system level of gama-aminobutyricacid (GABA) Safest drug for breastfeeding mom with bipolar disorder

SIDE EFFECT V OMITING AND NAUSEA A LOPECIA L IVER TOXICITY (HEPATOTOXICITY) P ANCREATITIS R ETENTION FAT(W.GAIN) O EDEMA (PERIPHERAL) A LLERGIC / APPETITE INCREASE T HROMBOCYTOPENIA / TERATOGENIC , TREMOR E FFECT SLEEP (INSOMNIA)

CHECK!!!! CBC LFT

ANTI PSYCOTIC ATYPICAL ANTI-PSYCOTIC LIKE OLANZAPINE, QUETIAPINE, RISPERIDONE, ARIPRAZOLE, ZIPRASIDONE, CLOZAPINE. EARLY, SHORT TERM USE: ADJUNCTS IN THE EARLY COURSE OF MANIC EPISODE IF PSCHOTIC SYMPTOM ARE PRESENT

SIDE EFFECT Anti-HAM (antihistaminic , antiadrenergic , antimuscarinic) Agranulocytosis about 1% Seizures about 2-5% Hyperlipidemia Glucose intolerance Weight gain Liver toxicity (so clinician monitor LFTs)

QUIZ Patient with bipolar disorder coming to the clinic, after suffering of blistering skin. Now, he is on the medication for bipolar disorder. Which drugs that may cause this problem?

A 32 year old female , newly given birth to a baby , she is a known case of bipolar, she is a breast feeding mother , she came to the clinic seeking medical help and refusing to be hospitalized . What is the safest drug that u will give her?

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