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Informatics in Pharmacy

Bipolar Disorder

August 13, 2018 By Dr. G, PharmD

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Manic Episode:

  • 1 week of abnormal and persistently elevated mood. inflated self-esteem, irritability, decreased need for sleep, flights of ideas, poor attention span, high-risk behaviors.
  • Bipolar 1: one or more manic or mixed episodes and major depressive episodes
  • Bipolar 2: one or more major depressive episodes accompanied by at least one hypomanic episode
  • Cyclothymic disorder: Periods of hypomania and depression that don’t meet criteria
  • Rapid cycling: Four episodes of mania or depression in one year.

Lithium:

  • Lithium is the gold standard for bipolar 1. Not good for unipolar depression, but has anti-suicidal effects in bipolar.  Effects take 1-2 weeks.  Most use antipsychotics or benzos during this period.
  • Initial lithium dose is 600-900mg/day in divided doses and then titrate.
    • Lithium has a narrow therapeutic index: 0.8-1.2 mEq/L.  A 300 mg increase can increase by 0.3 mEq/L.
    • >1.5 is toxic (GI complaints, tremor, altered mental status)
    • >2 can be lethal
    • Get trough 12 hours after last dose and every 1-2 weeks for 2 months and then every 3-6 months.
  • Get CBC, eletrolytes, renal function, thyroid function, urinalysis, ECG, and pregnancy test before starting.  Renal function test, thyroid test and urinalysis every 6-12 months
  • Lithium toxicity: lethargy, coarse tremor, confusion, seizures, coma and death
  • Renal impairment can increase dose
  • Avoid in pregnancy
  • Drug/Drug Drug/Food Interactions
    • Increase Lithium Concentrations: SSRIs, NSAIDs, ACE inhibitors/ARBs, Diuretics: thiazides, spironolactone, furosemide, metronidazole, tetracyclines, topiramate, medicines that affect electrolyte balance
    • Decrease Lithium Concentrations: theophylline, caffeine, Sodium bicarbonate and sodium chloride containing products, psyllium or ispaghula husk, urea, mannitol, acetazolamide, salt in food
    • Aggravate neurotoxicity:  haloperidol, risperidone, clozapine, phenothiazines, SSRIs, sumatriptan, tricyclic antidepressants, Calcium channel blockers, Carbamazepine, phenytoin, Methyldopa
    • Lithium can prolong the effects of Neuromuscular blocking agents
    • Anything that affects sodium or the kidneys affects lithium
  • Adverse effects: weakness, tremor, nausea, acne, hypothyroid, renal issues, polydipsia, hypercalcemia, parathyroid issues, calcium imbalance, confusion, leukocytosis, alopecia, weight gain, slurred speech, seizures
  • Lithium alternatives: carbamazepine (rapid cycling), oxcarbazepine (avoids some carbamazepine side effects), valproate without lamotrigine or lamotrigine with divalproex.

Filed Under: Guideline Materials and Tips, Psychiatry

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acid base acidosis acute coronary syndrome alkalosis analgesics anaphylaxis aortic dissection arrhythmia Beta-Blockers biostatistics blood pressure cardiac markers CHA2DS2-VasC cocaine COVID-19 diabetes diabetes inspidius Guidelines heart failure Heparin hypersensitivity hypertension hypovolemic shock intubation ionotropes journal club lipids LMWH medication safety morphine conversions myocardial infarction needs work NOAC NSTEMI obstructive shock pharmacoeconomics pheochromocytoma pressors reference materials right mi sedation septic shock shock STEMI Updated 2020