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23 Cards in this Set

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What medications can cause mania?
Alcohol
Drug Withdrawal
Anti-depressants
Dopamine augmenting agents
Hallucinogens
Marijuana
Steroids
Thyroid hormone
Xanthine
OTC Decongestants (ephedra, pseudoephedrine)
St. Johns Wort
What medical conditions can cause mania?
CNS Disorders
Infection
Electrolyte/Metabolic abnormalities
Endocrine disregulation
How do you design a pharmacotherapy plan for mania?
Lithium or Valproic acid + Benzodiazepine (Lorazepam)
Add an atypical anti-psychotic if the patient is psychotic
What are some other alternatives to Lithium and Valproic Acid?
Lamotrigine
Carbamazepine
Oxcarbamazepine
Which anti-psychotic can you choose if the patient is psychotic?
Olanzapine 10 mg QHS
What is the dose, as well as the acute and maintenance serum levels for lithium?
300 mg Tid

acute mania: 1.0-1.2 mEq/L
maintenance : 0.6-1.2 mEq/L
What is the starting dose for Valproic acid? What is the serum therapeutic range?
250 mg Tid

50-125 mcg/ml
What is the dose for Lorazepam?
2-40 mg/day QHS
As the patient becomes less psychotic, taper off the anti-psychotic. If the patient is in the depressed state, substitute the antipsychotic with an anti-depressant.
If the patient presented with leukopenia, what agent would you prefer?
Lithium - side effect of leukocytosis
What is the preferred mood stabilizer if the patient presents with manic and depressive behavior over the course of the day?
Valproic acid/divalproex
If you put the patient on lithium, what do you have to monitor?
Hepatic function
Renal function
CBC
Thyroid
ECG
Lithium levels
If a patient presented with bipolar disorder, needed lithium and had comorbid hypertension, what would you be your agent of choice?
Beta-blocker

Thiazide diuretics and ACE's/ARB's increase lithium levels
What is important to counsel a patient on if they are taking lithium?
Drink extra fluids when you are sweating and do no go on a sodium restricted diet without consulting your doctor. (Na, Li compete for reabsorption in the proximal tubule. Decreased Na leads to increase Li reabsorption and increased Li levels.)
In someone taking lithium, what otc painreliever would you recommend?
Aspirin or Acetaminophen are okay
Advil is not okay (NSAIDs increase Lithium levels)
If a patient reports diarrhea, you would be concerned about dehydration and increased lithium levels. What would you tell the patient?
Notify the physician to get Li levels
Drink extra fluids
Hold any further lithium doses until a level is obtained
Early signs of lithium toxicity.
Sluggish
Drowsy
NVD
Confusion
Loss of control of body movements
If giving carbamazepine, what would you monitor for?
CBC
Resolution of symptoms
Hepatic Function
Renal Function
Electrolytes
Carbamazepine levels
Rash
Pregnancy
What are individuals of asian descent screened for prior to carbamazepine therapy?
HLA-B*1502 gene associated with TENS and SJS
What would you recommend for contraception in a patient taking carbamazepine?
Alternative method of contraception or higher dose of oral contraception
(Carbamazepine induces the P450 3A4 isozyme and reduces OC levels)
Use EE 50 mcg and a 2nd method of contraception
What antibiotic would you want to avoid in a patient taking carbamazepine?
Erythromycin - Inhibit 3A4 isozyme
Other drugs that inhibit 3A4: Azoles, Isoniazid CCBs, Fluoxetine, Fluvoxamine, Ritonavir
What drug would you prefer in pregnancy?
Chlorpromazine
The other agents (lithium, valproic acid, carbamazepine cause defects in the 1st trimester)
If the patient is experiencing a server depressive episode, what regimen would you want to start?
Lithium or Lamotrigine + an anti-depressant
or Lithium + Lamotrigine
If psychosis is present, start an atypical anti-psychotic (Quetiapine is used in acute depressive episodes in bipolar disorder)
If a patient develops seizures, valproic acid could be the cause. Why is this?
Valproic acid (divalproex) can cause elevated serum ammonia levels, which can present in a worst case scenario as seizures with foaming at the mouth. The patient can also present with excessive sedation, confusion and disorientation