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Mood Stabilizers

Lithium
Carbamazepine
Oxcarbazepine
Valproic Acid
Lamotrigine

Lithium

effective for manic phase and long term maintenance
stabalizes mood without causing sedation
effect starts in days; full effect 2-4 weeks

Lithium - Mechanism of Action

unknown

Lithium - with Depression

can be given with an SSRI or buproprion during a depressive episode

Lithium- Side Effects

N, D, Wt gain, polyuria, tremor, hypothyroidism
must maintain hydration and sodium intake

Lithium - Drug Interactions

Increase Lithium Levels:
-dehydration
- ACE inhibitors (captopril, enalipril)
-metronidazole
-NSAIDS
-thiazide diuretics, phenothiazides, haloperidol, fluoxetine
Decrease Lithium Levels
- calcium channel blockers
-theophyline -> inc. excretion of Li
Increased Neurotoxicity
- antipsychotics
-SSRIs
-haloperidol and NMS

Lithium - Mild Toxicity

mild (early; over days): 1.5-2mEq/L
-ataxia, course tremor, confusion, diarrhea, drowsiness, muscle twitches, slurred speech
TX: hold doses, assess S&S, Li level, VS, Pt education, rehydration

Lithium - Mod/Severe Toxicity

>2mEq/L
- gradual or sudden onset
-muscle tremor, hyperreflexia, irregular pulse,hyper or hypoTN, EKG changes
-visual/tactile hallucinations, oliguria/anuria, seizures, coma, death
TX:
-hold all doses
-Assess S&S, Li level, VS, LOC, ABCs, metabolic labs, CBCdiff, EKG
-hydration, gastric lavage, hemodialysis

Lithium - Advantages

used 40 yrs
standard for euphoric and hypomania
maintenance and prophylaxis
may be more protective for suicidality during episodes than Valproic Acid
use alone or with SSRIs
inexpensive; variety of doses

Lithium - Disadvantages

labs (renal, thyroid, cardiac, CBCdiff, lytes)
slow onset of effect
narrow therapeutic index
++ S/E

Carbamazepine (Tegretol, Tegretol XR)

anticonvulsant that can be used to treat acute mania or prophylactic for mania
- works well for rapid cyclers
-autoinducer
- mechanism of action unknown

Carbamazepine - toxicity

- therapeutic range: 4-12 ug/ml
toxicity: > 8ug/ml
N,V,L, dizzy, drowsy, HA, blurred vision, diplopia, ataxia
-common with abrupt dosing changes

Carbamazepine - Side Effects

- blood dyscrasias (thrombocytopenia, leulopenia,
rare aplastic anemia
- Skin: Stevens-Johnson Syndrome
- Hyponatremia (esp. elderly)
- Cognitive effects: sedation, ataxia, dizzy
- Neuromuscular effects

Carbamazepine - Drug Interactions

Increase levels:
- calcium channel blockers, cimetidine, erythromycin
valproate
Decrease Levels:
- phenobarbitol
Carbamazepine causes decreased level/effect for:
- hormonal contraception
- theophylline
- warfarin

Carbamazepine - Advantages

- mgt of epilepsy and paroxysmal disorders
- more rapid onset than lithium; may be more effective for mixed mania and rapid cyclers
- generally well tolerated

Carbamazepine - Disadvantages

- auto inducer (stimulates its own oxidative
metabolism
- drug interactions
- labs: CBCdiff, liver and renal fcn

Oxcarbazepine (trileptal)

mono or adjuntive therapy for partial seizures in adults
adjunctive therapy for partial seizures in children

UNLABELED USE: Acute mania, atypical panic disorder

Oxcarbazepine (trileptal) - Mechanism Action

unknown
derrivative of Carbamazepine

Oxcarbazepine (trileptal)- Side Effects

dose dependent: N, HA, drowsy, dizzy, ataxia, tiredness
Idiopathic: hyponatremia, rash, wt gain

Oxcarbazepine (trileptal) - v. Carbamazepine

no lab monitoring
metabolic s/e
decreases effectiveness of hormonal BC

Valproic Acid (Depakote)

anticonvulsant; approved for use in mania and mixed bipolar states
-useful for rapid cyclers

Lamotrigine (Lamictal)

- monotherapy for generalized seizures in adults and
children
-adjunct therapy to partial seizures (refractory)
-maintenance mood stabilizer in BP 1 Depression
UNLABELED USE: Mood stabalized in rapid-cycling bipolar II

Lamotrigine (Lamictal) - Mech. Action

inhibits release of glutamate

Lamotrigine (Lamictal) - Adverse Effects

dizzy, HA, diplopia, ataxia, N, blurred v, somnolence, skin rash
BLACK BOX: Steven Johnson Syndrome
upgraded to Pregnancy C

Topiramate (Topamax)

partial and complex seizures
NOT bipolar disorder
no studies on efficacy or safety in mood dx
may be useful in resistant pts with comorbid substance abuse and impulse control disorders

Topiramate (Topamax)- Adverse Rxns

somnolence, dizzy, vision, unsteady, nervous, N
HTN crisis
extreme increases in body temp (NMS)

GABApentin (Neurontin)

complex partial seizures
generalized seizures
neuropathic pain
NOT affective for bipolar disorder

Atypical Antipsychotics for Bipolar Disorder and Psychosis

acute treatment and prohylaxis

Atypical Antipsychotics- Mechanism of Action

- enhances 5-HT and NE -> reduces symptoms of mood and anxiety
-antagonize 5-HT and alpha-2 adrenergic receptors to varying degrees

Atypical Antipsychotics - monitoring

wt gain
obesity
type II diabetes
metabolic syndrome

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