mood stablizer

8/11/2019 mood stablizer

1/50

Mood StabilisersPsychopharmacology


2/50

Mood Stabilisers

The treatment of bipolar disordermay be divided into threeoverlapping phases

Acute manic episode

Depressive episode

Prophylactic treatment

Only 1/3 of bipolar patientsexperience adequate relief with amonotherapy.


3/50

How they work?

They have no clear effect ondopamine?? So why are theyeffective in mania?

They have no clear effect serotonin??So why are they effective indepressive episodes?


4/50

Pregnancy categories


5/50

Lithium

First original mood stabiliser

Underutilised

Appears most effective in treatingacute mania

First psychiatric drug that required

blood level monitoring


6/50

Lithium

Manic episodes of bipolar disorder

Maintenance treatment for bipolardisorder

Bipolar depression

Major depressive disorder

Vascular headache

Neutropenia


7/50

Mechanisms

Generally unknownComplex in action

Alters sodium transport across cell

membranesAlter metabolism of

neurotransmitters catecholamines,

serotonin, GABA and glutamate- May alter intracellular signalling through actions

on second messenger systems


8/50

Second messenger systems

Method of cellular signalling

Cyclic adenosine monophosphate(cAMP)

intracellular signal transduction

A different process of

neurotransmission
http://en.wikipedia.org/wiki/Signal_transductionhttp://en.wikipedia.org/wiki/Signal_transduction


9/50

Lithium

Effective within 1-3 weeks

Goal of treatment is a remission insymptoms

Many patients only have a partialresponse


10/50

Concept of Augmentation

the combination of two or moredrugs to achieve better treatmentresults

Failure of monotherapy

Better tolerability


11/50

Pre-testing

Kidney function( should be repeated1-2)

Thyroid function

ECG for patients over 50

Metabolic monitoring Fasting plasma glucose level

Cholesterol and triglycerides

BMI


12/50

Side Effects

The reason to why lithium causesside effects is complex

Excessive actions at the same orsimilar sites that mediate actions

Renal side effects= acts ontransportation of ions


13/50

Side Effects

Polyuria

Polydipsia

Diarrhoea

Nausea

Weight gain

Goiter

Acne, rash, alopecia

leukocytosis


14/50

Life Threatening Side Effects

Lithium toxicityRenal impairment

Nephrogenic diabetes insipidus

ArrhythmiasCardiovascular changes\sick sinus

rhythm

Sick Sinus syndromeBradycardia

hypotension

T wave flattening and inversion


15/50

Toxicity

Toxic Levels are very close totherapeutic levels

Symptoms;

Diarrhoea Vomiting

Course tremor

Delerium

Coma

Seizures

Monitoring for dehydration


16/50

Dosing and Using

1800mg/day in divided doses (acute)

900-1200mg/day in divided doses(maintenance)

Dosage forms 450mg (slow release)

250mg tablets

start low and adjust dosage upwardas indicated by plasma levels


17/50

Dosing

Slow release= less gastric irritation,lower peak plasma levels and peakdose side effects

Use the lowest dose of lithiumassociated with adequate therapeuticresponse

Go low in the elderly

Rapid discontinuation= increaserelapse


18/50

Monitoring

Therapeutic Levels


19/50


20/50


21/50

Anticonvulsant medications

Sodium Valproate

Carbemazepine

Lamotrogine


22/50

Sodium Valproate

A first line treatment for bipolardisorder especially mixed state orrapid cycling bipolar.

Prescribed for; Mania

Maintenance treatment of Bipolar Disorder

Seizures

Migraine prophylaxis


23/50

How does it work?

Blocks voltage- sensitive sodiumchannels

Increases brain concentrations ofgamma-aminobutyric acid (GABA)

Relatively unknown why it does this


24/50

Sodium Valproate

Effects occur within a few days

Optimised at several weeks to onemonth

The goal is to see a remission in

symptomsAugmentation


25/50

Pre-testing

Platelet counts

Liver function testing

Coagulation testsMetabolic monitoring


26/50

Sides Effects

Due to Excessive actions at voltage sensitivesodium channels

Include;- Sedation - dyspepsia- Tremor - weight gain- ataxia - alopecia- tremor - polycystic ovarian

syndrome- headache - hyperandrogenisam- Abdominal pain - hyperinsulinemia

- nausea/vomiting - Lipid dysregulation- reduced appetite - decreased bone density- constipation


27/50

Life threatening/Dangerous Side

Effects

Hepatotoxicity

Liver failure

PancreatitisOverdose

Restlessness

Hallucinations

Sedation

Heart block

Coma


28/50

Dosage and Use

Range;Mania; 1200-1500mg/day

Migraine; 500-1000mg/day

Epilepsy; 10-60mg/day

100mg, 200mg and 500mg tabletsDosages are increased rapidly in the

case of mania.

May need divided dose due to halflife

Terminal mean half life of 9-16 hours

Metabolised by the liver


29/50

Drug interactions

Lamotrogine should be reduced by 50%

Plasma levels lowered by drugs such as;Carbemazepine

Phenytoin Plasma levels are increased by drugs

such as; Aspirin

Chlorpromazine Fluoxetine

NSAIDS


30/50

Warnings

HepatotoxicityMalaise

Weakness

Lethargy

Facial edema Anorexia

Vomiting

Jaundice skin and eyes

Pancreatitis Abdominal pain

Nausea

vomiting


31/50

Special Populations

Elderly

Pregnancy

Breast feedingPost partum issues


32/50

Carbamazepine

More commonly used to treatseizures

First anticonvulsant to be widelyused in the treatment of Bipolardisorders

Potentially an advantage in

treatment resistant bipolar and orpsychotic disorders


33/50

How it works

Blocks voltage sensitive sodiumchannels

Interacts with the open channelconformation of sodium channels

Inhibits release of glutamate


34/50

Carbamazepine

Goal of treatment is remission ofsymptoms

Effect usually occur within a fewweeks

Can be used a augment othermedications


35/50

Pre testing

Blood count

Liver function

Kidney functionThyroid function


36/50

Side effects

Sedation

Dizziness

Confusion

Unsteadiness

Headache

Nausea and vomiting

Diarrhoea

Blurred vision

Benign leukopenia

Rash

Weight gain


37/50

Dangerous side effects

Rare aplatic anemia

Agranulocytosis Ususal bleeding

Infections Fever

Sore throat

Steven Johnson syndrome (RASH)

Cardiac issues

SIADH


38/50

Dosage and Use

400-1200 mg/day

Comes in slow release

Should always be taken with food


39/50


40/50

Drug interactions

Other antiepileptic medications

Fluvoxamine, fluoxtetine

Decrease efficacy of

benzodiazepines, clozapine,haloperidol, lamotrogine, epilum andwarfarin

Can decrease effectiveness of thecontraceptive pill

Lithium


41/50

Special Populations

Pregnancy Category D

Breast Feeding


42/50

Lamotrigine

Seems to be more effective intreating depressive episodes ofbipolar

Used less than other anticonvulsantsfor Bipolar Disorder


43/50

How it works?

Voltage- gated sodium channelagonist

Inhibits the release of glutamate


44/50

Side effects

Benign rash (10%) Sedation Blurred vision Dizziness

Ataxia Headache Tremor Insomnia Poor coordination Fatigue Nausea and vomiting Can cause flu like symptoms in some people


45/50

Stevens Johnsons Syndrome

Rare serious rash Acute fever

Bullae on the skin

Ulcers on the mucousmembranes on lip,eyes, mouth and nasalpassages

Management Stop medication

Monitor and investigateorgan involvement

May require admission
http://www.globalskinatlas.com/imagedetail.cfm?TopLevelid=672&ImageID=1762&did=6%20%20%20%20%20%20%20%20%20


46/50

Dosage and Use

Monotherapy 100- 200 mg/day

Halved if used with other medication

Monitor for rash


47/50

Pharmacokinetics

Elimination half life 33 hours

Higher if used concurrently withother anticonvulsant medication

Metabolised through the liver


48/50

Drug interactions

Depressive effects may be increasedby other CNS depressants


49/50

Special populations

People with renal impairment

Hepatic Impairment

Elderly

Children and Adolescents

Pregnancy

Breast feeding


50/50

Atypical Antipsychotic Medication

Increasing use of antipsychoticmedication

Olanzapine, Risperidone, Quetiapine,

Ziprasidone and Aripripazole

Date post:	02-Jun-2018
Category:	Documents
Upload:	gunterwestrock
View:	220 times
Download:	0 times

mood stablizer

Documents