1 / 50

Mood Stabilisers

Mood Stabilisers. Psychopharmacology . Mood Stabilisers. The treatment of bipolar disorder may be divided into three overlapping phases Acute manic episode Depressive episode Prophylactic treatment Only 1/3 of bipolar patients experience adequate relief with a monotherapy. How they work?.

shaman
Download Presentation

Mood Stabilisers

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Mood Stabilisers Psychopharmacology

  2. Mood Stabilisers • The treatment of bipolar disorder may be divided into three overlapping phases • Acute manic episode • Depressive episode • Prophylactic treatment • Only 1/3 of bipolar patients experience adequate relief with a monotherapy.

  3. How they work? • They have no clear effect on dopamine?? So why are they effective in mania? • They have no clear effect serotonin?? So why are they effective in depressive episodes?

  4. Pregnancy categories

  5. Lithium • First original mood stabiliser • Underutilised • Appears most effective in treating acute mania • First psychiatric drug that required blood level monitoring

  6. Lithium • Manic episodes of bipolar disorder • Maintenance treatment for bipolar disorder • Bipolar depression • Major depressive disorder • Vascular headache • Neutropenia

  7. Mechanisms • Generally unknown • Complex in action • Alters sodium transport across cell membranes • Alter metabolism of neurotransmitters catecholamines, serotonin, GABA and glutamate • May alter intracellular signalling through actions on second messenger systems

  8. Second messenger systems • Method of cellular signalling • Cyclic adenosine monophosphate (cAMP) • intracellular signal transduction • A different process of neurotransmission

  9. Lithium • Effective within 1-3 weeks • Goal of treatment is a remission in symptoms • Many patients only have a partial response

  10. Concept of Augmentation • the combination of two or more drugs to achieve better treatment results • Failure of monotherapy • Better tolerability

  11. Pre-testing • Kidney function( should be repeated 1-2) • Thyroid function • ECG for patients over 50 • Metabolic monitoring • Fasting plasma glucose level • Cholesterol and triglycerides • BMI

  12. Side Effects • The reason to why lithium causes side effects is complex • Excessive actions at the same or similar sites that mediate actions • Renal side effects= acts on transportation of ions

  13. Side Effects • Polyuria • Polydipsia • Diarrhoea • Nausea • Weight gain • Goiter • Acne, rash, alopecia • leukocytosis

  14. Life Threatening Side Effects • Lithium toxicity • Renal impairment • Nephrogenic diabetes insipidus • Arrhythmias • Cardiovascular changes\sick sinus rhythm • Sick Sinus syndrome • Bradycardia • hypotension • T wave flattening and inversion

  15. Toxicity • Toxic Levels are very close to therapeutic levels Symptoms; • Diarrhoea • Vomiting • Course tremor • Delerium • Coma • Seizures • Monitoring for dehydration

  16. 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 upward as indicated by plasma levels

  17. Dosing • Slow release= less gastric irritation, lower peak plasma levels and peak dose side effects • Use the lowest dose of lithium associated with adequate therapeutic response • Go low in the elderly • Rapid discontinuation= increase relapse

  18. Monitoring • Therapeutic Levels

  19. Drug interaction Increase plasma levels; • NSAIDS • Diuretics • Angiotensin-converting enzymes • Anticonvulsants (carbemazepine and phenytoin) • Metronidazole • Calcium channel blockers Increase side effects • SSRI’s • Haloperidol

  20. Special Populations • Elderly • Pregnancy • Breast feeding

  21. Anticonvulsant medications • Sodium Valproate • Carbemazepine • Lamotrogine

  22. Sodium Valproate • A first line treatment for bipolar disorder especially mixed state or rapid cycling bipolar. • Prescribed for; • Mania • Maintenance treatment of Bipolar Disorder • Seizures • Migraine prophylaxis

  23. How does it work? • Blocks voltage- sensitive sodium channels • Increases brain concentrations of gamma-aminobutyric acid (GABA) • Relatively unknown why it does this

  24. Sodium Valproate • Effects occur within a few days • Optimised at several weeks to one month • The goal is to see a remission in symptoms • Augmentation

  25. Pre-testing • Platelet counts • Liver function testing • Coagulation tests • Metabolic monitoring

  26. Sides Effects • Due to Excessive actions at voltage sensitive sodium 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. Life threatening/Dangerous Side Effects • Hepatotoxicity • Liver failure • Pancreatitis • Overdose • Restlessness • Hallucinations • Sedation • Heart block • Coma

  28. Dosage and Use • Range; • Mania; 1200-1500mg/day • Migraine; 500-1000mg/day • Epilepsy; 10-60mg/day • 100mg, 200mg and 500mg tablets • Dosages are increased rapidly in the case of mania. • May need divided dose due to half life • Terminal mean half life of 9-16 hours • Metabolised by the liver

  29. 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. Warnings • Hepatotoxicity • Malaise • Weakness • Lethargy • Facial edema • Anorexia • Vomiting • Jaundice skin and eyes • Pancreatitis • Abdominal pain • Nausea • vomiting

  31. Special Populations • Elderly • Pregnancy • Breast feeding • Post partum issues

  32. Carbamazepine • More commonly used to treat seizures • First anticonvulsant to be widely used in the treatment of Bipolar disorders • Potentially an advantage in treatment resistant bipolar and or psychotic disorders

  33. How it works • Blocks voltage sensitive sodium channels • Interacts with the open channel conformation of sodium channels • Inhibits release of glutamate

  34. Carbamazepine • Goal of treatment is remission of symptoms • Effect usually occur within a few weeks • Can be used a augment other medications

  35. Pre testing • Blood count • Liver function • Kidney function • Thyroid function

  36. Side effects • Sedation • Dizziness • Confusion • Unsteadiness • Headache • Nausea and vomiting • Diarrhoea • Blurred vision • Benign leukopenia • Rash • Weight gain

  37. Dangerous side effects • Rare aplatic anemia • Agranulocytosis • Ususal bleeding • Infections • Fever • Sore throat • Steven Johnson syndrome (RASH) • Cardiac issues • SIADH

  38. Dosage and Use • 400-1200 mg/day • Comes in slow release • Should always be taken with food

  39. Pharmacokinetics • Metabolised in the liver by CYP450 • Half life of 26-65 hours initially then drops with repeated doses

  40. Drug interactions • Other antiepileptic medications • Fluvoxamine, fluoxtetine • Decrease efficacy of benzodiazepines, clozapine, haloperidol, lamotrogine, epilum and warfarin • Can decrease effectiveness of the contraceptive pill • Lithium

  41. Special Populations • Pregnancy Category D • Breast Feeding

  42. Lamotrigine • Seems to be more effective in treating depressive episodes of bipolar • Used less than other anticonvulsants for Bipolar Disorder

  43. How it works? • Voltage- gated sodium channel agonist • Inhibits the release of glutamate

  44. 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. Stevens Johnson’s Syndrome • Rare serious rash • Acute fever • Bullae on the skin • Ulcers on the mucous membranes on lip, eyes, mouth and nasal passages • Management • Stop medication • Monitor and investigate organ involvement • May require admission

  46. Dosage and Use • Monotherapy 100- 200 mg/day • Halved if used with other medication • Monitor for rash

  47. Pharmacokinetics • Elimination half life 33 hours • Higher if used concurrently with other anticonvulsant medication • Metabolised through the liver

  48. Drug interactions • Depressive effects may be increased by other CNS depressants

  49. Special populations • People with renal impairment • Hepatic Impairment • Elderly • Children and Adolescents • Pregnancy • Breast feeding

  50. Atypical Antipsychotic Medication • Increasing use of antipsychotic medication • Olanzapine, Risperidone, Quetiapine, Ziprasidone and Aripripazole

More Related