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The categories for today’s
Jeopardy on Mood Stabilizers
will be:
Lithium
Divalproex
Sodium
Carbamazepine
Lamotrigine
Antipsychotics
Lithium
Divalproex
Sodium
100
100
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100
200
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300
300
300
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400
400
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800
800
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900
900
Carbamazepine
Lamotrigine
Anitpsychotics
What is 12 hours? (Trough)
Blood levels should be drawn about this
many hours after the last dose
Row 1, Col 1
What is 0.6-0.8 mEq/L?
For maintenance treatment of Bipolar
disorder, lithium levels should
generally be above this
1,2
What is TSH & BUN/creatinine?
Before starting a young male patient on
lithium, labs that should
routinely be done are these
1,3
What is lithium level, TSH, BUN/creatinine?
In lithium maintenance treatment,
ideally these labs are done
1-2 times per year
1,4
What is tremor? (resting or postural?)
This lithium side effect can
be worsened by caffeine or
improved with propranolol
treatment
1,5
What is suicide?
Unlike any antidepressant or mood
stabilizer, Lithium treatment
decreases patient’s mortality
risk from this
1,6
What is dialysis?
Lithium toxicity with a lithium level
greater than 4.0 mEq/L is
treated with this
1,7
What is 5 days? (Lithium half life = ?)
To confirm therapeutic levels after
starting lithium or increasing the
dose, a lithium level
should be done after this
number of days
1,8
What is lithium toxicity?
For patients taking lithium, renal
impairment, sodium depletion,
or dehydration all increase
the risk of this
1,9
What is neural tube defect (spina bifida)?
Divalproex Sodium (Depakote)
exposure during the first
trimester of pregnancy increases
the risk this serious congenital
anomaly
2,1
What are LFT’s & platelets?
Before starting a male patient
on Divalproex Sodium
(Depakote), these two
lab tests should be done
2,2
What is decrease Lamotrigine dose by half?
If Divalproex Sodium (Depakote)
is added to the medication regimen
of a patient who is taking
Lamotrigine (Lamictal) this
should be done.
2,3
What is tremor?
Propranolol 2-3x’s per day may be
used to treat this common side
effect of divalproex (depakote)
2,4
What is under 2 years old ?
The age range of patients most at
risk for divalproex’s (depakote)
side effect of serious, possibly
fatal, hepatoxicity is this
2,5
What are GI side effects? (N/V/D, GI discomfort)
Patients on the generic form of
valproic acid (depakene) are at
greater risk of developing this
side effect than those on the
enteric coated divalproex
(depakote)
2,6
What is Headache? (indicated for migraine prophylaxis)
Ironically, divalproex (depakote)
is indicated as prophylaxis for
this condition, which is also one
of divalproex (depakote)’s
common side effects
2,7
What is 18 hour after the last dose?
If IR-last dose 10pm, blood draw 10am
If ER-last dose 10pm, blood draw 4 pm
For divalproex (depakote), while the
trough level of the Immediate Release
(IR) should be drawn 12 hrs after
the last dose, the trough level of
Extended Release (ER) should
be drawn at this time
2,8
What is decreased platelets? Thrombocytopenia
For a patient taking Divalproex
Sodium (Depakote), taking aspirin
increases the risk of this
2,9
What is auto-induction?
Over the first few weeks of taking
carbamazepine (tegretol) its t1/2
will decease to less than 50%of
its initial t1/2 due to this
3,1
What is neural tube defect?
Exposure of the fetus during the 1st
trimester of pregnancy leads to
an unacceptable risk of this
3,2
What is agranulocytosis & aplastic anemia?
Carbamazepine (tegretol) has a
black box warning for these two
rare (~1/100,000 = 0.001%)
but serious side effects on
the hematopoietic system
3,3
What is sodium?
This electrolyte may be abnormally
low in patients who are taking
carbamazepine (tegretol)
3,4
What is CYP 3A4?
CYP:
3A4
2D6
2C9
Carbamazepine (Tegretol) is both
a substrate & an inducer of this
cytochrome p450 enzyme system
which makes up ~55% of the
cytochrome p450 enzymes
3,5
What is pregnancy?
Carbamazepine (tegretol)’s drugdrug interaction with hormonal
birth control increases the
risk of this
3,6
What is oxcarbamazepine (trileptal)?
Closely related structurally to
carbamazepine (tegretol), this
medication has far fewer side
effects but is not FDA
approved for treatment of
bipolar disorder
3,7
What is liver function test?
Patients who are getting long term
treatment with divalproex (depakote) or
carbamazepine (tegretol) need to have
regular labs done to check
their medication blood levels,
platelets/blood count, and this
3,8
What is folate?
To  the risk of birth defects,
a woman on carbemazepine (tegretol)
who desires to become pregnant
should also take this medication
3,9
What is 10%?
Patients who start taking lamotrigine
(lamictal) have a this % risk of
developing a benign rash
4,1
What is Steven’s Johnson Syndrome?
While the side effect of a benign rash
is relatively common, the risk of a
severe rash is about 0.3%, and the
risk of this is about 0.02-0.1%
4,2
What is Steven’s Johnson Syndrome?
The 4 picture set
shows this side effect
of lamictal (lamotrigine)
4,3
What is increasing? (doubles)
The drug-drug interaction between
lamotrigine (lamictal) & divalproex
sodium (depakote) results in
lamictal’s blood level
doing this
4,4
What is FDA indication to treats bipolar depression
Lamotrigine (lamictal), quetiapine (seroquel),
lithium, olanzapine/fluoxetine (symbyax),
& latuda (lurasidone) all have this in
common regarding their usage in
the treatment of pts with bipolar disorder
4,5
What is FDA indication for use in maintenance
treatment of bipolar disorder?
Lamotrigine (lamictal), lithium,
quetiapine (seroquel), olanzapine
(zyprexa) & aripiprazole (abilify)
all have this in common regarding
their usage in treatment of pts
with bipolar disorder
4,6
What is an acute manic episode?
Lithium, divalproex (depakote),
carbamazepine ER (tegretol ER)
quetiapine (seroquel), ziprasidone (geodon),
& asenapine (saphris) are FDA indicated to
treat this phase of bipolar disorder
but lamotrigine (lamictal) is not
4,7
What is weight gain and sedation?
Lithium, divalproex (depakote), quetiapine
(seroquel), & olanzapine (zyprexa) with
regard to these two common side
effects are NOT side effects
of lamotrigine (lamictal)
4,8
What is Sodium channels?
The common mechanism of action
for the mood stabilizers
carbamazepine (tegretol),
divalproex (depakote), and
lamotrigine (lamictal) is
blocking these
4,9
What is olanzapine (zyprexa)?
This SGA has FDA indication to treat
acute mania or for maintenance
treatment of bipolar disorder, but of
all the SGA’s it has the highest risk for
weight gain, elevated lipids,
and diabetes
5,1
What is ziprasidone (geodon)?
This SGA has FDA indication to treat acute
mania or for maintenance treatment of
bipolar disorder, but must be taken with
food or > 50% will not be absorbed
in the digestive tract
5,2
What is aripiprazole (abilify)?
While this SGA has FDA indication
to treat acute mania or for
maintenance treatment of bipolar
disorder, it has a particularly long
half life of ~75 hours and takes
nearly 2 weeks to reach steady state
5,3
What is risperidone (risperdal)?
This SGA has FDA indication to treat
acute mania or for maintenance
treatment of bipolar disorder, but
at high doses (> 6 mg) it acts more
like a FGA and has a much higher
rate of EPS side effects
5,4
What is asenapine (saphris)?
This SGA has FDA indication to treat
acute mania & must be taken
sublingually because if it is
swallowed only ~5% will be
bioavailable due to 1st pass liver
metabolism
5,5
What is ziprasidone (geodon) &
aripiprazole (abilify)?
These 2 SGA’s, in addition to being
FDA indicated to treat acute mania or
for maintenance treatment of bipolar
disorder, are the least likely of the
SGA’s to cause weight gain or
metabolic syndrome
5,6
What is ziprasidone (geodon)?
This SGA is FDA indicated to treat acute
mania or for maintenance treatment of
bipolar disorder, but should not be used in
patient’s with ECG’s that show an
QTc > 500 milliseconds
5,7
What are quetiapine (seroquel), latuda (lurasidone)
& olanzapine (zyprexa)?
These three SGA’s are useful is FDA
indicated for treating bipolar
depression; two by themselves, the
other in combination with
fluoxetine (prozac)
5,8
What is aripiprazole (abilify maintena) &
olanzapine (zyprexa relprevv)
Risperidone (risperdal consta),
paliperidone (invenga sustenna),
and these 2 SGA’s are available
in a long acting injectable form
5,9