Anti-manic medications for the manic phase of Bipolar Disorder
Lithium
1. Dosage forms
- Lithium carbonate capsules or tablets - Eskalith® (1 capsule or
tablet=300mg =8mEq Lithium)
- Lithium carbonate time- released tablets - Lithobid® (1
tablet=300mg=8mEq Lithium)
- Lithium citrate syrup - lithionate® (1 teaspoonful = 5ml=560mg=8mEq
Lithium)
2. Time course of response to drug therapy
Acute manic episode subsides within 1 week to 10 days. A time lag of
5 to 10 days is often seen before therapeutic effect of lithium is
observed. Antipsychotics are used initially to quickly abort the manic
episode. The antipsychotic is tapered off as the lithium takes effect.
3. Lithium blood concentrations
During the acute phase:
During the maintenance phase:
0.8-1.2 mEq/liter
0.6-1.0 mEq/liter
4. Side effects of lithium therapy
a. Early side effects: common; they usually go away after several days
of treatment
- stomach upset: nausea, vomiting, diarrhea, stomach pain; taking
medication with meals helps. If this effect occurs later in therapy
or persists for more than 2 days, it may be a sign of toxicity and
professional advice should be sought.
- fine hand tremor: usually seen during activity
- fatigue, muscle weakness, dazed feeling
- increased thirst and frequent urination: patients should be
instructed to maintain a consistent daily intake of fluid and salt,
as lithium excertion is dependent on these substances.
Dehydration and salt restriction can increase lithium blood
concentrations leading to toxicity consumption of fluid and salt
can cause decreased lithium blood concentrations and loss of
therapeutic effect.
b. Persistent side effects: not dose related
- fine hand tremor: use of divided doses or a timed - released product
is often helpful
- increased thirst and urination
- increased white blood cell count
c. Late side effects: moderate toxicity. Lithium blood concentrations of
1.5 mEq/liter or greater
- more severe hand tremor, coarsening of the tremor
- reappearance of GI symptoms (nausea, vomiting, diarrhea) - see
above
- confusion
- hypothyroidism; can give thyroid hormone supplement
- ataxia
- slurred speech
d. Severe toxicity: overdose effects. Lithium blood concentrations of 2.5
mEq/liter or greater
- seizures
- coma
- cardiovascular collapse
- death
5. Advantages and disadvantages of lithium therapy
Advantages
- will control a manic patient without a
- will normalize mood
- very good prophylactically to decrease mood swings
- relapses, when they occur, are less severe and usually shorter in
duration blood concentration monitoring allows careful titration to
therapeutic concentration
- low drug cost
Disadvantages
- narrow range of therapeutic blood concentrations, requires close
monitoring to prevent toxicity
- patient compliance and understanding of the warning signs of toxicity is
important
- lag period before therapeutic effect in manic patients
- prophylactic effect may take 6 months to 1 year to maximize
- rapid cyclers are poor responders
- expense of blood concentration
All: Atypical Antipsychotic Medications
Schizophrenia Module
see Medication Handout for
Anticonvulsants:
Depakote/ Divalproex Sodium
1. Blood test for level: Desired plasma concentration is between 50 and 125
mg
2. Acute side effects: GI DISTRESS, sedation, rashes, cognitive dulling,
Decrease granulocytes and platelets; do appropriate blood tests
3. Long term side effects: hair loss, (give zinc and selenium) increased
appetite and wt. gain and cognitive dulling
4. Drug is metabolized in the liver by the cytochrome P450 system
5. Sign and symptoms of toxicity are: ataxia, visual hallucinations, coma
stupor, and increased sedation
6. Onset of action for symptom relief: 5 days to two weeks after serum
levels are >50mcg/ml
7. Dosage: 750 to 1500 mg daily in divided doses
C. Tegretol/Carbamazepine
1. Blood test for level: Plasma level 4-12 is therapeutic range
2. Acute side effects: Cognitive dulling, sedation, tremor, GI distress
3. Maintenance therapy side effects: after 4-6 weeks, hyponatremia, check
liver functions and CBC
4. Drug is metabolized in the liver by the cytochrome P450
5. Signs and symptoms of toxicity: dizziness, ataxia, diplopia, increased
sedation, stupor, and coma
6. Onset of action for symptom relief: 1 to 2 weeks after serum levels are >
4 mcg/ml
7. Dosage: 200 Mg to 1400 Mg daily in divided doses
Other anticonvulsants:
–
Trileptal (oxcarbamazine)-Headache, diarrhea.
–
Lamictal (lamotrigine)-start slow, best for bipolar depression. Has a very
serious side effect of severe rash
–
Neurontin(gabapentin)-Drowsiness and ataxia
–
Topamax(topiramate)-Memory problems, W t loss