Drugs used to treat Bipolar Disorder
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Transcript Drugs used to treat Bipolar Disorder
Drugs Used to Treat
Bipolar Disorder
Background Information
Episodes of Mania and Depression
Intervention when mood swings are
severe, disrupt life of the patient and/or
family
4 % population prevalence
At least 1 manic,hypomanic,or mixed
episode
Types/Common Terms
Bipolar I- Most severe, obscures normal
functioning, hospitalization common
Bipolar II- Hypomanic,Full manic episodes
rare. Depression often still severe
Cyclothymia- Milder form of BP II, “Bipolar
Spectrum Disorder”
“Rapid Cycling”- 4 or more episodes in a
12 month period,may not be permanent
Effects:
Estimated 1 out of 4-5 commit suicide
from inadequate or no treatment
Onset of illness around 25 yrs old and
untreated, often results in loss of approx.
9 yrs of life, 14 yrs of activity, 12 of
normal health
Prime candidates for lifetime treatment
express at least 2 episodes of mania
Mania vs.
Depression:Treatment
options
Manic Episode- anti-psychotics (ex.
Zyprexa), or benzodiazepines (sedating)
Depressive Episode- temporary coadministration with antidepressants
As a whole- mood stabilizers, classicallyLithium. Anti-epileptics are also currently
being used ( Tegretol, Depakote,
Neurontin, Lamictal)
Lithium
Widely recommended treatment for
Bipolar Disorder
60-80% success in reducing acute manic
and hypomanic states
However… issues in non-compliance to
take medication, side effects, and relapse
rate with its use are being examined in
terms of being the best option
History
1920’s- used as a sedative, hypnotic,
and anti-convulsant
1940’s- investigated as a salt
substitute for heart disease patients
-How did this work out?
- Poorly- many people died from
toxicity
- The Doctors decided that maybe
it wasn’t such a good idea
History Cont.
1949- experiments with animals led to
lethargy, and use for acute mania.
The logic was simply to make them too
tired to run out and repaint the entire
house, have wild sex and go shopping
This is where non-compliance fits in
(seen in up to 50% of patients)…
the patient feels they are being robbed of
their fun by taking meds, so they give
them up.
More On Non-compliance
Other reasons patients refuse meds:
-weight gain
- less energy, productivity
- feel disease has resolved, no longer
need medication
Relapse rate is high regardless of withdrawal
being gradual or acute, suicide risk back up
episodes are often worse than original
symptoms, so treatment is often life-long
So where does this leave
us?
Since its discovery, Lithium has been found to
be superior to placebo
In recent years though, efficacy is being
questioned:
-Long term results not as good as
expected
-28% discontinue use, 38% experience
relapse on the drug
*Even so, it is widely prescribed, demonstrates
considerable efficacy, and reduction in
mortality risks
Pharmacokinetics:
Peak blood levels reached in 3 hrs, fully
absorbed in 8 hrs
Absorbed rapidly and completely orally
Efficacy correlates with blood levels
Crosses blood-brain barrier slowly and
incompletely
Usually taken as a single daily dose
Kinetics Cont.
Approx. 2 wks to reach a steady state
within the body
½ of oral dose excreted in 18-24 hrs,rest
within 1-2 wks
Recommended .75-1.0 mEq/L, optimum
would be .5-.7 mEq/L, with 2 mEq/L
displaying toxicity
Metabolized b/f excretion
Important:
Because of its resemblance to table salt,
when Na+ intake is lowered or loss of
excessive amounts of fluid occurs, blood
levels may rise and create intoxication
Pharmacodynamics
No psychotropic effect on non-Bipolars
Affects nerve membranes, multiple receptor
systems and intracellular 2nd messenger
impulse transduction systems.
Interacts with serotonin
Potential to regulate CNS gene expression,
stabilizing neurons w/ associated multiple
gene expression change.
How does a simple ion do all
of this?
Even as a simple ion, it has complex
effects on multiple transmitter systems
and mood stabilizing attributes
This is due to a latter effect reducing a
neuron’s response to synaptic input, and
therefore stabilizing the membrane
Side Effects and Toxicity
Relate to plasma concentration levels, so
constant monitoring is key
Higher concentrations ( 1.0 mEq/L and up
produce bothersome effects, higher than 2
mEq/L can be serious or fatal
Symptoms can be neurological,
gastrointestinal, enlarged thyroid, rash,
weight gain, memory difficulty, kidney
disfunction, cardiovascular
Not advised to take during pregnancy, affects
fetal heart development
Combination Therapy
Combination therapy with Lithium and
anti-epileptics may demonstrate better
protection against relapse, greater
therapeutic efficacy, and studies support
this as a rule vs. an exception
Illegal Drug Use
More than 55% of Bipolar patients have a
history of drug abuse
Some abuse might occur before the first
episode, or after diagnosis
Used by some as a way to self-medicate
If Lithium Doesn’t Work
40% of Bipolars are resistant to lithium or
side effects hinder its effectiveness
Therefore, we must consider alternative
agents for treatment
Valproic Acid (Depakote)
An anti-epileptic, it is the most widely used
anti-manic drug
Augments the post-synaptic action of GABA at
its receptors (increasing synthesis and
release)
Best for rapid-cycling and acute-mania
Therapeutic blood levels: 50-100 Mg/L
Side effects include GI upset, sedation,
lethargy,tremor, metabolic liver changes and
possible loss of hair
Can also be used for anxiety, mood, and
personality disorders
Carbamazepine (Tegretol)
Superior to lithium for rapid-cycling,
regarded as a second-line treatment for
mania
Correlation between therapeutic and
plasma levels (estimated between 5-10
Mg/L)
Side effects may include GI upset,
sedation, ataxia and cognitive effects
Gabapentin
Primarily an anti-convulsant, yet also “off
label,” or without FDA approval for treatment
of Bipolar and many other anxiety, behavioral
and substance abuse problems, possibly pain
disorders
GABA analogue
not bound to plasma proteins, not
metabolized, few drug interactions
Half-Life is 5-7 hours
Side Effects include
sleepiness,dizziness,ataxia and double vision
Lamotrigine
Reported effective with Bipolar,
Borderline Personality, Schizoaffective,
Post-Traumatic Stress Disorders
98% of administered drug reaches plasma
Half-Life is 26 hrs.
Inhibits neuronal excitability and
modifies synaptic plasticity
Side Effects may include dizziness,
tremor, headache, nausea, and rash
Topiramate and Tiagabine
Two newer anti-convulsants that have
potential for use in the treatment of
Bipolar disorder
Atypical Anti-psychotics
3 types that may be used for BPClozapine, Risperidone, and Olanzapine
Risperidone seems more anti-depressant
than anti-psychotic
Clozapine is effective, yet not readily
used due to potential serious side effects
Olanzapine is approved for short-term
use in acute mania
Acetylcholinesterase
Inhibitors
Potentiating the action of acetylcholine
may exert relief from mania
This potentiation is the result of
inhibiting the enzyme acetylcholine
esterase
Omega-3 Fatty Acids
Obtained from plant or marine sources
Known to dampen neuronal signaling
transduction systems in a variety of cell
systems
Being investigated as a treatment for
Bipolar Disorder
Psychotherapeutic and
Psychosocial Treatments
Combination drug and psychotherapeutic
intervention is the most effective
treatment
Goals of Psychotherapeutic treatment are
to reduce distress and improve function
between episodes
May include cognitive behavioral,
psychodynamically oriented, family,
couples, interpersonal, and self-help
group therapies
Thank You