pharmacotherapy of mood disorders dr gian lippi consultant psychiatrist university of pretoria &...
TRANSCRIPT
![Page 1: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/1.jpg)
PHARMACOTHERAPY OF MOOD DISORDERS
DR GIAN LIPPI
CONSULTANT PSYCHIATRISTUNIVERSITY OF PRETORIA & WESKOPPIES HOSPITALFORENSIC UNIT
![Page 2: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/2.jpg)
CONTENTS
BASIC BACKGROUND PHYSIOLOGY
BASICS OF PHARMACOTHERAPY OF MOOD DISORDERS
ANTIDEPRESSANTS (ALL THE CLASSES)
MOOD STABILIZERS (ALL THE CLASSES)
![Page 3: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/3.jpg)
BASIC BACKGROUND PHYSIOLOGY
PRESYNAPTIC
MAO / COMT
POSTSYNAPTICSYNAPSE
EFFECT
RECEPTOR
NEUROTRANSMITTER
NEURON
![Page 4: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/4.jpg)
BASICS
ANTIDEPRESSANTS ARE THE MAINSTAY OF TREATMENT OF MAJOR DEPRESSIVE DISORDER (MDD)
- SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)
MOOD STABILIZERS ARE THE MAINSTAY OF TREATMENT OF THE BIPOLAR DISORDERS
- SEROTONIN NORADRENALIN REUPTAKE INHIBITORS (SNRIs) - SELECTIVE NORADRENALIN REUPTAKE INHIBITORS (NRIs) - NORADRENALIN DOPAMINE REUPTAKE INHIBITORS (NDRIs) - TRICYCLIC ANTIDEPRESSANTS (TADs) - TETRACYCLIC ANTIDEPRESSANTS (TTADs)
- NORADRENALIN & SPECIFIC SEROTONIN ANTAGONISTS (NASSAs) - SEROTONIN ANTAGONIST / REUPTAKE INHIBITORS (SARIs)
-MELATONIN ANTAGONISTS (MAs)
- MONOAMINE OXIDASE INHIBITORS (MAOIs) - REVERSIBLE INHIBITORS OF MONOAMINE OXIDASE (RIMAs)
- CLASSIC MOOD STABILIZER - ANTICONVULSANTS - ATYPICAL ANTIPSYCHOTICS
![Page 5: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/5.jpg)
ANTIDEPRESSANTS
![Page 6: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/6.jpg)
SSRIs, MECHANISM OF ACTION
PRESYNAPTIC
MAO / COMT
POSTSYNAPTICSYNAPSE
EFFECT
RECEPTOR
NEUROTRANSMITTER
NEURON
![Page 7: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/7.jpg)
SSRIs, GENERAL
DRUGS & DOSAGES - FLUOXETINE 20- 60mg po mane - PAROXETINE 20 - 50mg po mane (AKA Prozac) - CITALOPRAM 20 - 40mg po mane - ESCITALOPRAM 10 - 20mg po mane - SERTRALINE 50 - 200mg po mane - FLUVOXAMINE 50 - 150mg po bd
1ST LINE TREATMENT FOR MDD
MOST COMMON SIDE-EFFECTS - SEXUAL DYSFUNCTION (DECREASED LIBIDO, ANORGASMIA, erectile dysfunction) - NAUSEA, VOMITING, DIARRHOEA - HEADACHE - INSOMNIA
![Page 8: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/8.jpg)
SNRIs, MECHANISM OF ACTION
PRESYNAPTIC
MAO / COMT
POSTSYNAPTICSYNAPSE
EFFECT
RECEPTOR
NEUROTRANSMITTER
NEURON
![Page 9: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/9.jpg)
SNRIs, GENERAL
DRUGS & DOSAGES - VENLAFAXINE 75- 300mg po mane - DULOXETINE 60 - 120mg po mane
MOSTLY 2ND LINE TREATMENT FOR MDD
MOST COMMON SIDE-EFFECTS - GASTROINTESTINAL DISCOMFORT - SEXUAL DYSFUNCTION - SEDATION - HYPOTENSION & TACHYCARDIA
FOR TREATMENT AUGMENTATION, TREATMENT RESISTANT MDD & MDD WITH PROMINENT PAIN SYMPTOMS
- DRY MOUTH
![Page 10: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/10.jpg)
NRIs, MECHANISM OF ACTION
PRESYNAPTIC
MAO / COMT
POSTSYNAPTICSYNAPSE
EFFECT
RECEPTOR
NEUROTRANSMITTER
NEURON
![Page 11: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/11.jpg)
NRIs, GENERAL
DRUGS & DOSAGES - REBOXETINE 4 - 5mg po bd
MOSTLY INEFFECTIVE AS AN ANTIDEPRESSANT
MOST COMMON SIDE-EFFECTS - URINARY HESITANCY - CONSTIPATION
- NASAL CONGESTION - PERSPIRATION
FOR AUGMENTATION TREATMENT IN MDD
- DRY MOUTH
- HEADACHE
- DIZZINESS - DECREASED LIBIDO - INSOMNIA
![Page 12: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/12.jpg)
NDRIs, MECHANISM OF ACTION
PRESYNAPTIC
MAO / COMT
POSTSYNAPTICSYNAPSE
EFFECT
RECEPTOR
NEUROTRANSMITTER
NEURON
![Page 13: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/13.jpg)
NDRIs, GENERAL
DRUGS & DOSAGES - BUPROPION 150 - 300mg po mane ( can also be used for smoking cessation)
MOSTLY 2ND LINE ANTIDEPRESSANT
MOST COMMON SIDE-EFFECTS
- NAUSEA
FOR TREATMENT AUGMENTATION, MDD WITH PROMINENT HYPERSOMNIA & FATIGUE OR PATIENTS WITH SEXUAL DYSFUNCTION ON OTHER ANTIDEPRESSANTS
- HEADACHE - INSOMNIA
![Page 14: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/14.jpg)
TADs & TTADs, MECHANISM OF ACTION
PRESYNAPTIC
MAO / COMT
POSTSYNAPTICSYNAPSE
EFFECT
RECEPTOR
NEUROTRANSMITTER
NEURON
![Page 15: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/15.jpg)
TADs & TTADs, GENERAL
TADs - AMITRIPTYLINE 30 - 200mg po nocte
MOSTLY 2ND LINE ANTIDEPRESSANTS DUE TO LESS TOLERABLE SIDE-EFFECTS & RISK OF LETHAL ARRHYTHMIA WITH OVERDOSE
MOST COMMON SIDE-EFFECTS
- ORTHOSTATIC HYPOTENSION
- ANTICHOLINERGIC SIDE – EFFECTS, OFTEN SEVERE (CONSTIPATION, URINARY RETENTION,
- SEDATION
EFFECTIVE ANTIDEPRESSANTS
- CLOMIPRAMINE 10 - 250mg po nocte - IMIPRAMINE 10 - 200mg po nocte - TRIMIPRAMINE 30 - 300mg po nocte - LOFEPRAMINE 140 - 210mg po nocte (mostly used currently)
TTADs - MAPROTILINE 75 - 200mg po nocte (hardly used currently)
DRY MOUTH, BLURRED VISION)
- CARDIAC ARRHYTHMIAS WHICH CAN BE LETHAL IN OVERDOSES (MORE WITH TADs)
![Page 16: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/16.jpg)
MAOIs & RIMAs, MECHANISM OF ACTION
PRESYNAPTIC
MAO / COMT
POSTSYNAPTICSYNAPSE
EFFECT
RECEPTOR
NEUROTRANSMITTER
NEURON
![Page 17: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/17.jpg)
MAOIs & RIMAs, GENERAL
MAOIs - TRANYLCIPROMINE 5 - 100mg po bd
POWERFUL ANTIDEPRESSANTS NOT FOR 1ST LINE TREATMENT
MOST COMMON SIDE-EFFECTS - ORTHOSTATIC HYPOTENSION - INSOMNIA
TYRAMINE-INDUCED HYPERTENSIVE CRISIS
RIMAs - MOCLOBEMIDE 75 - 300mg po bd
- CAUSED BY INTAKE OF TYRAMINE – CONTAINING FOODS WHILST ON THE
- WEIGHT GAIN - OEDEMA - SEXUAL DYSFUNCTION
- SUCH FOODS MUST BE AVOIDED, THESE INCLUDE AGED CHEESES, FISH, BILTONG, MARMITE, SAUERKRAUT, BEER, CHIATI WINE, LIQUEUR
MEDICATION
![Page 18: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/18.jpg)
NASSAs, MECHANISM OF ACTION
PRESYNAPTIC
MAO / COMT
POSTSYNAPTICSYNAPSE
EFFECT
RECEPTOR
NEUROTRANSMITTER
NEURON
![Page 19: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/19.jpg)
NASSAs, GENERAL
CAN BE USED AS 1ST / 2ND LINE TREATMENT, OR IN AUGMENTATION TREATMENT OF MDD
MOST COMMON SIDE-EFFECTS - SEDATION
- INCREASED APPETITE
- MIRTAZAPINE 15 - 45mg po nocte
- WEIGHT GAIN
- DRY MOUTH
DRUGS & DOSAGES
OFTEN USED IN TREATMENT OF MDD WITH PROMINENT INSOMNIA
![Page 20: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/20.jpg)
SARIs, MECHANISM OF ACTION
PRESYNAPTIC
MAO / COMT
POSTSYNAPTICSYNAPSE
EFFECT
RECEPTOR
NEUROTRANSMITTER
NEURON
![Page 21: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/21.jpg)
SARIs, GENERAL
NOT 1ST LINE TREATMENT IN MDD
MOST COMMON SIDE-EFFECTS - SEDATION
- NAUSEA
- TRAZODONE 75 - 300mg po bd
- HEADACHE - DIZZINESS
DRUGS & DOSAGES
OFTEN USED IN TREATMENT OF MDD WITH PROMINENT INSOMNIA
MOSTLY INEFFECTIVE IN THE TREATMENT OF MDD
- ORTHOSTATIC HYPOTENSION
![Page 22: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/22.jpg)
MAs, MECHANISM OF ACTION
PRESYNAPTIC
MAO / COMT
POSTSYNAPTICSYNAPSE
EFFECT
RECEPTOR
NEUROTRANSMITTER
NEURON
22
![Page 23: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/23.jpg)
MAs, GENERAL
NOT 1ST LINE TREATMENT IN MDD
MOST COMMON SIDE-EFFECTS
- NAUSEA
- AGOMELATINE 25-50mg po nocte
- DIZZINESS
DRUGS & DOSAGES
OFTEN USED IN TREATMENT OF MDD WITH PROMINENT INSOMNIA
23
![Page 24: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/24.jpg)
MOOD STABILIZERS
![Page 25: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/25.jpg)
INDICATIONS & CATEGORIZATION
TREATMENT OF THE MAINTENANCE PHASE OF BIPOLAR DISORDERS
TREATMENT OF MANIC EPISODES
TREATMENT OF HYPOMANIC EPISODES
TREATMENT OF DEPRESSIVE EPISODES
TREATMENT OF MIXED EPISODES
3 GROUPS OF MOOD STABILIZERS - CLASSIC MOOD STABILIZER - ANTICONVULSANTS - ATYPICAL ANTIPSYCHOTICS
![Page 26: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/26.jpg)
CLASSIC MOOD STABILIZER
INDICATIONS
LITHIUM
- MOST EFFECTIVE IN TREATING & PREVENTING MANIC EPISODES
- CAN BE CONSIDERED FOR TREATMENT OF MIXED EPISODES & RAPID CYCLING, BUT NOT 1ST LINE- QUESTIONABLE EFFICACY IN TREATMENT, NOT PREVENTION OF BIPOLAR DEPRESSION
- 1ST LINE TREATMENT OPTION IN BIPOLAR DISORDERS (MAINTENACE PHASE)
DOSAGE, THERAPEUTIC INDEX & MONITORING OF LITHIUM BLOOD LEVELS
- DOSE IS ACCORDING TO TROUGH LEVEL OF LITHIUM IN THE BLOOD- START AT LOW DOSE, INCREASE SLOWLY & ADJUST DOSE ACCORDING TO LITHIUM LEVEL
- SAFE STARTING DOSE IS 500mg po mane - LITHIUM HAS A VERY NARROW THERAPEUTIC INDEX:
LITHIUM LEVEL OF 0,5 – 0.9 FOR THE MAINTENANCE PHASE LITHIUM LEVEL OF UP TO 1,5 FOR THE TREATMENT OF A MANIC EPISODE (ACUTE)
- LEVELS BELOW THIS RANGE RESULTS IN TOTALLY INEFFECTIVE TREATMENT - LEVELS ABOVE THIS RANGE CAN RESULT IN POTENTIALLY LETHAL LITHIUM TOXICITY - LITHIUM LEVELS NEED TO BE CHECKED 4 DAYS AFTER STARTING TREATMENT OR CHANGING DOSE - LITHIUM LEVELS NEED TO BE CHECKED 6-MONTHLY WHEN A PATIENT IN THE MAINTENANCE PHASE HAS STABLE BLOOD LEVELS WITHIN THE THERAPEUTIC RANGE - LITHIUM BLOOD LEVELS ARE TROUGH LEVELS, SO WHEN BLOOD IS DRAWN TO TO CHECK THE LEVELS, IT MUST BE DRAWN JUST BEFORE THE NEXT DOSE
![Page 27: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/27.jpg)
CLASSIC MOOD STABILIZER
MOST COMMON SIDE-EFFECTS
LITHIUM
- WEIGHT GAIN & FLUID RETENTION
- POSTURAL TREMOR
- NAUSEA, VOMITING, DIARRHOEA
- RENAL EFFECTS:
- CARDIAC EFFECTS SECONDARY TO HYPOKALAEMIA:
POLYURIA WITH SECONDARY POLYDIPSIA
T-WAVE FLATTENING OR INVERSION ON ECG
- TERATOGENESIS:
- TREMOR, DYSARTHRIA, ATAXIA
HYPOKALAEMIA RARELY NONSPECIFIC INTERSTITIAL FIBROSIS WITH MORE THAN 10 YEARS OF LITHIUM USE
- BENIGN, USUALLY REVERSIBLE THYROID EFFECTS: MOST COMMONLY HYPOTHYROIDISM HYPERTHYROIDISM GOITER & EXOPHTHALMUS
SINUS DYSRHYTHMIAS, HEART BLOCK, SYNCOPE EPISODES
LITHIUM TOXICITY
CAN CAUSE EBSTEIN’S ANOMALY IN THE UNBORN FETUS OF A PREGNANT MOTHER ON LITHIUM
- NAUSEA, VOMITING, DIARRHOEA - CARDIOVASCULAR CHANGES & RENAL DYSFUNCTION - MYOCLONUS & MUSCULAR FASCICULATIONS - SEIZURES, IMPAIRED LEVEL OF CONSCIOUSNESS, COMA
- MEDICAL EMERGENCY, TREAT BY STOPPING LITHIUM & PUSHING INTRAVENOUS FLUIDS
![Page 28: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/28.jpg)
CLASSIC MOOD STABILIZER
MONITORING OF THE PATIENT ON LITHIUM
LITHIUM
- CREATININE CLEARANCE (LITHIUM IS EXCRETED EXCLUSIVELY BY THE KIDNEYS, KIDNEY FUNCTION
FOR T-WAVE FLATTENING OR INVERSION, DYSRHYTHMIA/HEART BLOCK)
- FBC (CHECK LEUCOCYTES TO GET A BASELINE VALUE, LITHIUM CAN CAUSE LEUCOCYTOSIS)
- TSH (CHECK FOR HYPO/HYPERTHYROIDISM, LITHIUM CAN INTERFERE WITH THYROID FUNCTION)
- UKE (CHECK POTASSIUM & SIFT FOR KIDNEY DYSFUNCTION)
NEEDS TO BE INTACT)
- ECG (CHECK FOR DYSRHYTHMIA /HEART BLOCK)
BEFORE STARTING A PATIENT ON LITHIUM THE FOLLOWING SPECIAL INVESTIGATIONS NEED TO BE DONE TO CHECK IF HE/SHE IS A SUITABLE CANDIDATE FOR THE TREATMENT:
- ß-HCG IN FEMALES (LITHIUM IS TERATOGENIC)
- UKE (IN 1ST MONTH AFTER STARTING LITHIUM, THEN 6-MONTHLY IF NORMAL TO MONITOR POTASSIUM & LONG-TERM KIDNEY FUNCTION WHICH CAN DETERIORATE ON CHRONIC LITHIUM TREATMENT) - FBC (PERIODICALLY TO CHECK FOR LEUCOCYTOSIS) - TSH (IN 1ST MONTH AFTER STARTING LITHIUM, THEN 6-MONTHLY IF NORMAL TO CHECK FOR HYPO/HYPERTHYROIDISM) - ß-HCG IN FEMALES (PERIODICALLY TO CHECK FOR PREGNANCY) - ECG (IN 1ST MONTH AFTER STARTING LITHIUM, THEN PERIODICALLY TO CHECK - LITHIUM LEVELS (4 DAYS AFTER STARTING LITHIUM/CHANGING DOSE, THEN
3-6 MONTHLY TO CHECK FOR TOXICITY/SUB-THRESHOLD DOSING/NEED FOR DOSAGE ADJUSTMENT)
![Page 29: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/29.jpg)
ANTICONVULSANTS
DOSAGE - 250-1250mg po bd
VALPROATE
INDICATIONS- 1ST LINE TREATMENT OPTION IN BIPOLAR DISORDERS (MAINTENANCE PHASE)- MOST EFFECTIVE IN TREATING & PREVENTING MANIC EPISODES- TREATMENT OF CHOICE FOR MIXED EPISODES & RAPID CYCLING - NOT EFFECTIVE IN TREATMENT & PREVENTION OF DEPRESSION- ADVANTAGE OF BEING ABLE TO TITRATE DOSE UPWARDS RAPIDLY
MOST COMMON SIDE-EFFECTS- SEDATION- WEIGHT GAIN- THROMBOCYTOPAENIA- HAIR LOSS AT HIGH DOSES
- TREMOR
MONITORING OF THE PATIENT ON VALPROATE- LFT (BEFORE STARTING TREATMENT TO CHECK FOR IMPAIRED LIVER FUNCTION SINCE VALPROATE IS METABOLIZED BY THE LIVER, THEN 6-MONTHLY TO CHECK FOR THE RARE SIDE-EFFECT OF POTENTIALLY FATAL HEPATOTOXICITY SEEN MOSTLY IN PAEDIATRIC PATIENTS)
![Page 30: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/30.jpg)
ANTICONVULSANTS
DOSAGE - STARTING DOSE 200mg po bd, TITRATE UP SLOWLY BY 200mg AT A TIME
CARBAMAZEPINE
INDICATIONS
MOST COMMON SIDE-EFFECTS- RASH (EXFOLIATIVE DERMATITIS)- HYPONATREMIA & SYNDROME OF INAPPROPRIATE ADH SECRETION (SIADH)- GASTROINTESTINAL SIDE-EFFECTS- HEPATITIS- RARELY AGRANULOCYTOSIS/APLASTIC ANAEMIA (BONE MARROW SUPPRESSION)
MONITORING OF THE PATIENT ON CARBAMAZEPINE- LFT (BEFORE STARTING TREATMENT TO CHECK FOR IMPAIRED LIVER FUNCTION SINCE CARBAMAZEPINE IS METABOLIZED BY THE LIVER, THEN PERIODICALLY TO CHECK FOR HEPATITIS)
FOR HYPONATREMIA & SIADH)
- FALLEN OUT OF FAVOUR, NO LONGER ROUTINELY USED, ONLY IN SPECIFIC CASES- SAME USE PROFILE AS VALPROATE BUT SEEMS TO BE LESS EFFECTIVE
- MAINTENANCE DOSE 300-600mg po bd
- INTERFERES WITH THE METABOLISM OF OTHER DRUGS
- UKE (BASELINE BEFORE STARTING TREATMENT THEN PERIODICALLY TO CHECK
- FBC (BASELINE BEFORE STARTING TREATMENT THEN PERIODICALLY TO CHECK TO CHECK FOR BONE MARROW SUPPRESSION)
![Page 31: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/31.jpg)
ANTICONVULSANTS
DOSAGE - STARTING DOSE 25mg po nocte, TITRATE UP SLOWLY BY 25mg EVERY 2 WEEKS TO DECREASE THE
LAMOTRIGINE
INDICATIONS
MOST COMMON SIDE-EFFECTS
- 1ST LINE TREATMENT OPTION FOR PATIENTS WITH PROMINENT BIPOLAR DEPRESSION
- MAINTENANCE DOSE 100-200mg po nocte
- EFFECTIVE IN TREATING DEPRESSIVE EPISODES- TREATMENT OF CHOICE FOR PREVENTING DEPRESSIVE EPISODES- EFFECTIVE IN PREVENTING MANIC EPISODES- NOT EFFECTIVE IN TREATMENT OF MANIC EPISODES- POSSIBLE / QUESTIONABLE EFFICACY IN TREATMENT OF MIXED EPISODES & RAPID CYCLING
RISK OF STEVENS-JOHNSON SYNDROME
- DIZZINESS & ATAXIA - BLURRED VISION & DIPLOPIA - HEADACHE - SEDATION - NAUSEA & VOMITING - STEVENS-JOHNSON SYNDROME (IF A RASH DEVELOPS, STOP LAMOTRIGINE IMMEDIATELY)
![Page 32: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/32.jpg)
ATYPICAL ANTIPSYCHOTICS
DRUGS & DOSAGE - OLANZAPINE 10-20mg po nocte
INDICATIONS
MOST COMMON SIDE-EFFECTS
- ARIPIPRAZOLE 10-30mg po nocte
MONITORING OF THE PATIENT ON ATYPICAL ANTIPSYCHOTICS- BASELINE FASTING GLUCOSE & LIPOGRAM, BLOOD PRESSURE, WAIST
- QUETIAPINE 300-800mg po nocte
- METABOLIC SYNDROME (MS) – WEIGHT GAIN WITH CENTRAL OBESITY + HYPERTENSION
- EFFECTIVE IN TREATMENT OF MANIC EPISODES- EFFECTIVE IN PREVENTING MANIC EPISODES- EFFECTIVE IN TREATING DEPRESSIVE EPISODES- NOT EFFECTIVE IN PREVENTING DEPRESSIVE EPISODES- CAN BE CONSIDERED FOR TREATMENT OF MIXED EPISODES & RAPID CYCLING, BUT NOT 1ST LINE
+ HYPERCHOLESTEROLAEMIA + HYPERGLYCAEMIA - OLANZAPINE – SEVERE MS, SEDATION, DIZZINESS, DRY MOUTH, CONSTIPATION, DYSPEPSIA,
AKATHISIA - QUETIAPINE – MS, SEVERE SEDATION, DIZZINESS, POSTURAL HYPOTENSION- ARIPIPRAZOLE – HEADACHE, SEDATION, AKATHISIA, AGITATION, ANXIETY, DYSPEPSIA, NAUSEA
NOT MS
CIRCUMFERENCE, WEIGHT MEASUREMENT- FASTING GLUCOSE & LIPOGRAM, BLOOD PRESSURE, WAIST CIRCUMFERENCE, WEIGHT MEASUREMENT 1 MONTH AFTER STARTING TREAMENT, THEN 6-MONTHLY- MORE REGULAR MONITORING FOR OLANZAPINE OR IF THERE ARE SIGNS OF MS
![Page 33: PHARMACOTHERAPY OF MOOD DISORDERS DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT](https://reader035.vdocument.in/reader035/viewer/2022062408/56649eef5503460f94bfee4e/html5/thumbnails/33.jpg)
THE END