Table of contents
Overview
- Traditional: Lithium, Divalproex (Epival), and Carbamazepine (Tegretol)
o Need to monitor plasma levels
- New: new anticonvulsants (Gabapentin, lamotrigine oxcarbazepine, topiramate) + atypical antipsychotics
o No need to monitor plasma levels
o Atypical antipsychotics can stabilize mood (typicals cannot!)
- Mechanism: Not clear, likely GABA and glutamate
- Indications:
| | Lithium | Divalproex | Carbamazepine |
| “Classic Mania” | +++ | +++ | +++ |
| Mixed State | + | +++ | +++ |
| Rapid Cycling | + | +++ | + |
| Bipolar Depression | +++ | + | + |
| Chronic Aggression+ Borderline behavior | + | + | |
Lithium
Lithium (Carbolith SA, Duralith LA)
- 1st line bipolar,
- 2nd line depression: can be used to augment antidepressants in depression
- (Less response to mixed states or rapid cycling)
- Drug interactions: NSAIDs, ACEi, antihypertensives
- Na inversely proportional to Li levels
- AVOID in pregnancy
- Before starting: check lytes, kidney function
- S/E: (Kidney metabolism)
o Inhibits kidney concentrating ability: renal toxicity, Polyuria, polydipsia
o skin: acne, psoriasis
o ECG changes
o Fine tremor (tx w/ propranolol or change to LA)
o Leukocytosis
o Hypothyroidism
o Nausea (take w/ food or long acting)
o Wt gain
o Hair loss, skin problems, acne
- TOXIC in overdose:
o 0.7-1.0mEQ/L – therapeutic range (takes 5 days from dose change)
o 1.5-2.5 mmol/L – ataxia, coarse tremor, confusion, twitching, N/V/D
o 2.5 mmol/L – CV collapse, coma, convulsions, death
Divalproex (Epival)
Divalproex (Epival)/valproic acid (Depakene)
- Divalproes (enteric coated esther preparation of valproic acid) – less GI upset
- Good response to rapid cycling + mixed states, not as good for bipolar depression. Good for mania.
- Metabolized by liver
- Avoid in pregnancy (11% malformations)
- S/E:
o Wt gain
o Decr bone density
o Drowsy
o GI upset (switch to Divalproex, take w food)
o Hair loss (selenium and zinc supplements may help)
o Liver dysfunction (monitor)
o PCOS
o Thrombocytopenia (monitor)
o Tremor (treat with propranolol)
Carbamazepine (Tegretol)
Carbamazepine (Tegretol)
- 2nd line mood stabilizer (3rd line for depression). NOT used often.
- Useful for pain syndromes
- Liver Metabolism: Induces P450 3A4 (incuding own + other drug metabolism)
- Avoid in pregnancy (5.1% malformations)
- S/E: (Same as TCA – similar structure)
o Agranulocytosis + other blood problems
o Anticholinergic (blurry vision, constipation, urinary retention)
o Sedation, wt gain
o SJS - *** report any rashes to MD***
o Dizziness
o Induces P450 - causes levels of other drugs to drop (i.e. olanzapine won't work)
Newer Anticonvulsant Mood Stabilizers
Gabapentin (Neurontin)
- Poor in mood stabilizers (adjunct)
- Indications: Sleep, anxiety, pain syndromes
- W/D of prolongued use
Lamotrigine (Lamictal)
- Used for bipolar II maintenance (mild manias). Not good for acute mania.
- Titrate slow, well tolerated... take forever to reach treatment dose (>2months)
- S/E:
o 0.1% SJS - ***report all rashes to MD***
Oxcarbazepine (Trileptal)
- Great alternative to Carbamazepine
- Less S/E:
o Less agranulocytosis
o Lower incidence of SJS
o No need to monitor plasma levels
Topiramate(Topramax)
- Poor mood stabilizer
- Used in aggression, anger, impulsivity
- Wt loss, **cognitive S/E significant** nickname “Dopamax”
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