Rx Mood Stabilizers

    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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