NOWCOALITION FOR BIPOLAR DISORDER NOW Bipolar Pharmacotherapy Safety Concerns and Recommended Monitoring Common Side Effects
Fine hand tremor, thirst, polyuria, nausea, diarrhea, weight gain
Less Common, Potential y
Nephrotoxicity, teratogenicity, neurotoxicity (serum level related)
Serious Side Effects Early Signs of Lithium Toxicity
New onset of diarrhea, vomiting, drowsiness, muscular weakness, lack of coordination
Long-term Concerns Require
Decreased thyroid function, nephrotoxicity
Monitoring Baseline Evaluations
BUN, creatinine; thyroid function; serum pregnancy test or assessment
Monitoring
• 12 hrs post dose serum lithium level for monitoring; 5 to 7 days after initiating treatment
and after each dose change (2 levels to establish therapeutic dose); then every 6 months
• TSH, Ca2+, and weight after 6 months, then annual y
Comments
• Monitoring lithium levels and creatinine every 6 months minimizes the risk associated
• Obtain a lithium level if there is a concern about lithium toxicity, as indicated by new
findings of nausea, diarrhea, or change in tremor in someone previously stable on lithium
• Be alert to signs of possible hypothyroid disorder, as indicated by increased weight, cold
intolerance, or fatigue in someone stabilized on lithium treatment
• Recheck lithium levels if any diuretic medications are started or adjusted
• Long term lithium use may result in hyperparathyroidism and elevated Ca2+ levels; thus
DIVALPROEX/VALPROIC ACID Common Side Effects
GI symptoms, weight gain, headache, fatigue, dizziness, tremor
Less Common, Potential y
Teratogenicity, pancreatitis, polycystic ovary syndrome (in young women),
Serious Side Effects Baseline Evaluations
• Initial CBC + platelets, LFTs: be aware of bleeding during first 6 months
Monitoring
• Weigh initial y more often, then every 6 months
Comments
• Reinforce the importance of avoiding pregnancy for female patients
• Many potential y important drug-drug interactions. Tends to increase serum level of other
w w w . N O W B i p o l a r . o r g NOWCOALITION FOR BIPOLAR DISORDER NOW Bipolar Pharmacotherapy Safety Concerns and Recommended Monitoring CARBAMAZEPINE Common Side Effects
Dizziness, drowsiness, unsteadiness, nausea, vomiting
Less Common, Potential y
Serious, but very rare dermatological reactions (Stevens-Johnson syndrome, toxic
Serious Side Effects
epidermal necrolysis), teratogenicity, agranulocytosis, neutropenia
Baseline Evaluations
• HLA-B*1502 genotype screening in patients of Asian descent (screen for increased
genetic risk of Stevens-Johnson syndrome)
Monitoring
• Alert to signs of rash early in treatment course
• CBC, platelets, LFTs, serum sodium every 6 months
Comments
• Many important drug-drug interactions. Can significantly decrease serum levels of many
medications, including decreased ef ectiveness of many contraceptives
• Reinforce the importance of contraception for female patients
LAMOTRIGINE Common Side Effects
General y wel tolerated: initial nausea, dizziness, somnolence, headache sometimes
Less Common, Potential y
• Serious dermatological reactions (Stevens-Johnson syndrome, toxic epidermal
Serious Side Effects
necrolysis) much more frequent if medication is started at ful dose rather than increased
very slowly over time; use standard titration protocol or prepackaged "start-up" packs
Monitoring
• Alert to signs of rash early in treatment: especial y of mucosal membranes, palmar
surfaces, contiguous rash over upper chest and face
Comments
• If medication is discontinued > 3 days, must be restarted with same slow taper as with
w w w . N O W B i p o l a r . o r g NOWCOALITION FOR BIPOLAR DISORDER Adverse Events Associated with Atypical Antipsychotics FDA-Approved for Bipolar Disorder Olanzapine Risperidone Quetiapine Ziprasidone Aripiprazole Asenapine Metabolic Neurologic Cardiovascular Hormonal Adverse Events Associated with Atypical Antipsychotics Used Off-Label for Bipolar Disorder Clozapine Iloperidone Lurasidone Paliperidone Metabolic Neurologic Cardiovascular Hormonal w w w . N O W B i p o l a r . o r g NOWCOALITION FOR BIPOLAR DISORDER Monitoring Protocol for Patients Treated with Atypical Antipsychotics† Parameter Baseline Quarterly
†More frequent assessments may be warranted depending on clinical status
References
1. Correl CU. Individualizing treatment for patients with bipolar disorder: optimizing ef icacy, safety, and tolerability.
Current Psychiatry. 2010;9(11):49-81.
2. McIntyre RS, Konaski JZ. Tolerability profiles of atypical antipsychotics in the treatment of bipolar disorder. J Clin
3. Ng F, Mammen OK, Wilting I, et al. The International Society for Bipolar Disorders (ISBD) consensus guidelines for the
safety monitoring of bipolar disorder treatments. Bipolar Disorders. 2009;11:559-565.
4. American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists,
North American Association for the Study of Obesity. Diabetes Care. 2004;27:596-601. w w w . N O W B i p o l a r . o r g
DR. SCOTT O’CONNOR, DPM, FACFAS Fellow, American College of Foot & Ankle Surgery Diplomate, American Board of Podiatric Surgery Certified in Foot, Reconstructive Rearfoot/Ankle Surgery Extracorporeal Shock Wave Therapy (ESWT) What is ESWT? What is Plantar Fasciitis? Who is a Candidate for ESWT? What to Expect With ESWT After the Procedure ESWT in the Future Wha
Prevention and Control of Methicillin-Resistant Staphylococcus Aureus in Athletic Teams Staphylococcus aureus (“staph”) is a common type of bacteria that is found on the skin and in the nose of healthy people. It can cause infections in wounds or other places in the body. Penicillin is a drug that was once commonly used to treat staph infections. In the last few decades, many
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