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-push it higher on the basis of tolerability and effect.
-monitor complete blood cell count, liver function, and serum sodium.
if sodium concentrations fall
below 130 mEq/L
complete blood cell count
thyroid function tests
pregnancy test for women of childbearing age
Complete blood cell count
Renal function & Urinalysis
(Interstitial fibrosis glomerulosclerosis)
Thyroid function tests
50 to 125 mcg/mL.
after initiation or after a change of dose.
IF tolerated push the level upward in the range.
Nonresponse to treatment if the dose is too low
increases free concentrations.
risk IN young children— metabolic diseases several medications.
Dose and Pharmacokinetics
days for steady state
to see the full effects
mg/day then titrated Maintenance doses
based on serum concentrations
in acute mania
12 hours after the last evening dose
Perform renal function tests, thyroid function tests, and
a urinalysis every
Adverse Effects of lithium
Rash or ↑ psoriasis
Tremor Reduce dose (Cp)+
CNS ( agitation, confusion) Reduce dose (Cp)
GI (nausea/vomiting, diarrhea) Reduce dose; try extended-release
or give levothyroxine
Polydipsia/polyuria Reduce dose, manage intake, and try
Teratogenicity Avoid during first trimester
Neuroleptics Li may potentiate EPS
Carbamazepine ↑ CNS toxicity
Neuromuscular blockers Li prolongs action
Furosemide Little effect
Amiloride Little effect
first mesure :lithium level and sodium /renal function
serum levels greater than 1.5 mEq/L,
:vomiting, diarrhea ,lethargy,
:coarse tremor, confusion, seizures, and coma and may even result in
> 4 mEq/L
1)start with lower doses
- 2)correct the dosing schedule if
is also used
agent if rash is observed.
Risk factors include
1-concurrent use of valproic acid,
3- too high a dose
4-too rapid a dose titration.
onset of rash i
s most often noted during the first
2–8 weeks of therapy
and may also present as a Stevens-Johnson syndrome rash.
Carbamazepine, oral contraceptives, primidone, phenobarbital, andphenytoin can also induce the metabolism of lamotrigine.
Acute Depressive Episode
Acute Manic Episode
How to manage ?
How to manage?
mood swings that range from the lows of depression to the highs of mania
Bipolar disorder mean :
DSM-IV define the manic episode as
A manic episode is characterized by at least
of an abnormal elevated mood. and:
decreased need for sleep
flight of ideas
increased hyperactivity or agitation, and
involvement in high-risk,
activities without regard to the consequences
Types of Bipolar Disorders
first :what is the goal ?
return to usual levels of psychosocial functioning.
• Rapidly control agitation, aggression, and impulsivity
Antidepressants should be tapered and discontinued if possible.
-If it a“breakthrough” episode optimize the medicationdose.
-Achieve a higher serum level (but still withinthe therapeutic range).
Choose an initial treatment
Short-term adjunctive treatment with a benzodiazepine maybe helpful.
These drugs help with agitation
antipsychotics have received approval for use in
mania or mixed episodes
except for clozapine
**Olanzapine and aripiprazole
have been approved for use in bipolar
*lithum OR valproate OR anti psychotis (the first choice)
*Carbamzebine (second choice)
*For mixed episodes, valproate may be preferred over lithium
what is the goal?
-Remission of the symptoms of major depression and return
the patient to usual levels of psychosocial functioning.
- Avoid precipitating a manic or hypomanic episode.
IF a breakthrough depressive episode while
on maintenance treatment, optimize the medication dosage
Choose an initial treatment
Antidepressant monotherapy is not recommended
keep in mind :
*in maintainance all mood stabilizers can be used .
acute : all except clozapine as mono therapy
maintainance: olanazpine and arpiprazole
2)depressive eisodes :
acute :Qeitapine as add on therapy
maintainance :olanzapine and arpiprazole as mono therapy
quetiapine as add on therapy
but add on therapy