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Hypomania and mania_tenille_2011 (3)


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Hypomania and mania_tenille_2011 (3)

  1. 1. Hypomania or Mania
  2. 2. What is Bipolar….
  3. 3. Bipolar disorders …..individuals experiencing extremes of mood polarity. A manic episode is required for diagnosis. To diagnose mania: Mood symptoms and some or all of the other symptoms must have been present for at least one week. With mania these symptoms seriously disrupt the person's life and relationships. If these symptoms are present, but the person's life is not so seriously affected, then the term used is hypomania ('hypo' meaning 'less than').
  4. 4. Hypomania • No significant impairment in social and occupational function • No psychotic features • Usually no need for hospitalization
  5. 5. Symptoms of Hypomania • Feeling exceptionally confident with inflated self- esteem • Feeling a need for less sleep, and feeling rested after only a few hours’ sleep • Being more talkative than usual, or feeling a need to keep talking • Feeling full of ideas with racing thoughts • Being easily distracted, and darting from one activity to another • Increased goal-directed activity
  6. 6. Symptoms of Hypomania • Involvement in pleasurable activities that have a high potential for painful consequences (e.g. spending sprees that result in debt, or a sexual encounter that is later regretted) • Feeling very excited and in a euphoric mood for at least several days on end, which can switch to irritability, intolerance and rage • Increased activity and high energy levels • Being unusually friendly, seeking out people, including strangers • Increased productivity and creativity.
  7. 7. Mania Characterized by three features: • Persistent elevated mood (elation or irritability) • Increased activity • Poor judgment
  8. 8. Symptoms of Mania • Out of control of emotions and behaviour….very distressed • Normally amiable people may become increasingly angry, impulsive, emotional or irritable • Intense euphoria that nothing can disturb, but if their plans are foiled they may become irritable or uncontrollably furious • Some may become hostile • A few manics may become paranoid or violent and assault others verbally or physically • Very rapid speech, incessant and usually in a loud voice • Decreased sleep exhaustion • Food eaten quickly no regard for table manners • Poor nutrition -to impatient to eat • Increased libido
  9. 9. Symptoms of Mania • Answer questions at great length and continue talking when others speak • Speech may be riddled with jokes, puns, or irrelevant witticisms • Acting in theatrical roles and ways • Offer money or advice to passing strangers • Unable to sleep or sit still…often going for days with 2 or3 hrs sleep and not feeling tired • Socially frenetic…throwing parties, going to bars • Throw aside normal inhibitions and become sexually hyperactive or promiscuous • Due to impaired judgement very poor decision making skills. Overspending, over commitment, quitting jobs, etc.
  10. 10. Summary of Indicators….
  11. 11. Thinking and Speech • Thoughts are fast, abundant and varied • Delusional- i.e. they are genius • Ability to concentrate is reduced • Delusions are often religious, persecutory or paranoid • Speech may contain puns, jokes, rhymes and irrelevancies • Acute manic speech, that is increased in amount, accelerated and difficult or impossible to interrupt • Clang association-words strung together in rhyming phrases with no connected meaning.
  12. 12. Mood Labile- mood affect or behaviour that is subject to frequent or unpredictable change Elation-emotional reaction characterized by euphoria, excitement, extreme joyfulness, optimism, and self-satisfaction considered to be of pathologic origin when such a response does not realistically reflect a person's actual circumstances. Thus an elated mood may be characteristic of a manic state. Euphoric-feeling of great but often unjustified exaggerated happiness Optimistic -to take the most hopeful view Irritable- easily annoyed or angered Aggressive- angry and hostile
  13. 13. Perception Sometimes a person with severe episodes of mania or depression has psychotic symptoms too, such as hallucinations or delusions. The psychotic symptoms tend to reflect the person's extreme mood. For example, psychotic symptoms for a person having a manic episode may include believing he or she is famous and/or has a lot of money.
  14. 14. Hypomania/Mania Nursing Interventions
  15. 15. Intervention (Treatment of Mania) Initial Assessment •For acutely manic patients, referral to a specialist psychiatric service for in- or out-patient care is necessary because aggression, excessive spending and disinhibited behaviour (e.g. sexual indiscretions) are likely to damage the person’s reputation. •Involuntary hospitalization is frequently required to protect the patient and family from the effects of damage wrought by impaired judgement.
  16. 16. • If treatment occurs in an outpatient setting, it is crucial to closely monitor risky behaviour, particularly of a financial nature or when of potential harm to others (e.g. hazardous driving). A financial power-of-attorney may be necessary, particularly if there is a history of excess spending.
  17. 17. Screening Assessment: • Severity of symptoms • Level of functional impairment • Degree of insight • Presence/absence of psychosis • Risk to self (financial, sexual reputation) or others (violence) • Amount/quality of family support and/or community services Treatment Considerations: • Legal aspects (informed consent, mental capacity) • Care in least restrictive environment consonant with safety (risk of self-harm/ danger to others) • Mode of initial treatment (oral, iv, im)
  18. 18. Comprehensive Clinical Assessment • A full psychiatric history, and mental state and physical examinations, are necessary to confirm the diagnosis, rule out organic causes (including prescription or illicit drugs), identify physical complications (e.g. dehydration) and ascertain level of risk to self or others.
  19. 19. Clinical assessment requires patient cooperation. This may not be possible if the patient is irritable or aggressive. • History taking and mental state assessment: includes risk assessment (potential for violence, degree of financial harm, risky sexual behaviour – exploitation; communicable diseases such as HIV, herpes, hepatitis C) • Physical examination: exclude organic causes (neurological disorder, systemic disease, substance misuse, prescription medication-induced) or physical sequelae of mania (e.g. dehydration, emaciation) • Check compliance with mood stabiliser • Cease any antidepressant • Conduct routine physical investigations (urea & electrolytes, full blood count, liver function tests, thyroid function tests, therapeutic drug monitoring of mood stabiliser serum concentrations) • Additional investigations if indicated (e.g., brain scan, cognitive/dementia screen, EEG)
  20. 20. Pharmacological Treatment • Acute mania in bipolar disorder is typically treated with mood stabilizers and/or antipsychotic medication. • The first is use of a mood stabiliser (lithium, valproate, carbamazepine or olanzapine) for the elevated mood. • The second is concurrent use of an antipsychotic or benzodiazepine (or their combination) to calm or sedate until the mood stabiliser takes effect (approximately 1 week). If olanzapine is used as a mood stabiliser, no other antipsychotic is required.
  21. 21. Therapeutic drug monitoring • Pharmacological treatments need to be prescribed and monitored carefully to avoid harmful side-effects such as neuroleptic malignant syndrome with the antipsychotic medications. Continuing treatment • Following remission of an initial episode of mania, the mood stabiliser is continued for at least 6 months. • Benzodiazepines or antipsychotics are withdrawn once the episode has resolved.
  22. 22. Psychological Treatments • The limitations of medication in alleviating symptoms and functional impairment highlight the need for psychosocial interventions which aim to reduce symptoms, prevent relapse and recurrence, restore social and psychological functioning and support patient and family.
  23. 23. Specific goals include: • a therapeutic alliance • adherence to medication • regular cycles of activity and sleep • improved symptoms and coping Psychological adjustment covers: • stigma • fear of recurrence • interpersonal difficulties • marital, family and parenting issues • educational or occupational disruption • negative consequences of acute episodes
  24. 24. Psycho-education • This offers patient and family a conceptual and practical approach to the illness and its treatment, identification of early warning signs, and increases satisfaction with treatment and adherence. It improves compliance and thus reduces relapse rates.
  25. 25. Cognitive therapy (CT) • Cognitive therapy aims to identify and manage stress, prodromes and symptoms, and to prevent relapse or recurrence through monitoring and challenging negative assumptions and thoughts. Interpersonal and social rhythm therapy (IPSRT) • Patients are guided to regulate their ‘social rhythms’ when stressed and to address interpersonal problems linked to the onset and persistence of bipolar episodes.
  26. 26. Group therapy (GT) • This has been applied as an adjunct to medication. The emphasis is on adherence and ‘here and now’ interpersonal issues, lithium monitoring and problem-solving. Family-focused treatment (FFT) • This covers such aspects as communication, problem solving skills and psychoeducation, which deals with multiple family stresses leading to high levels of expressed emotion.
  27. 27. The role of psychological treatments • Psychological treatments combined with medication yield the most effective and enduring outcome.
  28. 28. Hypomania (A type of Bipolar depression) Usually the first episode of Hypomania is depression- Some interventions: Quieting response • Can reduce insulin independence • Can do this anywhere • Relieves stress and anxiety • Helps manage depression • Refuting irrational ideas • Managing your self talk • Helps you rationalise • Helps promote emotional health • Self hypnosis • Form of relaxation • Allows you to concentrate and remember a particular event • It is a heightened state of awareness where you are more open to suggestion.
  29. 29. Nursing Interventions • Remove all possible hazards so that the client is in a safe environment - as this ensures the client will be safe from harm during their manic episode. • Speak to the client in a quiet, calm way - so that the client will not see the nurse as a threat and may encourage the client to calm down. • Encourage the client to avoid alcohol, caffeine and excess sugar - as these can cause an elevation in mood.
  30. 30. • Remove all excess stimuli from the client’s environment - as this will promote calming and relaxation. • Encourage client to continue their medication and not miss any doses - as this will help reduce a manic mood. • Gently promote reality orientation - to help the client come out of their manic episode.
  31. 31. NURSING INTERVENTIONS: MANIA • Observe client every 15 minutes or as needed. Remove all sharp objects from room (particularly if client is suicidal). •Reinforce and focus on client’s strength . •Assist client in evaluating the positive as well as negative aspects of life. •Encourage appropriate expression of feelings and emotions. •Encourage client to engage in regular periods of recreational therapy that suits them (i.e. Cooking class, playing volleyball). •Encourage client independence in performing ADLs and provide assistance as per necessary.
  32. 32. Pharmacology
  33. 33. Lithium
  34. 34. Indications 1. Treatment of mania and hypomania. 2. Lithium may also be tried in the treatment of some patients with recurrent bipolar depression, for which treatment with other antidepressants has been unsuccessful. 3. Prophylactic treatment of recurrent affective disorders
  35. 35. Dosage and Administration • A simple treatment schedule has been evolved which, except for some minor variations, should be followed whether using Lithium carbonate therapeutically or prophylactically. • The minor variations to this schedule depend on the elements of the illness being treated
  36. 36. 1. In patients of average weight (70 kg) an initial dose of 400-1,200mg of Lithium carbonate may be given as a single daily dose in the morning or on retiring. Alternatively, the dose may be divided and given morning and evening. When changing from other lithium preparations serum lithium levels should first be checked, then Lithium carbonate therapy commenced at a daily dose as close as possible to the dose of the other form of lithium. As bioavailability varies from product to product (particularly with regard to retard or slow release preparations), a change of product should be regarded as initiation of new treatment. 2. Four to five days after starting treatment (and never longer than one week) a blood sample should be taken for the estimation of serum lithium level. 3. The objective is to adjust the Lithium carbonate dose so as to maintain the serum lithium level permanently within the diurnal range of 0.5 – 1.5 mmol/L.
  37. 37. Serum lithium levels should be monitored weekly until stabilization is achieved. In practice, the blood sample should be taken between 12 and 24 hours after the previous dose of Lithium carbonate. ‘Target’ serum lithium concentrations at 12 and 24 hours Units are mmol/L At 12 hours At 24 hours Twice daily 0.7 – 0.10 0.5 – 0.8 Once daily 0.5 – 0.8
  38. 38. 4. Following stabilisation of serum lithium levels, the period between subsequent estimations can be increased gradually but should not normally exceed three months. Additional measurements should be made following alteration of dosage, on development of intercurrent disease, signs of manic or depressive relapse, following significant change in sodium or fluid intake, or if signs of lithium toxicity occur.
  39. 39. 5. Whilst a high proportion of acutely ill patients may respond within three to seven days of the commencement of Lithium carbonate therapy, Lithium carbonate should be continued through any recurrence of the affective disturbance. This is important as the full prophylactic effect may not occur for 6 to 12 months after the initiation of therapy. 6. In patients who show a positive response to Lithium therapy, treatment is likely to be long term. Careful clinical appraisal of the patient should be exercised throughout medication (see Precautions).
  40. 40. Lithium should be taken with food, as it causes less nausea than on an empty stomach.
  41. 41. Use in the Elderly In elderly patients or those below 50kg in weight, it is recommended that the starting dose be 400mg. Elderly patients may be more sensitive to undesirable effects of lithium and may also require lower doses in order to maintain normal serum lithium levels. It follows therefore that long term patients often require a reduction in dosage over a period of years. Not recommended for use in Children and Adolescents
  42. 42. Pharmacodynamics • Lithium carbonate provides a source of lithium ions that may act by competing with sodium ions at various sites in the body. • Therapeutic concentrations of lithium have almost no discernible psychotropic effects in normal volunteers but considerable effect in patients suffering from affective disorders. • The mechanism of action is unknown.
  43. 43. Pharmacokinetics • Lithium ions are almost completely absorbed from the gastrointestinal tract, complete absorption occurring after about 8 hours. Peak plasma concentrations occur after about 2-4 hours. • Lithium initially distributes into extracellular fluid and then to most other tissues. The final volume of distribution equals that of total body water. • Lithium slowly enters cerebrospinal fluid achieving at steady state 40% of the plasma concentration. • Elimination occurs via the kidneys but lithium can also be detected in sweat and saliva. • The biological half-life is variable ranging from 7-20 hours and may be longer at night. • Poor renal function impairs excretion. • Lithium is able to cross the placenta and is excreted in breast milk.
  44. 44. Precautions Lithium carbonate is contra-indicated in the following conditions: • Patients with significant cardiovascular or renal disease • Conditions associated with hyponatraemia such as Addison’s disease, dehydrated or severely debilitated patients, and patients on low sodium diets • Known hypersensitivity to lithium or to any of the excipients
  45. 45. • Pretreatment physical examination and laboratory testing are required prior to commencement of therapy, and should be repeated at frequent intervals. The patient should maintain a normal diet with adequate salt and fluid intake during therapy. • It is important to ensure that renal function is normal - if necessary a creatinine clearance test or other renal function test should be performed. • Cardiac and thyroid function should be assessed before commencing lithium treatment. • Patients should be euthyroid before the initiation of lithium therapy. Renal function, cardiac function and thyroid function should be reassessed periodically.
  46. 46. Adverse Effects
  47. 47. Lithium Toxicity Lithium toxicity is closely related to serum lithium concentrations and can occur at doses close to therapeutic concentrations
  48. 48. Nephrotoxicity • Up to one-third of patients on lithium may develop polyuria with a urinary output of up to three litres per day. This is usually due to lithium blocking the effect of ADH and is reversible on lithium withdrawal. Patients should be warned to inform their doctors if they develop polydipsia, polyuria, nausea or vomiting. • However, long term treatment with lithium may also result in permanent changes in kidney histology and impairment of renal function. High serum concentrations of lithium including episodes of acute lithium toxicity may aggravate these changes. • The minimum clinically effective dose of lithium should always be used. • Renal function should be monitored in all patients and not only in those who develop polyuria or polydipsia, e.g. with measurement of blood urea, serum creatinine and urinary protein levels in addition to the routine serum lithium estimations.
  49. 49. Encephalopathic syndrome An encephalopathic syndrome, characterised by weakness, lethargy, fever, tremulousness, confusion, extrapyramidal symptoms and leucocytosis has occurred in a few patients treated with lithium and neuroleptics. In some instances, the syndrome was followed by irreversible brain damage. Because there is a possible causal relationship between these events and treatment with lithium and neuroleptics. Patients receiving combined therapy should be monitored closely for early evidence of neurological toxicity and treatment discontinued promptly if symptoms appear. This encephalopathic syndrome may be similar to or the same as neuroleptic malignant syndrome.
  50. 50. Effects of impending lithium intoxication fall into two groups: 1. Gastro-Intestinal Increasing anorexia, diarrhoea and vomiting. 2. Central Nervous System Muscle weakness, lack of co-ordination, drowsiness or lethargy progressing to giddiness and ataxia, tinnitus, blurred vision, dysarthria, coarse tremor and muscle twitching. At blood levels above 2-3 mmol/L there may be a large output of dilute urine, with increasing disorientation, seizures, coma and death
  51. 51. Patient Education • Caution should be exercised to ensure that diet and fluid intake are normal, thus maintaining a stable electrolyte balance. This may be of special importance in very hot weather or work environment. Infectious diseases including colds, influenza, vomiting, diarrhoea, intercurrent infection, fluid deprivation and drugs likely to upset electrolyte balance, such as diuretics, may all reduce lithium excretion thereby precipitating intoxication. • Clear instructions regarding the symptoms of impending toxicity should be given by the doctor to all patients and if necessary family members of patients receiving long term lithium therapy Patients should also be warned to report if polyuria or polydipsia develop. Episodes of nausea and vomiting or other conditions leading to salt/water depletion (including severe dieting) should also be reported to their health care provider. • There is epidemiological evidence that lithium may be harmful to the foetus in human pregnancy. It is strongly recommended that lithium be discontinued before pregnancy. • Elderly patients are at a greater risk of lithium toxicity.
  52. 52. Interactions If one of the following medicines is initiated, regular monitoring of serum lithium levels and for signs of lithium toxicity should be performed during concomitant treatment. Lithium dosage should either be adjusted or concomitant treatment stopped, as appropriate.
  53. 53. Interactions that may increase lithium concentrations • Selective serotonin re-uptake inhibitors (SSRIs) • Metronidazole • Tetracyclines • Topiramate • Non-steroidal anti-inflammatory drugs (NSAIDs) • ACE inhibitors • Thiazide diuretics (may cause a paradoxical anti-diuretic effect resulting in possible water retention and lithium intoxication) • Spironolactone • Frusemide • Angiotensin-II receptor antagonists • Other drugs affecting electrolyte balance may alter lithium excretion, e.g. steroids
  54. 54. Interactions that may decrease lithium concentration • Xanthines (theophylline, caffeine) • Sodium bicarbonate and sodium chloride containing products • Psyllium or ispaghula husk • Urea • Mannitol • Acetazolamide.
  55. 55. Interactions that may cause neurotoxicity • Neuroleptics: risperidone, clozapine, phenothiazines, and particularly haloperidol may lead to, in rare cases, neurotoxicity in the form of confusion, disorientation, lethargy, tremor, extra-pyramidal symptoms and myoclonus • SSRIs: sumitriptan and tricyclic antidepressants have been associated with episodes of neurotoxicity, and may precipitate a serotoninergic syndrome - either event justifies immediate discontinuation of treatment • Calcium channel blockers: may lead to a risk of neurotoxicity in the form of ataxia, confusion and somnolence, reversible after discontinuation of the drug. Lithium concentrations may be increased or decreased • Carbamazepine or phenytoin may lead to dizziness, somnolence, confusion and cerebellar symptoms • Methyldopa.
  56. 56. Other Interactions • Lithium may prolong the effects of neuromuscular blocking agents • Thioridazine may increase risk of ventricular dysrhythmias, Iodide and lithium may act synergistically to produce hypothyroidism • There have also been case reports of lithium interactions with baclofen, cotrimoxazole, acyclovir and prostaglandin- synthetase inhibitors. The clinical significance of these interactions is uncertain.
  57. 57. Side effects Are usually related to serum lithium concentrations and are infrequent at levels below 1.0 mmol/L. • Mild gastrointestinal effects, nausea, vertigo, muscle weakness and a dazed feeling may occur initially, but frequently disappear after stabilisation. Fine hand tremors, polyuria and mild thirst may persist. Weight gain or oedema may present in some patients but should not be treated with diuretics. • Hypercalcaemia, hypermagnesaemia and hyperparathyroidism have been reported. Skin conditions including acne, psoriasis, generalised pustular psoriasis, rashes and leg ulcers have occasionally been reported as being aggravated by lithium treatment. • Long term treatment with lithium may be associated with disturbances of thyroid function, including goitre, hypothyroidism and thyrotoxicosis. Lithium-induced hypothyroidism may be managed successfully with concurrent thyroxine. • Memory impairment may occur during long term use. After a period lasting 3-5 years, patients should be carefully assessed to ensure that benefit persists. It is vital to bear in mind that lithium can be lethal, if prescribed or ingested in excess
  58. 58. The following reactions appear to be related to serum lithium concentrations Adverse reactions can occur in patients with serum concentrations within the therapeutic range (i.e. below 1.5 mmol/L or lower in the elderly). • Body as a whole.- Oedema • Cardiovascular. -Arrhythmia, hypotension, ECG changes including non specific T wave changes, oedema, Raynaud's phenomena, peripheral circulatory collapse, bradycardia, sinus node dysfunction. • Dermatological.- Alopecia, acne, folliculitis, pruritus, psoriasis exacerbation, rash. • Endocrine.- Euthyroid goitre, hypothyroidism, rare cases of hyperthyroidism, hyperglycaemia, hypercalcaemia, hypermagnesaemia, hyperparathyroidism, weight gain. • Gastrointestinal. -Anorexia, nausea, vomiting, diarrhoea, gastritis, excessive salivation, abdominal pain. • Haematological.- Leucocytosis. Hypersensitivity.-Angioedema. • Neuromuscular/CNS. -Tremor, fasciculations, twitching clonic movements of extremities, ataxia, choreoathetoid movements, hyperactive deep tendon reflexes, extrapyramidal symptoms, syncope, seizures, slurred speech, dizziness, vertigo, nystagmus, somnolence, stupor, coma, hallucinations, taste distortion, taste impairment, scotomata, pseudotumour cerebri, autonomic effects including blurred vision, dry mouth, impotence/sexual dysfunction. Myasthenia gravis has been observed rarely. • Renal. -Symptoms of nephrogenic diabetes insipidus.
  59. 59. Overdose • There is no specific antidote to lithium intoxication or poisoning. In the event of accumulation, lithium should be stopped and serum estimations should be carried out every six hours. • Under no circumstances should a diuretic be used. Osmotic diuresis (mannitol or urea infusion) or alkalinisation of the urine (sodium lactate or sodium bicarbonate infusion) should be initiated. • If the serum lithium level is over 4.0 mmol/L, or if there is a deterioration in the patient's condition, or if the serum lithium concentration is not falling at a rate corresponding to a half-life of under 30 hours, peritoneal or haemodialysis should be instituted promptly.This should be continued until there is no lithium in the serum or dialysis fluid. Serum lithium levels should be monitored for at least a further week to take account of any possible rebound in serum lithium levels as a result of delayed diffusion from body tissues.
  60. 60. Summary • Lithium is a drug that is known to be very effective in the treatment of disorders that involve mania and hypomania. However, it has many serious risks mainly associated with the level of serum lithium concentrations. It is important to maintain concentrations between 0.5 and 1.5 mmol/L. • Once safe therapeutic serum levels have been established, levels should be monitored at least 3 monthly or more frequently as indicated. • It is important to educate the client to monitor for signs of toxicity. • Long term use or high serum levels have been associated with permanent adverse effects such as memory loss and kidney disease and signs of these should be monitored for regularly. • Lithium has many possible side effects. If a client is experiencing symptoms not attributable to obvious other causes it might be a good idea to check the list of side effects. • Be aware that many other drugs may interact adversely with Lithium. In particular Haloperidol and other neuroleptics may increase the risk of Neuroleptic Malignant Syndrome.
  61. 61. Carbamazepine
  62. 62. Action Decreases synaptic transmission in the CNS by affecting sodium channels in the neurons.
  63. 63. Side Effects • CNS: Ataxia, drowsiness, fatigue, psychosis, vertigo. • EENT: Blurred vision, corneal opacities. • RESP: Pneumonitis. • CV: CHF, hypertension, hypotension, syncope. • GI: Hepatitis.
  64. 64. • GU: Hesitancy, urinary retention. • DERM: photosensitivity, rashes, urticaria. • ENDO: syndrome of inappropriate antidiuretic hormone. • HEMAT: Agranulocytosis, aplastic anaemia, thrombocytopenia, eosinophillia, leukopenia. • MISC: chills, fever, lymphadenopathy
  65. 65. Contraindications • Hypersensitivity. • Bone marrow depression. Pregnancy (only use if benefits outweigh risks to fetus). • Use cautiously in cardiac disease hepatic disease, and older men with prostatic hypertrophy, increased intraocular pressure.
  66. 66. Interactions • May decrease effectiveness of corticosteroids, doxycycline, felbamate, quinidine, warfarin, estrogen containing contraceptives, barbiturates, cyclosporine, benzodiazepines, theophyline, lamotrigine, valporic acid, bupropion and haloperidol. • Danazol increases blood levels. • Concurrent use of Mao Inhibitors may result in hyporexia, hypertension, seizures and death. • Verapamil, diltiazem, propoxyphene, erythromycin, clarithromycin, SSRI’s, anti depressants or cimeidine increase levels and may lead to toxicity increased risk of hepatotoxicity from isoniazid. • Felbamate decreases carbamazepine levels but increases levels of active metabolite. • Acetaminophen may decrease effectiveness and increase risk of toxicity. Lithium increases risk of CNS toxicity. • Non depolarizing neuromuscular blocking agents may decrease duration of action. Grapefruit juice increases serum levels and effect.
  67. 67. Patient Education • Instruct patients to take Carbamazepine around the clock as prescribed. Take missed doses as soon as remembered but not just before the next dose. Do not double dose. Notify health care professional if more than one dose is missed. Medication should be gradually discontinued to prevent seizures. • May cause dizziness or drowsiness. Advise patients to avoid driving or other activities requiring alertness until response to medication is known. • Instruct patients that fever, sore throat, mouth ulcers, easy bruising, unusual bleeding, abdominal pain, chills rash, pale stools, dark urine or jaundice should be reported to a health care professional immediately.
  68. 68. • Advise patient not to take alcohol or other CNS depressants concurrently with this medication. • Caution patients to use sunscreen and protective clothing to prevent photosensitivity reaction. • Advise female patients to use a non hormonal form of contraception while on Carbamazepine. • Emphasize the importance of follow up lab tests and eye exams to monitor for side effects.
  69. 69. Sodium Valproate Trade name: Epilim
  70. 70. Classification: • Anticonvulsant – treatment of seizures • Antipsychotic – treatment of manic episodes, maintenance and prophylaxis of bipolar
  71. 71. Pharmacodynamics • Not fully established • Increase levels of γ-aminobutyric acid (GABA) • GABA - an inhibitory neurotransmitter which blocks the transmission of signal from one neuron to the other balancing neuronal excitability in the brain stabilising mood (anti-manic property) (Porth & Matfin, 2009)
  72. 72. Side Effects Common side effects • Nausea or vomiting • Abdominal cramps • Increase in appetite • Increase in weight • Diarrhoea • Headache • Tremor • Unsteadiness when walking, dizziness or light-headedness • Depression • Hair loss • Feeling tired or drowsy Serious side effects • More frequent or more severe seizures (fits) • Blood clotting problems • Spontaneous bruising or bleeding • Skin rashes • Signs of liver problems such as vomiting, loss of appetite, generally feeling unwell, tiredness, yellowing of the skin and/or eyes, dark urine or blood in urine, pain in the abdomen • Swelling of the feet and legs, weight increase due to fluid build up • Fainting • Bizarre behaviour • Severe upper stomach pain, often with nausea, vomiting and/or loss of appetite especially when prolonged (Medsafe, 2009)
  73. 73. Contraindications • Pre-existing hepatic dysfunction or family history of severe hepatitis, particularly medicine related. • Hypersensitivity to the medicine • Urea cycle disorders • Hepatic porphyria (heme in the haemoglobin is not made properly) (Medsafe, 2010)
  74. 74. Precautions • Pregnancy: risks have to be weighed • Paediatrics • Pancreatitis: may result in fatalities but very rarely reported. • Hepatic dysfunction: Raised liver enzymes are not uncommon particularly if used in conjunction with other anticonvulsants, and are usually transient or respond to dosage reduction. • Impaired renal function • Diabetes: Care should be taken when treating diabetic patients with Epilim syrup which contains sucrose 3.6 g/5 mL • Surgery: Prolongation of bleeding time, sometimes with thrombocytopenia, has occurred with epilim therapy. Platelet function should be monitored before surgery is undertaken in patients receiving Epilim. • Suicidal Behaviour and Ideation: increase the risk of suicidal thoughts or behaviour in patients taking these drugs for any indication. • Abrupt withdrawal (Medsafe, 2010)
  75. 75. Interaction • Caution is advised when using Epilim in combination with newer anti-epileptics whose pharmacodynamics may not be well established. • Other medicines used to treat epilepsy e.g. phenobarbitone, methylphenobarbitone, primidone, phenytoin, carbamazepine, clonazepam, felbamate, lamotrigine, diazepam, lorazepam, oxcarbamazepine and ethosuximide • Alcohol: Valproic acid may potentiate the CNS depressant activity of alcohol. • Carbamazepine: Valproate may displace carbamazepine from protein binding sites and may inhibit the metabolism of both carbamazepine. • Anti-depressants e.g. Monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants – increase CNS depression and lower seizure threshold
  76. 76. Interaction continued... • Antipsychotic medicines including clozapine • Anticoagulants e.g. Warfarin • Aspirin (and other salicylates) • Zidovudine (used to treat viral infections) • Mefloquine (used to treat malaria) • Cimetidine (used to treat stomach ulcers) • Erythromycin and carbapenem antibiotics such as Invanz and Merram. (Medsafe, 2009) (Medsafe, 2010)
  77. 77. Patient Education • Follow the instructions on the label of the medicine or as directed by your doctor. • The tablets take on moisture from the air so it is important that they are left sealed in the foil until taken. • The sodium valproate liquid should not be mixed with other fluid. • If drowsy or less alert do not drive or operate machinery. • If being prescribed other medicines or buying medicines from a pharmacy or supermarket check that they will not interfere with sodium valproate. • Do not stop taking this medicine without your doctor's advice. • Tell your Doctor immediately or go to the Accident and Emergency department of your nearest hospital if you have any thoughts of harming yourself or committing suicide.
  78. 78. Patient Education continued... • Tell your doctor immediately if you notice any of the following: (these are serious side effects and may require immediate medical attention) – more frequent or more severe seizures (fits) – blood clotting problems – spontaneous bruising or bleeding – skin rashes – signs of liver problems such as vomiting, loss of appetite, generally feeling unwell, tiredness, yellowing of the skin and/or eyes, dark urine or blood in urine, pain in the abdomen – swelling of the feet and legs, weight increase due to fluid build up – fainting – bizarre behaviour – severe upper stomach pain, often with nausea, vomiting and/or loss of appetite especially when prolonged
  79. 79. References Doran, C. M. (2008). The Hypomania Handbook The Challenge of Elevated Mood. Philadelphia: Lippincott E.Suppliers (2009). Sodium Valproate Controlled release. Images retrieved April 25, 2011, from swf.html Elder, R., Evans, K. & Nizette, D. (2009). Psychiatric and mental health nursing. (2nd ed). Australia: Elsevier/Mosby. Emory University, (2011). What is bipolar disorder. Images retrieved April 25, 2011, from Garret, S. (2011). Retrieved from: Gauld, N. (n.d.). Epilim (Sodium valproate): A patient’s guide. Retrieved April 23, 2011, from GlaxoSmithKline. (2011). Bipolar disorder, what is it?, Images retrieved April 25, 2011, from tips/bipolar/what-it-means.html
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