BPAD

1. Hypomania or Mania

2. What is Bipolar….

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').

5. Hypomania
• No significant impairment in social and occupational function
• No psychotic features
• Usually no need for hospitalization

6. 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

7. 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.

8. Mania
Characterized by three features:
• Persistent elevated mood (elation or
irritability)
• Increased activity
• Poor judgment

9. 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

10. 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.

11. Summary of Indicators….

12. 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.

13. 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

14. 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.

15. Hypomania/Mania
Nursing Interventions

16. 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.

17. • 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.

18. 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)

19. 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.

20. 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)

21. 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.

22. 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.

23. 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.

24. 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

25. 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.

26. 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.

27. 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.

28. The role of psychological treatments
• Psychological treatments combined with
medication yield the most effective and
enduring outcome.

29. 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.

30. 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.

31. • 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.

32. 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.

33. Pharmacology

34. Lithium
http://www.medsafe.govt.nz/profs/datasheet/l/LithicarbFCtab.pdf

35. 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

36. 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

37. 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.

38. 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

39. 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.

40. 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).

41. Lithium should be
taken with food, as it
causes less nausea
than on an empty
stomach.

42. 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

43. 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.

44. 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.

45. 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

46. • 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.

47. Adverse Effects

48. Lithium Toxicity
Lithium toxicity is closely related to serum
lithium concentrations and can occur at doses
close to therapeutic concentrations

49. 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.

50. 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.

51. 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

52. 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.

53. 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.

54. 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

55. Interactions that may decrease
lithium concentration
• Xanthines (theophylline, caffeine)
• Sodium bicarbonate and sodium chloride containing
products
• Psyllium or ispaghula husk
• Urea
• Mannitol
• Acetazolamide.

56. 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.

57. 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.

58. 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

59. 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.

60. 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.

61. 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.

62. Carbamazepine

63. Action
Decreases synaptic transmission in the CNS by
affecting sodium channels in the neurons.

64. Side Effects
• CNS: Ataxia, drowsiness, fatigue, psychosis,
vertigo.
• EENT: Blurred vision, corneal opacities.
• RESP: Pneumonitis.
• CV: CHF, hypertension, hypotension, syncope.
• GI: Hepatitis.

65. • 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

66. 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.

67. 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.

68. 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.

69. • 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.

70. Sodium Valproate
Trade name: Epilim

71. Classification:
• Anticonvulsant – treatment of seizures
• Antipsychotic – treatment of manic episodes,
maintenance and prophylaxis of bipolar

72. 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)

73. 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)

74. 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)

75. 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)

76. 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

77. 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)

78. 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.

79. 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

80. References
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http://www.youtube.com/watch?v=MBUOoQk0hhU
You tube video..
http://www.youtube.com/watch?v=OY-notfOQhk&feature=related