Tuesday, March 9, 2010

Bipolar disorder

Bipolar disorder - Acute

Definition  

Mental illness characteristically involving cycles of depressive and manic, hypomanic, or mixed-symptom episodes , previously known as manic-depressive disorder


 

Medical History  

* Genetic predisposition

* Environmental Stressors

* Residual Mood Symptoms

* Cyclothymia

* Recurrent major depression

* Seafood Consumption


 

Findings  

* Suicidal intent

* Mania

* Depression

* Disability

* Loss of appetite

* Weight loss

* Insomnia

* Euphoria

* Hyperirritability

* Decreased sleep

* Violent behavior - Acute

* Aggressive behavior

* Pressure of speech

* Psychomotor agitation

* Motor retardation

* Does not adhere to rules and boundaries

* Hypersexuality state

* Self-neglect


 

Differential Diagnosis  

* Other mental disorders


 

Treatment  


 

Drug Therapy  


 

Acute management of bipolar disorder with mania or mixed episode  


 

LITHIUM CARBONATE

Adults: 1800 mg/day orally in 2 to 3 divided doses; desired serum lithium level ranging between 1 to 1.5 mEq/L


 

VALPROATE SODIUM  

Adults: In hospitalized patients, start initial dosage of 20 to 30 mg/kg IV per day; after obtaining a valproate level, adjust the dose to achieve a serum level between 50 and 125 mcg/mL ; maximum 60 mg/kg/day


 

CARBAMAZEPINE

Adults: Start initial dosage of 200 to 600 mg orally in 3 to 4 divided doses daily; in hospitalized patients, increase in increments of 200 mg/day up to 800 to 1000 mg/day unless side effects develop, with slower increases thereafter as indicated ; maximum 1600 mg/day


 

OLANZAPINE

Adults (monotherapy): 10 to 15 mg orally once daily; may increase/decrease dosage by 5 mg/day at intervals of at least 1 day; usual effective dosage range is 5 to 20 mg/day; maximum 20 mg/day

Adults (in combination with lithium or valproate): 10 mg orally once daily; may increase/decrease dosage by 5 mg/day at intervals of at least 1 day; usual effective dosage range is 5 to 20 mg/day; maximum 20 mg/day


 

RISPERIDONE

Adults (monotherapy or in combination with lithium or valproate): Initial dose 2 to 3 mg orally once daily, increase or decrease in increments of 1 mg/day with intervals of not less than 24 hours; maximum 6 mg/day)

Pediatrics (10 to 17 years; monotherapy only): Initial dose 0.5 mg orally once daily, increase in increments of 0.5 or 1 mg/day at intervals not less than 24 hours, to a target dose of 2.5 mg/day; maximum 6 mg/day


 


 

Outpatient management and maintenance of bipolar disorder with mania or mixed episode  


 

LITHIUM CARBONATE

Adults: Begin in low divided doses, such as 300 mg orally 3 times daily, and titrate upward to serum concentrations of 0.5 to 1.2 mEq/L ; typical daily dosage is 900 to 1200 mg/day


 

VALPROATE SODIUM  

Adults: Start at 250 mg orally 3 times daily; titrate the dose upward by 250 to 500 mg/day every few days, depending on clinical response and side effects, generally to a serum concentration of 50 to 125 mcg/mL; once patient is stable, simplify to once- or twice-daily dosing; maximum 60 mg/kg per day

Note: Bioavailability of the extended-release preparation, Divalproex ER®, is about 15% less than that of the immediate-release preparation; doses of Divalproex ER® will need to be increased proportionately


 

LAMOTRIGINE

Adults (patients not taking enzyme-inducing drugs or valproic acid): 25 mg/day orally for 2 weeks, then 50 mg/day for 2 weeks, then 100 mg/day for 1 week, then 200 mg/day; usual maintenance dose of lamotrigine in patients not taking enzyme-inducing drugs or valproic acid is 200 mg/day

Adults (added to valproic acid regimen): 25 mg/day orally every other day for 2 weeks, then 25 mg/day for 2 weeks, then 50 mg/day for 1 week, then 100 mg/day; usual maintenance dose of lamotrigine in patients taking valproic acid is 100 mg/day

Adults (added to enzyme-inducing antiepileptic drug regimen without valproic acid): 50 mg/day orally for 2 weeks, then 100 mg/day for 2 weeks in divided doses, then 200 mg/day for 1 week in divided doses, then 300 mg/day for 1 week in divided doses, then may increase up to the usual maintenance dose of 400 mg/day in divided doses


 

CARBAMAZEPINE

Adults: Start initial dosage of 200 to 600 mg orally in 3 to 4 divided doses daily; increase slowly up to maintenance dose of approximately 1000 mg/day; typical range is 200 to 1600 mg/day ; extended release preparation is dosed twice daily rather than 3 to 4 divided doses daily


 

OLANZAPINE

Adults (monotherapy): 5 to 20 mg orally once daily after achieving a responder status for an average duration of 2 weeks


 

RISPERIDONE

Adults (monotherapy or in combination with lithium or valproate): Start initial dosage of 2 to 3 mg orally once daily; for maintenance, dosage adjustments should be made in increments of 1 mg/day at intervals of at least 24 hours; maximum 6 mg/day


 


 

Bipolar I disorder with mania and agitation  


 

OLANZAPINE

Adults: Initial, 10 mg IM; lower dose of 5 mg or 7.5 mg may be used if indicated; usual effective dosage range is 2.5 mg to 10 mg. Subsequent doses are up to 10 mg IM; maximum of three 10 mg doses given 2 to 4 hours apart; monitor for orthostatic hypotension prior to the administration of repeated doses


 


 

Treatment of depressive episodes associated with bipolar disorder  


 

QUETIAPINE FUMARATE  

Adults: 50 mg orally once a day on day 1, then 100 mg once daily on day 2, then 200 mg once daily on day 3, then 300 mg once daily on day 4, all doses given at bedtime, then maintenance dose 300 mg/day ; patients requiring higher doses should receive 400 mg on day 5, increased to 600 mg on day 8


 


 

Treatment of acute manic episodes associated with bipolar I disorder as either monotherapy or adjunct therapy to lithium or divalproex  


 

QUETIAPINE FUMARATE  

Adults: Initiate in twice daily oral doses totaling 100 mg/day on Day 1, increased to 400 mg/day on Day 4 in increments of up to 100 mg/day in twice daily divided doses; further dosage adjustments up to 800 mg/day by Day 6 should be in increments of no greater than 200 mg/day; usual effective dosage range is 400 to 800 mg/day; maximum 800 mg/day


 

Procedural Therapy  


 

In addition to pharmacotherapy for patients with bipolar disorder  

* Psychotherapy: Evidence supports the efficacy of psychotherapy for patients with bipolar disorder when combined with pharmacotherapy .


 

Alternative therapy for patients with bipolar disorder  

* Electroconvulsive therapy: ECT is a potential treatment for patients with severe or treatment-resistant mania, mixed episodes, and depressive episodes, especially with pregnancy, psychotic features, or catatonic features .

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SYSTEM BASED CLASSIFICATION OF DISEASES

SYSTEM BASED CLASSIFICATION OF DISEASES

Bone and Joint Diseases

  1. Gout and Hyperurecemia
  2. Osteoarthritis
  3. Rheumatoid Arthritis
  4. Acute coronary Syndroms

Cardiovascular Diseases

  1. Arrhymias
  2. Cardiopulmanary Resuscitation
  3. Heart Failure
  4. Hypertension
  5. Hyperlipidemia
  6. Ischemic Heart Diseases
  7. Shock
  8. Stroke
  9. Venous Thromboembolism

Dermatrologic Diseases

  1. Acne
  2. Psoriasis
  3. Skin Disorders and Cutaneous Drug Eruptions

Endocrine Diseases

  1. Cirrhosis
  2. Portal Hypertension

Gastrointestinal Diseases

  1. Irritable Bowel Syndrome
  2. Constipation
  3. Diarrhea
  4. Gastroesophagal Reflux Disease
  5. Hepatitis, Viral
    1. Hepatitis A
    2. Hepatitis B
    3. Hepatitis C
  6. Nausea and Vomiting
  7. Pancreatitis
  8. Peptic Ulcer disease

Gynecologic and Obstetric Diseases

  1. Contraception
  2. Hormone therapy

Hematologic Diseases

  1. Anemia
    1. Megaloblastic Anemia

i. Megaloblastic Anemia due to Folate Deficiency

ii. Megaloblastic Anemia due to Vitamine B12 Deficiency

    1. Sickle Cell anemia
    2. Hemolytic Anemia
    3. Iron Deficiency Anemia
    4. Aplastic Anemia
    5. Iron Deficiency Anemia

Infectious Diseases

  1. Central Nervous System infections
  2. Endocarditis
  3. Fungal infections, Invasive
  4. Gastrointestinal Infection
  5. HIV / AIDS
  6. Intra-Abdominal Infection
  7. Respiratory Tract infections, Lower
  8. Respiratory Tract infections, Upper
  9. Sepsis and Septic Shock
  10. Sexually transmited Diseases (STD)
  11. Skin and soft tissue infection
  12. Tuberculosis
  13. Urinary tract infection and prostatitis

Neurologic Diseases

  1. Epilepsy
  2. Headache
    1. Migraine
    2. Cluster Headache
  3. Pain management
  4. Parkinson’s Diseases
  5. Status epilepticus

Nutritional Diseases

  1. Enteral Nutrition
  2. Obesity
  3. Parentaral Nutrition

Onchologic Diseases

  1. Breast cancer
  2. Colorectal Cancer
  3. Lung cancer
  4. Lymphomas
  5. Prostate cancer
  6. Cervical Cancer
  7. Esophageal Cancer
  8. Gastric Cancer
  9. Head and Neck Cancer
  10. Lung Cancer
  11. Ovarian Cancer
  12. Pancreatic Cancer
  13. Primary bone Cancer
  14. Primary Brain cancer
  15. Testicular Cancer
  16. Thyroid Gland Cancer
  17. Urinar Bladder cancer
  18. Uterine Cancer

Ophtalmic Diseases

  1. Glaucoma

Psychiatric Diseases

  1. Alzhimer’s Diseases
  2. Anxiety Disease
  3. Bipolar Diseases
  4. Depressive diseases
  5. Schizophrenia
  6. Sleep Diseases
  7. Substance-Related Diseases

Renal Diseases

  1. Acid base Diseases
  2. Acute renal Failure
  3. Chronic Renal Failure
  4. Drug Dosing in renal insufficiency
  5. Electrolyte Homeostasis

Respiratory Diseases

  1. Allergic Rhinitis
  2. Asthma
  3. Chronic Obstructive Pulmonary Diseases

Urologic Diseases

  1. Benign Prostatic, Hyperplasia
  2. Erectile Dysfunction
  3. Urinary Incontinence