1. LITHIUM: Usual Dose : Acute – 600 mg.1800mg Maintenance 900-1200 mg. Half- life : - 24 hrs. Therapeutic serum level : 0.6-1.2 mEq/L Common Side Effects: a. N/V. diarrhea, polyuria, polydipsia,

weight gain, tremor and fatigue. Warnings: Lithium toxicity: teratogenicity

A. Therapeutic Serum levels (0.6-1.2 mEq/L): Usual manifestations: a. Hand tremor(fine) b. Memory problems c. Goiter d. Hypothyroidism e. Mild diarrhea f. Anorexia g. Nausea h. Edema I. Weight gain j. Polydipsia, polyuria

Mild to Moderate Toxicity (1.5-2mEq/L): a. Diarrhea b. Vomiting c. Drowsiness d. Dizziness e. Hand tremor (coarse) f. Muscular weakness g. Lack of coordination h. Dry mouth

Moderate to Severe Toxicity( 2-3 mEq/L): a. Previous symptoms and: b. Ataxia C. Giddiness D. Tinnitus E. Blurred vision F. Large output of dilute urine G. Delirium H. Nystagmus

Severe Toxicity (>3mEq/L): A. Previous symptoms and B. Seizures C. Organ failure D. Renal failure E. Coma F. Death

Key Nursing interventions for patients taking Lithium: 1. Prepare the patient for expected side effects without

instilling anxiety. 2. Discuss the side effects that should subside (e.g., nausea,

dry mouth, diarrhea, thirst, mild hand tremor, weight gain, bloatedness, insomia, lightheadedness).

3. Identify the side effects that require immediate notification of the physician (e.g., vomiting, severe tremor, sedation,muscle weakness, vertigo).

4. Suggest taking lithium with meals to reduce nausea. 5. Suggest drinking 10 to 12 glasses of water per day to

reduce thirst and maintain normal fluid balance. 6. Advise the patient to elevate the feet to relieve ankle

edema. 7. Advise the patient to maintain a consistent dietary sodium

intake, but to increase sodium if a major increase in perspiration occurs.

Patients Guidelines for Taking Lithium: 1. Must be taken on a regular basis, preferably at the same

time daily. A patient who forgets a dose, should wait until the next

scheduled time to take the lithium, but should not take twice the amount at that time, because lithium toxicity could occur.

2. When lithium treatment is initiated, mild side effects would occur. Thus most of these side effects are transient and do not indicate lithium toxicity. Additionally, in some patients taking lithium, some foods such as celery and butter fat have an unappealing taste.

3. Serious side effects of lithium that necessitate its discontinuance include vomiting, extreme hand tremor, sedation, muscle weakness, and vertigo. The prescribing physician should be notified immediately if any of these side effects occur.

4. Lithium and sodium are eliminated from the body through the kidneys. An increase in salt intake increases lithium elimination, and a decrease in salt intake decreases lithium elmination. Thus, the patient must maintain a balanced diet and salt intake. The patient should consult with the prescribing physician before making any dietary alterations.

5. Various situations can require an adjustment in the amount of lithium administered to a patient- for example, the addition of a new medication to the patient’s drug regimen, a new diet, or an illness with fever or excessive sweating.

6. For determination of lithium levels, blood should be drawn in the morning approximately 8 to 12 hours after the last dose was taken.

A. Carbamazepine: Usual dose: 800-1000mg and titrated

upward until side effects or serum levels reached.

Half-Life : 12-17 hrs. induces own metabolism

Therapeutic Serum level: 4-12mcg/ml. Common side effects: N/V, dizziness,

sedation, rash, HA. Warnings: Blood dyscrasias;

teratogenicity.

Mechanism of Actions: It is effective for most patients who do not

respond to lithium or to the valproates, has faster onset of action compared to lithium. Effective for patients with a rapidly cycling bipolar episode. The effectiveness of carbamazepine might be related of its inhibition of its kindling activity in the brain.

It normalize sodium channel activity(and sodium influx), thus increasing the threshold of stimulation needed for cell firing.

B. Divalproex: Usual dosage: 1000-1500 mg Half-life: 6-16 hrs. Therapeutic serum level: 50-115mcg/ml Common side effects: N/V, sedation, weight gain, hair loss. Warnings: Hepatoxicity, teratogenicity, pancreatitis. History: Valproic acid (Depakene) and divalproex sodium

(Depakote) have been used since the 1960’s as antiepileptic agents. In 1995, these drugs were approved for the treatment of mania and considered first-line agents.

Mechanism of Actions: Effective for patients with a rapid cycling variant of bipolar disorder and for those with mania secondary to a general medical condition(Lennkh and Simhandl, 2000) Have rapid onset, can be used initially without attempting lithium, and are well tolerated, with little effect on cognition.

C. Lamotrigine: (Lamictal) Usual dose : Begin at 25-50 mg and increase by 12.5-

25 mg a week, up to 250 mg bid. Half-life : - with chronic use. Therapeutic level: N/A Common side effects: HA, sedation, cognitive dulling,

insomnia, ataxia, N/V, dizziness, diplopia. Warnings: Serious rash, e.g., Stevens Johnson; breast-

feeding? Mechanism of Actions: This drug works by manipulating

the GABA system, thus inhibiting neuronal firing. Other mechanism of actions including blocking of voltagegated sodium and calcium channels, further inhibiting neuronal conduction. It inhibits the excitatory neurotransmitter glutamate.

D. Oxcarbazepine: (Trileptal) Usual dosage: 600-2400 mg in two or three

divided doses. Half-life: 7-20 hrs with active metabolites Therapeutic level: 15-35 mdg/ml. Common side effects: Fatigue, N/V,

dizzeness, sedation. Diplopia, hyponatremia Warnings: Teratogenicity, breastfeeding? Mechanism of Action: Structurally related to

carbamazepine and has similar pharmacologic activity. However, this drug does not cause some of the more serious adverse reactions associated with carbamazepine.

E. Gabapentin: (Neurontin) Usual dosage: 900-4000mg in 3 divided

doses. Half-life: 5-7 hrs. Therapeutic level: N/A Common side effects: Sedation, fatigue,

tremors, nausea, dry mouth, dizziness, diplopia, hyperthermia.

Warnings: Teratogenicity, breast feeding? Mechanism of Actions: Used as an adjunctive

role and not as monotherapy, also effective if the patient is also experiences anxiety. It has similarity with lamotrigine.

A. Olanzapine: (Zyprexa) Atypical drug. a. Approved as monotherapy for acute

and maintenance treatment of bipolar disorder. Controls Mania and acts as a mood stabilizer.

b. This particular pharmacologic profile might reduce the risk of precipitating a depression after treatment for acute mania.

c. Associated with significant weight gain in some patients.

B. Risperidone (Risperdal) Atypical Drug a. Effective agent for acute bipolar

disorder. b. It does not cause as much weight gain

as other mood stabilizers.

C. Quetiapine (Seroquel) Atypical Drug a. Can control acute mania and rapidly

cycling mania, and is used prophylactically.

D. Ziprasidone (Geodon) Atypical drug a. Treatment of acute bipolar disorder. b. Causes little or no weight gain and is

reported to be well tolerated. E. Clozapine (Clozaril) Atypical drug a. Very effective for the treatment and

prophylaxis of acute mania: however, the same concern associated with its more conventional antipsychotic use remains problematic- that is agranulocytosis. Hematologic monitoring is required.

F. Aripiprazole (Abilify) Third generation agent

a. The newest antipsychotic, sometimes referred to as a novelty drug and has also been shown to be effective in the treatment of bipolar disorder.

A. Lithium - Tablets: Lithotabs Capsules: Eskalith,Lithane, Lithonate, Carbolith Long-acting : Lithobid, Eskalith CR

B. Anticonvulsants – Carbamazepine(Tegretol) Divalproex Na (Depakote) Gabapentin(Neurontin) Lamotrigine (Lamictal) Oxcarbazepine(Trileptal) Topiramate (Topamax) Valproic acid (Depakene)

C. Antipsychotics – Aripiprazole (Abilify) Clozapine (Clozaril) Olanzapine (Zyprexa) Quetiapine (Zyprexa) Risperidone (Risperdal) Ziprasidone (Geodon)

A. Elevated Mood. B. Increase in activities. C. Flight of Ideas. D. Racing thoughts. E. Inflated self-esteem. F. Decreased need for sleep. G. Agitation. H. More talkative than is usual. I. Pacing, hand wringing. J. Extreme restlessness. K. Losses temper often. L. Significant irresponsible behavior. M. Increased goal directed activities(e.g. sexual, social). N. Impaired excessive involvement in pleasurable activities, with high

potential for painful consequences. O. Delusions. P. Hallucinations.