MOOD STABILIZERS

INTRODUCTION

A mood stabilizer is a psychiatric medications used to treat mood disorders characterized by

intense and sustained mood shifts as, “feeling good one minute and then bad the next”. The most
common is bipolar disorder, where the mood stabilizers suppress swings between Mania and
Depression, and these drugs are used in the borderline treatment of personality disorder.
Most mood stabilizers are anticonvulsants with the important exception of Lithium, which is
the oldest and best known mood stabilizing drug. Most mood stabilizers are purely antimanic agents,
means they are effective for treating mania and mood cycling and shifting.
Drugs commonly classed as Mood Stabilizer include:
 Lithium carbonate
 Valproic acid (epicene), diavalproex sodium (depakote) and sodium valporate
 (depacon).
 Carbamazepine (Tegretol)
Most Mood stabilizers are anticonvulsants expect Lithium

LITHIUM CARBONATE
The earliest of the mood stabilizers
 Effects indirectly discovered in 1949, but not widely used until 1970.
 The effectiveness of agent lithium led researchers to believe that mania was due to lithium
deficiency.
 Also the most widely prescribed, first line agent.
 Available as lithium carbonate and lithium citrate.

Drug Name : Lithium (Eskalith, Lithobid, Lithonate, Eskalith C.k)

Therapeutic class : Antimanic drug
Route : Oral
Dosage : 1800mg/day in divided doses (acute)
900-1200mg/day in divided doses maintenance

53
 CLASS OR TRADE MECHANISM OF
S.N. DOSES SIDE EFFECTS NURSING RESPONSIBILITY
GENERIC NAME NAME ACTION
1. LITHIUM Camcolit, 1800mg/day After ingestion, Lithium  Neurological—Benign,  Obtain baseline data, cardiac,
Eskalith, in divided is completely absorbed by nontoxic, dysphoria, lack haematology and electrolyte, renal
Li-Liquid, doses (acute) the GI tract serum of spontaneity, slowed function, thyroid function.
Liskonum, 900- concentration peak in 1 to reaction time, memory  Obtain ECG and electrolyte level
Lithicarb, 1:1/2 hrs for standard
1200mg/day difficulties, tremor, ataxia, before and periodically during
preparation and 4 to 4:1/2
in divided neuro muscular inability, therapy
hrs for controlled release
doses preparation. Lithium does
seizures, coma, and death.  Assess neurological and psychiatric
maintenance. not bind to plasma state institute safety measures as
protein, it is not  Miscellaneous – needed to prevent injury.
metabolised and is peripheral neuropathy,  Monitor lithium blood level, WBC
excreted through kidney. benign intracranial count and thyroid and kidney
The plasma half life is hypertension, function last
initially 1-3 days and 2-4 myasthenia gravis,  Monitor fluid intake and output
days after administration altered creativity,  Watch for edema and weight gain.
for more than one year. lowered seizure  Advice the patient to take with food
The blood brain barrier threshold. or milk to minimize GI upset.
permits only slow pass
 Instruct patient to swallow the tablet
age of lithium and single  Endocrine- Goitre,
dose cause toxicity and a
not crush.
hypothyroidism,
long term interaction is  Tell patient beneficial effect may
exophthalamus,
slow to resolve. take 1-3 weeks to appear
hyperthyroidism
The half life of lithium is  Advice to limit food and beverage
about 20 hrs and  Cardiovascular- benign
with caffeine as it interacts with drug
equilibrium is reached action
T-wave changes, sinus
after 5-7 days of  Maintain fluid intake.
node dysfunction,
clearance is decreased  Emphasis for blood test.
with renal insufficiency  Instruct patient to carry medical
 Renal- concentrating
and increased in
defect, polyuria, reduced identification all time.
adolescents. The
GFR, nephritic syndrome  Advice to avoid activity needed
excretion of lithium
mental alertness.
54
increase during  Dermatological- acne,  Avoid
in first trimester of
pregnancy but decreases hair loss, psoriasis,
pregnancy.
after delivery. Lithium is rashes  Avoid breast feeding.
excreted in breast milk  Caution for dehydration and sodium
and in significant amount  GI- loss of appetite,
depletion.
in faeces and sweat. nausea, vomiting,
 Teach sign and symptom of lithium
diarrhoea, altered
toxicity.
carbohydrate  Tremor with beta blocker
metabolism, fluid
propronolol levo thyroxine-
retention.
hypothyroidism and goiter.
 Renal toxicity decrease dose.
 Body image- weight gain
 Polyurea amiloride drink plenty 8-
in 60% patient
12 glass of water.

55
Availability

 Capsules-150mg, 300mg, 600mg.

 Capsules slow release-150mg, 300mg
 Syrup (citrate)-300mg (8meq li/5ml)
 Tablets—300mg
 Tablets Extended Release—300mg, 450mg
 Tablets (slow Release)—300mg

Chemistry

Lithium is a monovalent ion. It is the third lightest element and the lightest of the alkali metals. A
group that contains sodium, potassium rubidium, cesium and francium. Some 300mg of lithium is
contained in 1597mg of lithium carbonate (Li12c03)

Mechanism of Action

The actions have been hypothesized as:-

1. It affects the Na+, K-ATPase and accumulates intracellular as a substitute of Na+.

2. It inhibits the acetylated cyclase and thus decreases CAMP intracellular.
3. It inhibits the release of catecholamine at the synopses.
4. It decreases the postsynaptic serotonin 5HT2 receptor sensitivity

Pharmacological action

After ingestion, Lithium is completely absorbed by the GI tract.

Serum concentration peak in 1 to 1:1/2hrs for standard preparations and 4 to 4:1/2 hrs for controlled
release preparations.

Lithium does not bind to plasma proteins, is not metabolized and is excreted through kidneys.

The plasma half -life is initially 1-3days and 2-4days after administration for more than one year.

The blood brain barrier permits only slow passage of lithium and single dose cause toxicity and a
long term interaction is slow to resolve.

Therapeutic indication

BIPOLAR I DISORDER:

1. Manic Episodes: Lithium controls mania and prevents relapse in about 80% of persons
with bipolar disorder. Lithium alone exerts anti-manic effects in 1 to 3 weeks. To control
manic initially a benzodiazepine such as clonazepam, lorazepam or a dopamine receptor
antagonist such as haloperidol or chlorpromazine is administered in first few weeks.
56
 2. Depressive Episode: Lithium is effective in the treatment of major depressive disorder
and depressive disorder and depression associated with Bipolar I Disorder.
Antidepressants can trigger mania in persons with bipolar disorder; lithium mono therapy
is an ideal treatment for mania and depression. When a depressive episode occurs in a
person taking maintenance lithium, the differential diagnosis should include lithium-
induced hypothyroidism, substance abuse and lack of compliance. Treatment includes
increasing lithium concentration unto 1 to 1.2meq/lit. Adding supplemental thyroid
hormone 25mcg/day.

3. Major Depressive Disorder: - About 50% of antidepressant non-respondents do respond

when lithium 300mg three times a day is added to antidepressant regimen.

4. Schizoaffective Disorder and Schizophrenia: - Lithium is used for persons whose

symptoms are resistant to treatment with SDA’s and dopamine receptor antagonist. Some
persons of schizophrenia who cannot take antipsychotic drugs may benefit from lithium
treatment alone. The aggressive outbursts of schizophrenia patients are reduced by lithium
treatment.

5. Aggression: -Lithium is used to treat aggressive outbursts in persons with schizophrenia,

prison inmates, explosive disorder, and children with conduct disorder and to treat
aggression and self-mutilation in persons with mental retardation

Precautions

Use cautiously in Diabetic patients as it may induce seizures or exacerbate a seizure disorder.
Dehydrated, debilitated, medically ill patients are susceptible to side effects and toxicity.
Leukocytosis is common.
Use cautiously in hepatic or thyroid disease, cardiovascular or renal disease, systemic
infection, severe sodium depletion.

Adverse effects

Neurological—Benign, nontoxic, dysphasia, lack of spontaneity, slowed reaction time,

memory difficulties. Tremor-Postural, occasional extra pyramidal. Toxic-coarse tremor,
ataxia, neuro-muscular irritability, seizures, coma, death.
Miscellaneous-Peripheral neuropathy, benign intracranial hypertension, myasthenia gravis,
altered creativity, lowered seizure threshold.
Endocrine---Thyroid goiter hypothyroidism, exophthalamus, hyperthyroidism
Cardiovascular—Benign-T-wave changes, sinus node dysfunction
Renal—Concentrating defect, polyuria, reduced GFR, nephritic syndrome
Dermatological—Acne, hair loss, psoriasis rash
GI—Appetite loss, nausea, vomiting, diarrhea, altered carbohydrate metabolism, fluid
retention.
Body Image- weight gain in 60% patients.

Dosage and clinical guidelines

Initial Medical Workup:

Before administration of Lithium, routine laboratory work up and physical examination

57
should be done. The lab test include

 Serum Creatinine concentration(24hr urine)

 Electrolytes
 Thyroid function(TSH,T3, T4)
 A complete blood count
 ECG
 Pregnancy Test.

Dosage Recommendations:

 300mg 3 times a day

 For patients with renal impairment it should be 300mg once or twice daily.
 An eventual dosage between 900 and 1200mg/day gives plasma concentration of 0.6 to
1meq/l and a dose of 1200 to1800mg usually produces therapeutic concentration of 0.8 to
1.2meq/l.
 The use of divided doses reduces gastric upset and avoids single high peak lithium
concentrations. Lithium concentration should be determined routinely ever 2 to 6 months and
promptly in persons with non-compliance.

Administration:

 Beware that dosages are individualized according to lithium blood level and response.
 Give with food or milk to minimize GI upset.
 Make sure patient swallows slow release tablet whole without chewing or cutting
 When switching patient from immediate release tablet to slow or controlled release form give
same total daily dosage
 Immediate release tablets are given 3 to 4 times daily where as controlled release forms twice
daily 12hrs apart.

LITHIUM TOXICITY

Common causes for an increase in lithium levels

 Decreased sodium intake

 Diuretic therapy
 Decreased Renal functioning
 Fluid and electrolyte loss, sweating, diarrhoea, dehydration, fever vomiting
 Medical illness
 Overdose
 No steroidal anti-inflammatory drug therapy

Ways to maintain a stable lithium level

 Stabilize dosing schedule by dividing doses or use of sustained-release capsules.

 Ensure adequate dietary sodium and fluid intake (2 to 3L/day).
 Replace fluid and electrolytes lost during exercise or gastrointestinal illness.
 Monitor signs and symptoms of lithium side effects and toxicity.
 If patient forgets a dose, a dose may be taken if less than 2hrs have elapsed; if longer than
2hrs, the dose should be skipped and the next dose taken as scheduled; never double up on
doses.

58
 Sign and symptoms of toxicity

A) Mild to Moderate Intoxication: (Lithium level-1.5 to 2 meq/l)

 G.I. : Vomiting, Abdominal pain, Dryness of mouth
 Neurological : Ataxia, Dizziness, Slurred speech, Nystagmus, Lethargy or
Excitement, Muscle weakness.
B) Moderate to Severe Intoxication: (Lithium level-2.0 to 2.5meq/l)
 G.I. : Anorexia, Persistent nausea, and vomiting.
 Neurological : Blurred vision, muscle fasciations, clonic limb Movements,
convulsions, hyperactive deep tendon Reflexes, delirium, syncope, EEG changes,
stupor, Coma, circulatory failure.
C) Severe Intoxication: (Lithium level above 2.5 meq/l)
 Generalized convulsions, oliguria, and renal failure death

Management of lithium toxicity

 Take patient immediately to hospital emergency room.

 Assess quickly, Obtain rapid history of incident especially dosing, offer support and
explain the patient.
 Hold all Lithium doses.
 Check blood pressure, pulse, rectal temperature, respirations and level of
consciousness. Be prepared to initiate stabilizations, protect airway and provide
supplemental oxygen.
 Obtain lithium blood level immediately; obtain electrolytes, BUN, Creatinine,
urinalysis, CBC.
 Electrocardiogram, monitor cardiac status.
 Limit lithium absorption with activated charcoal and gastric lavage for acute ingestion.
 Vigorously hydrate: 5 to 6l/day; balance electrolytes IV line, indwelling catheter
 Patient will be bedridden; range of motion, frequent turning, and pulmonary toilet.
 In moderately severe cases:
- Implement osmotic diuresis with urea or mannitol.
- Increase lithium clearance with aminophylline and alkalinize the urine with IV
sodium lactate
- Ensure adequate intake intake of sodium chloride to promote excretion of lithium.
- Implement peritoneal or hemodialysis in the most severe cases (serum levels
between 2.0 and 4.0meq/ml) with decreasing urinary output and deeping CNS
depression.
 Repeat dialysis every 6 to 10hrs unless it comes in non toxic range.
 Ascertain reasons for lithium toxicity, increase health teaching efforts, assess for
depression and suicidal intent.

Drug interactions with lithium

Antipsychotic : Encephalopathy, worsening of EPS, Altered RBC and Plasma concentration

of lithium.
Antidepressants : Occasional reports of serotonin-like syndrome
Anticonvulsants : Neurotoxicity with Carbamazepine
Non-steroidal : May reduce renal lithium clearance and increase serum
Diuretics : Reduced renal lithium clearance and increased serum concentration
Potassium sparing loop : Increased lithium concentration

59
 Osmotic (Mannitol) : Increased renal lithium clearance and decrease Lithium Concentration.
Xanthine (Aminopyhlline, Caffeine, theophylline) : Increase renal lithium clearance and
decrease lithium concentration
Acetazolamide : Increased lithium clearance
ACE Inhibitors : Reduced lithium clearance increased Concentration

Possible effect of lithium on laboratory values

 WBC : Increased count

 Serum Glucose : Increased count
 Serum Magnesium : Increased Level
 Serum potassium : Decreased level
 Serum uric acid : Decreased level
 Serum thyroxin : Decreased level
 Serum cortical : Decreased level
 Serum parathyroid hormone : Increased level due to adenoma
 Serum Calcium : Increased level
 Serum phosphorous : Decreased level

Nursing responsibilities

Obtain baseline data, cardiac, haematology and electrolyte, renal function, thyroid
function.
Obtain ECG and electrolyte level before and periodically during therapy.
Assess neurological and psychiatric state institute safety measures as needed to prevent
injury.
Monitor lithium blood level, WBC count and thyroid and kidney function last.
Monitor fluid intake and output.
Watch for oedema and weight gain.
Advice the patient to take with food or milk to minimize GI upset.
Instruct patient to swallow the tablet not crush.
Tell patient beneficial effect may take 1 to 3 weeks to appear.
Advice to limit food and beverages with caffeine as it interacts with drug action.
Maintain fluid intake.
Emphasis for blood test.
Instruct patient to carry medical identification all times.
Advice to avoid activity needed mental alertness.
Avoid in first trimester of pregnancy.
Avoid breastfeeding.
Caution for dehydration and sodium depletion.
Teach sign and symptoms of lithium toxicity.
Tremor with beta blocker-propronolol,levo thyroxin-hypothyroidism and goiter.
Renal toxicity decrease dose.
Polyuria- Amiloride-drink plenty 8 to12 glass of water.

60
SODIUM VALPORATE

Drug Name : Valporate Sodium

Therapeutic Class : Anticonvulsant, mood stabilizer, ant migraine agent
Pharmacologic Class : Carboxylic acid derivative
Dosage : 1200-1500mg/day
Route : Oral, intramuscular

AVAILABILITY
Valporate Sodium : Depiction Inj 100 mg/ml in 5ml, Syrup 250 mg/500mg
Valporate Acid : Depalene (capsules liquid filled 250 mg
Divalproese Sodium : Depakote–125mg,250mg,500mg
DepakoteER, 250mg, 500mg
Depakote Sprinkle cap 125 mg.

Valporate is used to treat bipolar I Disorder and is equal in efficacy and safety to
lithium.Valporate is also used for the treatment of schizo- affective disorders; impulses control
disorders, behavioural agitation. Valporate is also used for epilepsy and effective prophylaxis against
migraine headaches.

CHEMISTRY
Available formulation includes valproic acid, diavalproex sodium, and a 1:1 mixture of valproic
acid and sodium valporate and sodium valproic injection. There are therapeutically equivalent
because at physiological PH, valproic acid dissociates into valporate ion. It is called acid because it
rapidly converted to the acid form in the stomach.

Molecular structure of Valporate acid

PHARMACOLOGICAL ACTIONS
All valporate formulations are rapidly and completely absorbed after and administered. The
steady-state half life of valporate is about 8 to 17 hours and clinically effective plasma concentrations
usually maintained with closing one or four times a day. Protein binding becomes saturated and
concentration of therapeutically effective free valporate increase at serum concentrations above 50 to
100 mg/ml. it increases level of gamma-amino butyric acid in brain, reducing seizure activity.

61
THERAPEUTIC INDICATIONS

1) Bipolar Disorder (Acute episodes) - Valporate effectively controls manic symptoms. Also
reduces overall psychiatric symptoms. Initially 750 mg of diavalproex delayed release PO
daily ion divided doses. Titrate rapidly to desired effect or trough level of 80-120 mcg/ml.
Do not exceed 60 mg/kg/day. Persons with mania usually respond 1 to 4 days after valporate
sodium concentration rise above 50 mg/ml. using gradual dosing statistics this serum
concentration may be achieved within 1 week of initiation of dosing.
2) Schizoaffective Disorder - Valporate is effective in treating the short term phase of the bipolar
type of schizoaffective disorder valporate in more effective adjacent with lithium,
Carbamazepine or a serotonin-doper antagonist. Valporate is ineffective for psychotic
symptoms.
3) Other Mental Disorders - Valporate can effectively control physical aggression, restlessness,
agitation, verbal aggression with dementia organic brain disorders. Valporate is effective in
combination with psychotropic drugs in major depression disorder, panic disorder, post
traumatic stress disorder, OCD, bulimia nervous, alcohol and sedative cocaine detoxification,
borderline personality disorder.
4) To prevent Migraine - 250 mg diva prone delayed release PO bid or 500 mg daily p.o for 1
wk unto 1g/day.

62
 CLASS OR TRADE MECHANISM OF NURSING
S.N. DOSES SIDE EFFECTS
GENERIC NAME NAME ACTION RESPONSIBILITY
1. VALPORATE 1200- All valporate Common  Take with food.
SODIUM 1500mg/ day formulations are  Gastrointestinal irritation  Extended release tablets to
rapidly and completely  Nausea swallow them whole.
absorbed after and  Sedation  Inform patient taking
administered. The  Tremor capsules that he may swallow
steady-state half life of  Weight gain them whole or open them and
valporate is about 8 to  Hair Loss sprinkle contents onto a
17 hours and clinically teaspoon of semisolid food
effective plasma Uncommon: such as pudding.
concentrations usually  Vomiting  Advice patents relatives that
maintained with  Diarrhea valproate syrup shouldn't be
closing one or four  Ataxia taken with carbonated
times a day. Protein  Dysarthria beverages.
binding becomes  Persistent elevation of hepatic transmarine.  Advise patient to
saturated and immediately report
concentration of Rare malaise, weakness and
therapeutically  Fatal hepatotoxity lethargy, appetite loss,
effective free  Reversible thrombocytopenia vomiting, yellowing of skin or
valporate increase at  Platelet dysfunction eyes.
serum concentrations  Coagulation disturbances  Closely monitor neurologic
above 50 to 100  Agrannulocytosis status, watch for seizures.
mg/ml. it increases  Encephalopathy and coma  Instruct patient to avoid
level of gama-amino  Respiratory muscle weakness alcohol.
butyric acid in brain,  Respiratory factors  Stress importance for follow-
reducing seizure  Weight gain up laboratory tests.
activity.  Contraindicated in pregnancy causes tubal
defects.
 Polycystic ovary disease has been reported
in woman using valporate.

63
OFF-LABEL USES

 Chorea
 Photosensitivity –related seizures.
 Seductive –hypnotic withdrawal.

CONTRAINDICATIONS

 Hypersensitivity to drug
 Hepatic impairment
 Urea cycle disorders
 Pregnancy

PRECAUTIONS

Use cautiously in -
 Bleeding disorders, organic brain disease, bone marrow depression, renal impairment.
 Post traumatic seizures.
 History of hepatic disease.
 Breast feeding patients.
 Children

ADVERSE EFFECTS OF VALPORATE

Common:
 Gastrointestinal irritation
 Nausea
 Sedation
 Tremor
 Weight gain
 Hair Loss
Uncommon:
 Vomiting
 Diarrhoea
 Ataxia
 Dysarthia
 Persistent elevation of hepatic transmarine.
Rare:
 Fatal hepato-toxicity
 Reversible thrombocytopenia
 Platelet dysfunction
 Coagulation disturbances
 Edema Hemorrhagic pancreatitis.
 Aganulocytosis
 Encephalopathy and coma
 Respiratory muscle weakness
 Respiratory factors
 Weight gain
 Contraindicated in pregnancy –causes Tubal defects.
 Polycystic ovary disease have been reported in woman using valporate

64
DRUG INTERACTIONS

Valporate is commonly co-administrated with lithium, Carbamazepine and dopamine receptor

antagonists.
Drug Interaction reported with Valporate

Lithium : Increased tremor

Antipsychotic : Increased sedatives, increased EPS delirium and stupor
Clozapine : Increased sedation, confessional syndrome
Carbamazepine: Acute psychosis, ataxia, nausea, lethargy, may decease valporate concentrations
Antidepressant : Amitriptyline and fluoxetine may increase valporate serum concentration.
Diazepam : Serum cone increased by valporate

LABORATORY INTERFERENCES

Alanine aminotransferase, alkaline phosphates asparatate aminotransferase, bilirubin increased levels

 Bleeding Time : prolonged

 Ketene bodies : false positive results
 Platelets, white blood cells : decreased counts
 Thyroid function test : interference with result

LABORATORY TESTS DURING VALPORATE THERAPY

Prior to treatment

 Liver function test

 CBC
During Treatment

 Liver function test at 1 month then every 3 to 24 months

 CBC at 1 month then every 3 to 24months
 Mild transominase elevation – monitoring every 1 to 2 wks if stable then every 3 months.
 Monitor valporate blood level – therapeutics range is 50 to 100 mg/ml

65
CARBAMAZEPINE

Drug Name : Apo-Carbamazepine, alretol, epitol, Novo-Tegretol, Tegrelot, Tegrelot- XR

Pharmacologic class : Iminostilbene,
Therapeutic class : Anticonvulsant
Dosage : 400-1200/day, under 6 years: 10-20mg/kg/day.
Route : Oral

AVAILABILITY

 Capsules (extended release) : 200m, 300mg

 Oral suspensions : 100mg/5ml
 Tablets : 200mg
 Tablets (chewable) : 100mg, 200mg
 Tablets (extended release) : 100 mg, 200mg, and 400mg

Carbamazepine is effective for the treatment of acute mania and for the prophylactic treatment of
bipolar I disorder. It is a first line agent along with Lithium and valproic acid. It is also used to treat
partial and generalized onset epilepsy and trigeminal neuralgia.

Molecular structure of Carbamazepine

USES AND GUIDELINES

Carbamazepine can be used alone or with any antipsychotic drug for mania episodes. The
combination of Lithium and Carbamazepine one used together should be monitored closely for CNS
toxicity. A 3 week trial of Carbamazepine at therapeutic plasma concentration usually suffers to
determine whether the drug will be effective for mania. When Carbamazepine and Valporate are
used in combination, the dosage of Carbamazepine should be decreased, because valporate displaces
Carbamazepine binding on protein and the dosage of valporate may need tobe increased.

PHARMACOLOGICAL ACTIONS

Carbamazepine is absorbed slowly and eventually from the GI tract and absorption is
enhanced when the drug is taken with meals. Peak plasma concentrations are reached 2 to 8 hours
after a single dose, and steady state levels are reached after 2 to 4 days of steady dose.

The suspension form is absorbed faster. The half life of Carbamazepine at the initiation of
treatment has a wide range during long term the half life decreases to a range of 12 to 17 hours
because of induction of hepatic enzymes which reaches its maximum level after about 1 month of
therapy.

66
THERAPEUTIC INDICATIONS

1) Bipolar Disorder (Manic episodes): Carbamazepine is an effective anti-manic agent in 50 to

70% of all persons within 2 to 3 wks of initiation.
2) Depressive Episodes: About 25 to 33% of the depressed persons it is effective.
3) Schizophrenia and scherzo affective disorder: Prominent positive symptoms (hallucinations)
respond. Aggressive outburst.
4) Impulse Control Disorders: It is effective in controlling impulsive aggressive behaviours in
non-psychotic persons of all ages.
5) Post traumatic stress disorder used to treat agitation and aggression.
6) Alcohol and Benzodiazepine withdrawal: Effective in control of symptoms associated with
alcohol withdrawal.

CONTRAINDICATION

 Hypersensitivity to drug or ICAs

 MAO inhibitor use within post 14 days
 Bone marrow depression
 Pregnancy or breast feeding.

PRECAUTIONS

Use cautiously in
 Cardiac disease, hepatic disease, increased intra acute pressure, seizure disorders, glaucoma.
 Elderly males with prostatic hypertrophy
 Psychiatric patients
ADVERSE EVENTS

Dosage Related Adverse Effects

 Double or blurred vision
 Vertigo
 GI disturbances
 Taste performance impairment
 Haematological effects
Idiosyncratic Adverse effects
 Aganulocytosis
 Stevens-Johnson syndrome
 Aplastic Anemia
 Hepatic failure
 Rash
 Pancreatitis
 Weight gain, chills, fever.

67
 CLASS OR TRADE MECHANISM OF NURSING
S.N. DOSES SIDE EFFECTS
GENERIC NAME NAME ACTION RESPONSIBILITY
1. CARBAMAZEPINE Apo 400- Carbamazepine is Dosage Related Adverse Effects  Tell patient that he may
Carbamazepine, 1200/day absorbed slowly and  Double or blurred vision sprinkle contents of
alretol, epitol, Under 6 eventually from the GI  Vertigo extended release capsule
Novo- Tegretol, years: 10-20 tract and absorption is  GI disturbances over food but should not
Tegrelot, mg/kg/day enhanced when the  Taste performance impairment crush or chew capsule.
Tegrelot-XR drug is taken with  Haematological effects  Adverse patient that
meals. Peak plasma coating on extended
concentrations are Idiosyncratic Adverse effects release capsule may be
reached 2 to 8 hours  Agranulocytosis visible in slots because it
after a single dose, and  Stevens-Johnson syndrome isn’t absorbed.
steady state levels are  Aplastic Anemia  Tell patient to take drug
reached after 2 to 4  Hepatic failure with meals to minimize GI
days of steady dose.  Rash upset.
The suspension form  Pancreatitis  Avoid driving as alertness
is absorbed faster. The  Weight gain, chills, fever. and vision is affected.
half life of  Advise patient to avoid
Carbamazepine at the excessive sun exposure
initiation of treatment and to wear protective
has a wide range clothing and sunscreen.
during long term the  Inform female patient that
half life decreases to a drug may interface with
range of 12 to 17hours hormonal contraception.
because of induction of
hepatic enzymes which
reaches its maximum
level after about 1
month of therapy.

68
DRUG INTERACTIONS

Acetammophen : Increased risk of acetaminophen induced hepatotoxicity, decreased

acetaminophen efficiency. Anticoagulants ibuprofen increased metabolism
of these drugs, causing decreased efficiency.

Barbiturates : Decreased barbiturate blood level, increased carbamazepine blood level.

Charcoal : Decreased Carbamazepine absorption

TCA’s : Increased Carbamazepine blood level and greater risk of toxicity, increased
TCA blood level.

NAQ inhibits : High fever, H.T, seizures

LABORATORY INTERFERENCES

Transient decrease in thyroid stimulating hormone. Blood urea nitrogen, Eosinophils, liver function
tests, increased values of Granulocytes, hemoglobin, platelets, thyroid functions tests, WBC’s
decreased values.

Drug food : Grape fruit juice increased drug blood level and effects.

Drug –Herbs : Plantain inhibited GI absorption of drug.

NURSING RESPONSIBILITIES:

1. Give lithium soon after meals to reduce gastric irritability.

2. Observe for side effects and lithium toxicity.
3. Check the BUN, creatinine and ECG in case of toxicity.
4. If side effect is present record report and treat it immediately after consulting with
psychiatrist.
5. Maintain the blood lithium level.
6. Check the weight before and after administration of lithium.
7. Record intake and output to assess the kidney function.
8. Restrict sodium intake.
9. Check the liver function test.
10. Monitor the vital sign carefully.
11. Adequate amount of fluid should be administered.
12. Observe the sign of dehydration.
13. Educate the patient and his family about side-effects.

69