Medications
Carbamazepine |
Valproic Acid |
Lamotrigine |
Oxcarbazepine and topiramate are less frequently used and recommended for maintenance treatment of bipolar disorder. |
Purpose
Heal treat and manage bipolar disorders by various mechanisms |
Slowing the entrance of sodium and calcium back into the neuron and thus extending the time it takes for the nerve to return to its active state |
Inhibiting glutamic acid (glutamate) which in turn suppresses CNS excitation |
Therapeutic Uses
Treatment and prevention of relapse of manis and depressive episodes |
Especially useful for clients who have mixed mania and rapid cycling bipolar disorders |
Complications of Lamotrinige
Complication |
Nursing Action and Education |
Double vision, blurred vision, dizziness, headache, nausea, and vomiting |
Caution clients about performing activities requiring concentration or visual acuity |
Serious skin rashes: stevens-johnsons syndrome |
Instruct clients to withhold medications and notify the provider if rash occurs. To minimize the risk of serious rash, the initial dosage should be low and advanced slowly |
Contraindications/ Precautions
Carbamazepine and valproic acid are pregnancy risk category D and can result in birth defects |
Lamotrigine is a pregnancy risk category C, but can cause cleft lip and paleet if taken during the first trimester. Clients should discuss breastfeeding while taking lamotrigine with the provider |
Carbamazepine is contraindicated in clients who have bone marrow suppression or bleeding disorders. Clients should avoid breastfeeding |
Valproic acid is contraindicated in clients who have liver disorders. Clients of child-bearing potential should use contraception while taking valproic acid |
Monitor plasma valproic acid and Carbamazepine levels while undergoing treatment. The therapeutic blood level range for Carbamazepine is 4 to 12 mcg/mL. Therapeutic blood level range for valproic acid is 50 to 120 mcg/mL. |
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Complications of Carbamazepine
Complication |
Nursing Action and Education |
CNS effects: Cognitive function is minimally affected, but CNS effects can include nystagmus, double vision, vertigo, staggering gait, and headaches |
Administer low dose initially, then gradually increase dose. Administer dose at bedtime. Avoid driving and other activities that involve alertness at the beginning of treatment. CNS effects should subside within a few weeks |
Blood Dyscrasias: leukopenia, anemia, thrombocytopenia |
Obtain baseline CBC, and platelet, and perform ongoing monitoring. Observe for indications of bruising and bleeding of gums. Monitor and report sore throat, fatigue, or other indications of infection or bleeding |
Teratogenesis |
avoid use in pregnancy |
Hypo-osmolality: promotes secretion of ADH, which inhibits water excretion by the kidneys and places clients who have heart failure at risk for fluid overload. |
Monitor blood levels of sodium levels. Monitor for edema, decreased urine output, and hypertension |
Skin disorders: dermatitis, rash, stevens-Johnson syndrome (which is potentially life threatening) |
Treat mild reactions with anti-inflammatory or antihistamine medications. Wear sunscreen. Notify provider if stevens-johnsons syndrome rash occurs and withhold medication |
Hepatotoxicity: evidenced by anorexia, nausea, vomiting, fatigue, abdominal pain, and jaundice |
Assess baseline liver function, and monitor liver function regularly. Avoid using in children under 2. Administer lowest effective dose. observe for indications and notify provider if they occur. |
Complications of Valproic Acid
Complication |
Nursing Action and Education |
GI Effects: nausea, vomiting, indigestion |
Manifestations are usually self-limiting. Take medications with food or switch to enteric coated pills to reduce GI effects. |
Hepatotoxicity: anorexia, nausea, vomiting, fatigue, abdominal pain, jaundice |
Assess liver function, and monitor liver function regularly. Avoid using in children younger than 2. Administer lowest effective dose. Notify provider if they occur. |
Pancreatitis: nausea, vomiting, abdominal pain |
Monitor amylase levels. Discontinue medication if pancreatitis develops |
Thrombocytopenia |
monitor platelet counts. Observe for manifestations (bruising) and notify the provider |
Teratogenesis |
Avoid use in pregnancy |
Weight Gain |
Follow a healthy low calorie diet, engage in regular exercise, and monitor weight |
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Interactions for Carbamazepine
Indications |
Nursing Action and Education |
Oral contraceptive, warfarin |
Concurrent use causes a decrease in the effects of these medications due to stimulation of hepatic metabolizing enzymes. Monitor for therapeutic effects of warfarin. Dosage can be adjusted. |
Grapefruit juice: inhibits metabolism, thus increasing carbamazepine levels |
avoid intake of grapefruit juice |
Phenytoin and phenobarbital: decrease the effects of carbamazepine by stimulating metabolism |
Monitor phenytoin and phenobarbital levels. Adjust dosage of medications as prescribed |
Interactions for Lamotrigine
Interaction |
Nursing Action and Education |
Carbamazepine, phenytoin, and phenobarbital: these promote liver drug metabolizing enzymes, thereby decreasing the effect of lamotrigine |
Monitor for therapeutic effects. Adjust dosage of medications as prescribed |
Oral contraceptives: Lamotrigine can reduce progestin levels, estrogen-containing contraceptives can reduce leveles of lamotrigine |
Lamotrigine dosage change can be required when beginning or stopping oral contraceptive therapy |
Valproic Acid: inhibits metabolizing and thus increases the half life of lamotringe |
Monitor for adverse effects. adjust dosage of medication as prescribed |
Interactions of Valproic Acid
Interaction |
Nursing Action and Education |
Phenytoin and Phenobarbital: blood levels of these medications are increased when used concurrently with valproic acid |
Monitor phenytoin and phenobarbital levels. Adjust dosage of medications as prescribed. |
Nursing Evaluation of Medication Effectiveness
Depending on therapeutic intent, effectiveness is evidenced by the following |
Relief of manifestations of acute mania (flight of ideas, excessive talking, agitation) or depression (fatigue, poor appetite, psychomotor retardation) |
Mood stability |
Ability to preform ADLs |
Improved sleeping and eating habits |
Appropriate interactions with peers |
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