Discussion Response to JS
I agree with JS that bipolar disorder is a mental disease that causes unusual mood shifts, activity levels, and energy. It was formerly called manic-depressive illness. According to the case presented, I agree that the symptoms of flight of ideas, being “busy”, reduced sleep are characteristic of a manic episode. I agree with the decision to start lithium 300mg BID because the other drugs were antipsychotics whereas the patient is positive for the CYP2D6*10 allele that affects their metabolism. Lithium is also the first-line drug for acute mania. Its short therapeutic range and short half-life prompt division of doses into two doses (Baldessarini et al., 2018).
The patient came back with a similar presentation and reported non-compliance. Therefore, I concur with the decision to assess the rationale for non-compliance and educate the patient on the drug effects and pharmacology. This is because the patient has not given lithium a chance to realize its full benefits. I also agree that the levels need to be monitored to prevent toxicity. The patient came back with complaints of side effects of nausea and diarrhea which made her stop until it resolves. I concur with the decision to change to a sustained release formula. This is because the symptoms are side effects of immediate-release lithium but not indicators of toxicity. Therefore, changing to sustained release eliminates the effects while giving lithium a chance (Rosenthal & Burchum, 2018).
Discussion Response to KW
I agree with the decision to begin Lithium 300mg BID. This is because mood stabilizers reduce neuronal atrophy in bipolar patients by manipulating its signaling pathways. Furthermore, lithium reduces suicide risk and is approved for acute mania and as maintenance therapy (Baldessarini et al., 2018). The patient came back with similar symptoms and reports to be taking the drug “on and off” only when “she feels like needs it”. I concur with the decision to assess the reasons for non-compliance and educate the client on drug effects and pharmacology. He makes an interesting point that effective patient teaching is directly related to the avoidance of non-compliance. Additionally, evaluating the level of understanding of the client is essential in assessing compliance at follow-up visits. I agree that some patients may miss the high levels of energy during mania or disagree with the bipolar diagnosis making it difficult to comply with medication instructions (Hirschfeld et., 2010).
I concur with the decision to change lithium to a sustained release preparation at the same dose and frequency. This is because the client had reported side effects of nausea and diarrhea. However, these are not signs of toxicity. Therefore, maintaining the dose and frequency is warranted. I agree that educating both the patient and family regarding bipolar disorder and the importance of complying with medication is paramount (Jimmy & Jose, 2011).
References
Baldessarini, R. J., Tondo, L., & Vázquez, G. H. (2018). Pharmacological treatment of adult bipolar disorder. Molecular Psychiatry, 24(2), 198-217
Hirschfeld, R. M. A., Bowden, C. L., Gitlin, M. J., Keck, P. E., Suppes, T., Thase, M. E., Wagner, K. D., Perlis, R. H. (2010). Practice guideline for the treatment of patients with bipolar disorder (2nd ed.).
Jimmy, B., & Jose, J. (2011). Patient medication adherence: Measures in daily practice. Oman
Medical Journal, 26(3), 155–159
Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.