FINAL WORK

BIPOLAR (LAMOTRIGINE)

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Brian, a person with bipolar disease who is 48 years old, has been using the programme for a
long time. He lives with his wife and four kids and works as a businessman. The National
Institute of Mental Health (2020) states that during manic periods, when their judgement is
compromised, persons with bipolar disease may misuse drugs or alcohol and engage in other
high-risk activities. The results of the study may help to explain Brian's admission that he
used cocaine during a manic episode and his assertion that he used to drink heavily,
especially at night. Brian takes 100 mg of lamotrigine per day. He has a history of insufficient
compliance with medication due to the complexity of his disease, and in the last 18 months,
he has skipped or cancelled evaluation appointments at least three times (Geddes and
Miklowitz, 2013). Brian's spouse called his neighbourhood mental health team to voice her
worries and request a visitation at her house. She said that Brian has been having trouble
sleeping. When using lamotrigine, the National Alliance on Mental Illness (2018) advised
against mixing illicit substances and alcohol. They can lessen the benefits, make your
condition worse, and intensify the negative effects of the medication. She continued by
saying that after working twelve hours a day, seven days a week, to keep his company out of
debt and problems, Brian may go two or three nights without sleep. Brian revealed that he is
taking 50 mg of his prescription Lamotrigine instead of the recommended 100 mg during the
house visit that his wife had requested. He said he decided to reduce his medication so he
could stop taking it on his own without help from a doctor. According to Newman (2021), a
patient with bipolar illness may need to take mood stabilisers like lamotrigine for the
remainder of their lives. The best person to discuss the length of time and dose of your
medication based on the severity and nature of your symptoms is your physician.

A medicine that acts on the brain to stabilise mood is lamotrigine. Bipolar disorder,
sometimes referred to as manic depression, is approved for treatment with it (National
Alliance on Mental Illness, 2021). Over the past few decades, lamotrigine has undergone an
impressive series of thorough studies that have proven it to be an efficient and well-tolerated
treatment for bipolar disorder. Its effectiveness is mostly associated with improvements in
depression symptomatology throughout the acute and maintenance phases (Bowden, 2015).
Although there is evidence to support the limited effectiveness of lamotrigine in treating
bipolar illness (Bowden and Singh, 2012), its place in combination therapy for maintenance
treatment is well-established. Research suggests that there are benefits to mixing lamotrigine
with lithium or sodium valproate as opposed to using it alone (Miranda, Miranda, and
Teixeira, 2019). Compared to a placebo, lamotrigine monotherapy considerably prolonged

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the time until future mood episodes required further medication or electroconvulsive
treatment in two well-known double-blind investigations that lasted 18 months. Furthermore,
lamotrigine outperformed a placebo in terms of prolonging the depressive interfering phase.
These effects of lamotrigine were reported by freshly diagnosed manic/hypomanic and
depressive individuals (Berk, 2013). Lithium was superior to lamotrigine in terms of delaying
manic/hypomanic episodes, whereas lamotrigine was beneficial in pooled statistics (van der
Loos et al., 2011). According to Nassir et al. (2018) despite the medication's requirement to
be gradually titrated at the beginning of therapy to prevent severe rashes that resemble
Stevens-Johnson syndrome, the drug is remarkably well-tolerated with prolonged use. Still,
headache, insomnia, exhaustion, and sleepiness are perhaps the most frequent adverse effects.
According to Bhagwagar and Goodwin (2015), One of lamotrigine's biggest benefits is that,
unlike lithium, it usually doesn't require serum level monitoring or result in weight gain.
Additionally, according to the British National Formulary (2008), adults should take 25
milligrammes once a day for 14 days as the first dosage. After that, they can be up-titrated to
50 milligrammes for an additional 14 days, and then they can increase in stages to 100
milligrammes every 7–14 days: maintenance dose: 100–200 mg once or twice a day; if
needed, increase to 500 mg; if beginning again after five days without treatment, repeat the
following titration procedure. You can utilise the oral form of administration with or without
meals. Lamotrigine is a derivative of phenyl triazine; its several mechanisms of action have
been well summarised (Ketter, Manji, and Post, 2013).

According to research by Hahn et al. (2014), It has been demonstrated that lamotrigine
selectively blocks N- and P-type calcium channels in particular brain areas. It also affects
how voltage-dependent sodium channels are regulated, which helps to alleviate the delayed
elimination condition that is brought on by too much sodium channel activity. Moreover,
lamotrigine affects the production of stimulated amino acids, such as aspartate and glutamate,
and may have positive effects on GABA (gamma-aminobutyric acid), according to Ketter,
Manji, and Post (2013). Selective suppression of supranormal brain processes is a hallmark of
bipolar disease; nevertheless, the underlying pathophysiology is yet unknown. This finding
has important therapeutic implications since it provides a logical explanation for the neural
stabilisation process seen in seizure disorders (Hahn et al. 2014).

It is thought that lamotrigine partially modulates serotonin reuptake to produce its

antidepressant effects (Weisler et al., 2018). Furthermore, evidence-based study indicates that
its glutamatergic action may be the source of its neuroprotective and therapeutic qualities as

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well as possible modulation of peripheral glutamate levels in bipolar illness (Robillard and
Conn, 2012). Pharmacokinetics is the term used to describe the combination of scientific and
biological methods in a physiological and pharmacological environment (Hedaya, 2012).
Lamotrigine is quickly and completely absorbed when taken orally; food has no discernible
effect. It has a 98% bioavailability and very little first-pass metabolism. Because peak plasma
concentrations are reached in one to five hours and the plasma protein binding is only about
55%, interactions with drugs that show significant plasma protein binding are unlikely.
(Milosheska et al., 2016). Most of the inactive metabolites of lamotrigine are produced
through the liver channel and include lamotrigine 2N-glucuronide. Less often, N-methyl
metabolites, N-oxide, and 5N-glucuronide are produced and are all removed by the kidney
(Mallaysamy et al., 2013). Lamotrigine's kinetics are linear and its dosage ranges from one to
seven hundred milligrammes per day. Its typical elimination half-life in healthy volunteers is
around 24 hours (Gulcebi et al.,2011). Age, sex, and lifestyle choices like smoking have been
shown to have no impact on lamotrigine's kinetics, however, liver and renal damage reduces
the drug's clearance. Additionally, it's estimated that non-Caucasians have an excretion rate
that is around 25% lower (Rivas et al., 2018).

Pharmacodynamics is the study of how drugs affect the molecular structure,

physiology, biochemistry of the human body, involving chemical relations and receptor
binding (Mitra-Ghosh et al. 2020). Medicine's pharmacodynamics may be impacted by
physiologic changes connected to illnesses such as genetics, thyrotoxicosis, malnutrition, and
Parkinson's disease. (Ware et al., 2016). These illnesses have the potential to modify binding
protein amount, receptor sensitivity, and receptor binding conditions. But there's still a lot to
know and comprehend about how bipolar illnesses naturally occur (Dubovsky et al., 2019).
Lamotrigine's methodology effectiveness in the treatment of bipolar disorder is unknown,
however, it may stabilise the neuron membrane by inhibiting sodium and calcium channels in
presynaptic neurons (Ware et al., 2016). An individual with bipolar illness participated in a
controlled clinical study after experimental studies revealed that people with epilepsy who
received lamotrigine treatment had improvements in their mood (Dubovsky et al., 2019).
Nurses must possess a fundamental understanding of pharmacodynamics, which covers the
mechanism of action and physiological effects of drugs, in order to contribute rationally to
the achievement of the therapeutic aim. In order to inform patients about their prescriptions,
patients' pharmacological reactions—both positive (efficacy) and negative (side effects)—

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such as fatigue, headaches, nausea, vomiting, dizziness, and rash—are assessed. Anaemia and
a rise in suicidal thoughts are examples of severe side effects (Mitra-Ghosh et al., 2020).

In the context of the Brian case study, it is clear that Brian's choice to reduce his medication
dosage to stop completely was unethical. He can make decisions about his own care and
treatment in accordance with the Mental Capacity Act of 2005 (Brown et al., 2015). Based on
the limited information provided in the case study on Brian's ability, the nurse ought to
endorse Brian's strategy. When a patient chooses to accept or reject medical treatment, nurses
have a duty to respect, support, and record that decision (Nursing and Midwifery Council,
2018, p.7). This idea is consistent with the requirements stated in the NMC (Nursing and
Midwifery Code). However, in order to assist Brian, a nurse would have to evaluate the risks
associated with him cutting down on his medication without first speaking with his
prescriber, with the goal of stopping altogether, and collaborate with Brian to ensure he is
informed of the repercussions. The nurse ought to clarify that bipolar illness is a difficult
condition to treat because of its cyclical nature and recurrent residual symptoms.
Accordingly, compliance and maintenance management are necessary (Beyer et al., 2018).
Furthermore, research has shown that 20–60% of people with bipolar illness either stop
taking their medications or do not comply with their prescribed regimen. Consequently, every
attempt needs to be made to increase treatment and drug adherence (Annemieka et al., 2013).
Because of how unwell Brian is, the nurse might have to tell him to take his medicine as
prescribed. In order to help Brian, the nurse would need to effectively communicate with him
to understand his reasons for lowering his dosage and his plan to stop taking his medication.

Brian's preference to lower his dosage and stop therapy may have been influenced by his
severe insomnia. Though Lamotrigine has the potential to cause insomnia, or sleeplessness.
According to Newman (2021) when using lamotrigine, stay away from alcohol and other
narcotics. They could worsen the patient's illness, lessen the medication's effectiveness, and
raise side effects like Brian's sleeplessness. It would be crucial for the nurse to ascertain if
Brian's insomnia started as soon as he started taking his medication or if it had been present
for some time. This would enable the nurse to ascertain if the negative effects of insomnia are
linked to the usage of medicine or to an underlying medical condition or way of life issue. In
order to determine if lamotrigine is now offering a therapeutic benefit, the nurse would need
to ascertain Brian's current degree of medication adherence in addition to endorsing his

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decision to stop taking his prescription. Brian could think the drug is useless if his current
medication adherence is poor, as indicated by the case study data. According to Dagani et al.
(2017) research recognised Your doctor will assess if you are taking the recommended
amount of medicine if you currently have bipolar disorder and experience depression or if
your condition gets worse. If not, they'll change the dose or suggest a different drug. Another
ethical dilemma is whether praising medicine's advantages would suggest that the nurse
disregarded Brian's choice to stop taking it. One may claim that investigating other
therapeutic methods would help Brian. According to Fagiolini et al. (2015) combining several
therapies is the most effective way to manage bipolar illness. Mood stabilisers,
antidepressants, antipsychotic medications, electroconvulsive therapy (ECT), adjuvant
medications, psychosocial and psychoeducational treatments, and other medications may be
used in the treatment of bipolar disease. Research by Palma et al. (2016) supports the use of
ECT for the treatment of mixed states, mania, and bipolar depression. Crucially, research
shows that the majority of patients who do not respond to medicine will react to
electroconvulsive therapy (ECT). The development of ultra-brief pulse width stimulation has
significantly lessened the negative cognitive consequences of electroconvulsive therapy
(ECT), and this important breakthrough is expected to have a major impact on bipolar
disorder treatment (Loo et al., 2011; Bahji et al., 2019).

Grunze et al. (2013) claimed that research has demonstrated the significant benefits of
psychosocial therapy in addition to pharmaceutical treatment for bipolar disorder throughout
both the acute and maintenance phases of the illness's care. Data on the effectiveness of
psychoeducational therapies in group and individual settings are backed by research. These
therapies include a range of techniques, including family-centered intervention, cognitive-
behavioral therapy, and interpersonal and social rhythm therapy (IPSRT) (Lauder et al.,
2016). Improved functioning, higher treatment adherence, and a decreased chance of
recurrence have all been linked to these psychological treatments. These programmes'
fundamental elements include educating patients about their condition, identifying early signs
of relapse, controlling stress, upholding social and daily routines, resolving interpersonal
conflicts, expressing feelings, and encouraging adherence to both pharmaceutical and non-
pharmacological treatment (Deckersbach et al., 2014).

Psychoeducation might be taken into consideration for both the family and the service user.
The intention is to explain the sickness to the service user and their family. They might be
given straightforward descriptions of the condition, potential treatments, possible drug

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adverse effects, and the course of treatment (Goldstein and Hafeman, 2021). Giving family
members and other caretakers the chance to communicate their feelings and discomfort is
essential. Psychoeducation might be used to address important concerns with treatment
adherence and early diagnosis of subsequent episodes (Novick and Swartz, 2019).
Furthermore, it is important to promote psychoeducation as an ongoing process, get input
from previous sessions before starting a new one, and customise it to the requirements of the
patient and carers (Miklowitz et al., 2021). In order to support Brian even more, the focus
should be on food and lifestyle changes, exercise, and quitting alcohol, cigarettes, and other
drugs. Antipsychotic medication use is known to increase the risk of metabolic side effects
and cardiovascular mortality in patients with bipolar disorder; therefore, it is important to
counsel all bipolar patients on dietary and lifestyle modifications to reduce these risks (Bauer
et al., 2016).

According to Sylvia (2013) part of Brian's comprehensive treatment, a general practitioner

(GP) would perform some clinical and physical examinations, such as electrocardiography
and blood tests, however they shouldn't be done on a regular basis. Furthermore, in 2020, the
National Institute for Health and Care Excellence (NICE) advised against routinely
monitoring lamotrigine plasma levels unless there are obvious indications of toxicity,
ineffectiveness, or inadequate adherence to therapy. Ethical principles are an additional
crucial tool for managing the brain. They are a component of a standardised theory that
supports moral laws and are neither biassed nor arbitrary. Because healthcare professionals
need to be aware of clinical circumstances and make morally right judgements while abiding
by relevant laws, ethics are crucial in these contexts (Jahn, 2011). The researcher goes on to
say that respect for autonomy is a cornerstone of ethical standards, mandating that carers
honour the decisions made by persons judged competent to make decisions about their own
care and treatment. However, the carer must first use good communication to ascertain the
patient's knowledge, purpose, and lack of controlling influences before granting autonomy
(Jahn, 2011).

Lastly, the nurse ought to send a pamphlet on Brian's illness that gives people access to
online forums and support groups, like the bipolar UK forum, where they can talk to others,
exchange stories, and learn more. Studies show that people with bipolar illness have a fifteen
to twenty times higher risk of suicide than the general population. further proved that up to
50% of people with bipolar illness had made at least one attempt at suicide (Sylvia et al.,
2013). If a patient is suicidal, they should go to the closest emergency room right away. If

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they are experiencing severe depression, they should get in touch with their local mental
health crisis team, care coordinator, or medical practitioner right away.

In conclusion, the data suggests that researching a patient's past and current conditions might
enhance nursing practice. Pharmacokinetics and pharmacodynamics studies are also required
in order to get the desired therapeutic impact. It might be unethical to assist someone like
Brian in making a medical decision. On the other hand, conducting a thorough person-
centered evaluation while referencing the body of current research helps ensure safe and
moral behaviour.

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