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Ask the Mental Health Expert Archives 2001-2004

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Combination Medication for Bipolar

Q. I am interested in the effectiveness of Lamictal 100 mg on bipolar disorder in conjunction with Prozac 20 mg and Tamazepam and klonopin PRN to treat mania. I understand Lamictal is not approved by the FDA for bipolar, but for seizures. I'm also interested in the weight factor with Lamictal (loss, gain, etc.) Finally, Topimax has come to my attention recently. Do you think this is a more suitable medication for a typical Bipolar who has manic and depressive episodes approximately two times each year?

A. Please understand that I can't advise you on whether a particular medication or combination of medications is right or helpful for any patient I have not personally evaluated. That said, there is a great deal of research now going on regarding the use of lamotrigine [Lamictal] for bipolar disorder, either alone or in combination with other agents.

Lamotrigine [LTG] is gaining increasing support as an agent for bipolar depression and prophylaxis (long-term prevention of bipolar mood swings). It may also be effective in mania, but its slow rate of dosage increase limits this use. Rare but potentially serious skin rashes have been reported with lamotrigine, which has slowed its acceptance by clinicians. It can also have other side effects. However, several clinical studies show it to be generally safe and well-tolerated. (If you want to see some professional articles on LTG, here are a few resources: Calabrese JR, Rapport DJ, Shelton MD, et al. Clinical studies on the use of lamotrigine in bipolar disorder. Neuropsychobiology. 1998; 38:185-191; and Calabrese JR, Bowden CL, McElroy SL, et al. Spectrum of activity of lamotrigine in treatment-refractory bipolar disorder. Am J Psychiatry. 1999c; 156:1019-1023.).

On the issue of weight, all the conventional mood stabilizers (lithium, valproate, carbamazepine) tend to cause weight gain, with lithium and valproate producing more weight gain than carbamazepine. One study of weight gain in patients with epilepsy compared valproate [Depakote] with lamotrigine [LTG] and found that, on average, valproate was associated with significantly greater weight gain than LTG (about 13 lbs vs 1 lb, after 8 months of treatment). These results are not necessarily transferable to patients with bipolar disorder who are also taking several other medications that can affect weight. (For example, fluoxetine [Prozac] and similar medications can lead to initial weight loss, often followed by re-gain of weight).

Recently, another anticonvulsant--topiramate [Topamax]--has been investigated as a mood stabilizer. Since there have not been any controlled studies yet, the jury is still out, though early indications seem to suggest it may be helpful as an adjunct (add-on) to conventional mood stabilizers. Topiramate is actually associated with weight loss, and thus, is sometimes useful to patients who have gained a great deal of weight on other medications. However, as I tell our psychiatry residents, "Topiramate is not chicken soup!". There are several common side effects associated with it, such as mental slowing, tingling or numbness, tremor, as well as rare side effects such as increased risk of kidney stones or glaucoma.

Still, it has been very helpful in some patients with bipolar disorder. The bottom line: the only person who can really advise you on the best regimen for a particular patient with bipolar disorder is an expert in bipolar disorder who has evaluated that patient!

Other Resources:

March 2002

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