Does Topomax work
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Does Topomax work? (Teri)

Hi Dr. Phelps- I sure enjoy your dowm to earth approach! Have read most of your pages and decided that this partial relief of symptoms that I have been livng with the last few years just ain't good'nuff. It definitely has taken it's toll. I work so hard to stay stable- get enough slep- keep structured-take my meds and I still cycle. I am 42 years old and have been bipolar since probably 15- altho I went thru the standard misdiagnosis of depression and anxiety for a few years before anyone got the bigf picture. Seems like that happened to a lot of us.Was pout on large doeses of tryclics for several years(why did they used to do that?) and started rapid cycling after that. I have been on almost every mood stabilizer there is- and countless combinations and just when I find something that works- it seems to stop working.The side effects that happen when I am on enough meds to stop most of the cycle- are intolerable.And this time of year -I get really looney and want to avoid it being any worse than it has to be.I am a caregiver for my adult daughter who is brain injured and diabetic and I just got to keep it together. Am curious about topamax. Read Dr. Ivan's info on it(and emailed it to my pdoc- who has just been made chief of staff and is going to be less available now....gulp.!) and wondered if you had any experience with it. Have a pdoc who is pretty open to suggestions-and good with using small doses of several meds to work synergistically- but we are about at the end of the line here.He has NEVER told me that we need to get rid of all my symptoms. It just seemed like it was to be expected that I would not ever get complete relief.Is this a new concpet. I really like my guy and trust him-but I have been led astray by the best in the past..... I also have severe ADHD on top of the bipolar and finding the right cocktail just seems to be an ongoing exhausting task. ANYWAY- my point ( and um- I DID have one..) was- to see what your take on topamax was. I know there are no long term studies and that! you can get kidney stones if you don't drink a lot of water and that it can reduce the effectiveness of birth control pills.Blah Blah Blah. I just want to know-DOES IT WORK and for who and will med-i-cal cover it. I have Kaiser med-i-cal. Thank so much for your time-You are a really good Doc and I appreciate what you are doing on these pages.Sorry for the rambling-it has been a tough week-Teri

Dear Teri --
Thanks for your thoughts and your encouragement, too.  Understand that while I shoot for 100% symptom control, I don't always help people get that.  On the other hand, it sure seems that those who do get more stable courses over time than those who don't, and that the fewer remaining symptoms, the better things turn out over time, so I think it's definitely the goal to shoot for.  You recognize that in shooting for it though, you're setting yourself up for lots of med's, and lot's of trials of things that don't work, so there's a trade-off there somewhat.

For the experience of multiple folks on the med, see about.com's collection.  There are 4 very brief testimonials, 2 very positive, and I would add that I personally have seen several people get those kinds of positive results.  One woman had been through almost all the mood stabilizer combinations I could think of and was still struggling, losing her job, having pretty bad mixed state symptoms.  We slowly added topiramate and she not only got much better, almost "normal" for her (which still had it's weak spots, lots of pretty bad trauma a ways back), but we were able to stop everything else -- although when we stopped verapamil, a sort of minor mood stabilizer in most experts' categories, her depression came back and we added it back in.   That's the best outcome I've seen (I'll bet that's enough to convince you!?).  Second best: a woman most pdoc's would diagnose as borderline personality disorder -- cutting self, overdosing on lithium somehow that looked pretty deliberate as a means of self-harm, really troubled relationships -- stopped having bulimia, started sleeping, and basically stopped looking like "borderline" after going on topiramate, and she ended up going all the way up to 675mg before she stopped seeing additional benefit as the dose went up.  She used to take 3 or 4 mg of Klonopin, a Valium cousin, and has stopped that on her own (also not generally the kind of thing people with "borderline" are famous for).

So, yep, it can be great.  It can also be terrible: worst, it can raise anxiety (not very common, in my experience so far; I think that's what the about.com negatives are referring to as "hypomania"? or rather, my people I think were experiencing a form of "hypomania").  Next worst, it can make people really confused, almost as bad as lithium when people are seriously lithium-toxic -- but that's much less likely if you go up at 1/4 the manufacturer's rate of increase: I use 12.5 mg. increments every 4 days (equivalent of 25mg a week, one half the original rate) and people seem to handle that much better, even tolerating doses that made them very confused when they arrive at the same dose more slowly.  I have people cut the pill, even though the pharmacist may tell you don't; and now there's a "sprinkles" format that may solve that problem -- if it's like Depakote, you should be able to open it and use only half at a time (but the pill cutting really hasn't been too much of a problem).  Just make sure you go slow....

Dr. Phelps


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