How to set the dose for Topomax
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How to set the dose for Topomax

Q: I began on Topomax at a high dosage (200 mg/day) 4 weeks ago along with Neurontin (1200 mg/day) for BPII. While the high dosage did scare me, I believe I have found my miracle! I am 25 and have suffered for 15 years, only diagnosed in Jan 00. I have been out of work since Jan and for the first time since I can remember I felt focused, motivated, not hypomanic, but prepared to move on in life. However, because of the side effects (minimal considering) of some forgetfulness and lack of "finding" the correct word at times my doctor decreased my dosage of Topomax one week ago to 100 mg/day. I realize that my Psychiatrist has had minimal experience with Topomax Within one week my life has seemed to fall completely backwards. What is your take on this? And what would your next move be? I realize that my Psychiatrist has had minimal experience with Topomax, so I am seeking as much outside information from those who have as possible. Thank you.

Dear Tina --
I was just working on this today with two different people.  Both having that same side effect of memory and word finding problems.  I've seen that side effect a lot, although I'm not sure how much more experience I have using this medicine than your doc'.

Here are some thoughts.  I have definitely seen people have this side effect at 125mg, lower to 100 or 75mg, get rid of the side effect, and then be able to taper more slowly back up to 125mg or even higher and not get the side effect the second time around (wow, eh? -- but careful, don't get your hopes up too high, it doesn't happen this way every time; but it 's worth a try, obviously).

Secondly, at this point I tell my patients their challenge is to find the optimal balance between symptom coverage and side effects.  I today decided to try having one woman adjust her dose using the 15mg "sprinkles" format that you can open up (it's a capsule) and sprinkle on food -- for kids with epilepsy.  Using that you should be able to adjust the dose by 7.5mg increments pretty easily.

So I'd go down pretty quick to a dose where your memory and vocabulary recover, although that seems to take at least several days even after you arrive at the dose that's going to be ok.  Then I'd go up very slowly, like by 7.5mg per week or even slower, as you approach the point where the problem seems to develop again.  Try discussing that option with your doctor.  Some are more comfortable "giving you the reins" than others.

Dr. Phelps


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