How fast to increase Topomax? 

Q: I'm a forty two year old married mother of two diagnosed with bipolar II last year. I was on 3200 mg Neurontin for several months and had some good response to it but didn't feel even all the time . I'm now working with my pdoc trying Topomax. About three weeks ago I started on 25mg each day for five days then adding adding another 25mgs for 5days. I 've spoken to my doctor every five days . I'm now up to 100mg . I'm still also taking 1600mg og Neurontin. The only odd side effect is some tingling in my hands . I also take lorazepam at night to help me sleep. I have two questions for you. Does this long dosing sequencing schedule seem extreme to you? And ......... Should I just forget all the new medicines and just come to terms with the fact that I'm bipolar and lithium might just be the right medicine and cheapest too.? Thanks! Meghan

Dear Meghan --
1.  Long dosing schedule -- yep, that's how it's done all right; in fact, I've generally gone even slower as the numbness thing, and worse yet, the confusion/memory/balance problems that often go with the numbness, seem less likely to occur with slower increase rates.  I'm not sure yet about the numbness, but I'm absolutely certain that if you go slower, the confusion thing is less likely.  I've had folks get to 100-125 mg and get really zonked (thus the going nickname for the drug, "Stupimax"), who could take an even higher dose when they got there more slowly.  At a rate of 12.5mg every 4 days, which is just a little less than 25mg a week, things seem to go better.  Bottom line: your doc' is right, and you might consider going even more slowly; or even backing down until the numbness is gone, and trying again more slowly (especially if you're having any memory problems).

2.  Forget all the new medicines?  Well, how well did lithium work?  Haven't tried it yet?  Oh, do try lithium.  But if it caused side effects, do indeed consider the new stuff: lamotrigine can be a miracle (I had one patient have to stop it for a rash scare who tried virtually everything else, so we finally tried it again and crossed our fingers and watched for a rash like hawks, and fortunately she did fine and feels "normal" again now.  And if you think topiramate goes up slow, be prepared: my rate for lamotrigine is 12.5mg every two weeks for a month, then 12.5 mg a week after that, to anywhere between 50 and 200mg -- now that's slow, eh?  but fortunately, lots of people see effects at 25mg, and at least one of my patients clearly saw a difference at 12.5!).  And there's a new version of carbamazepine called oxcarbazepine (used in Europe >10 yrs.) that may turn out to be the simplest thing yet, as far as likelihood of benefit versus likelihood of side effects.  So, yep, keep trying 'em, for sure.  This takes a lot of work to find the best combo' for you, but for almost all of my patients in your shoes, it's been worth it.

Dr. Phelps

Published January, 2001