Carnitine : Meridia
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Q:  Carnitine : Meridia


Dear Dr. Phelps,

I recently enrolled my 10 year old bipolar son in a research study run by a distinguished childhood bipolar expert.  During our initial interview she presented some interesting information.  I have many questions for her but at that time my son was beginning a rage and we had to leave before I actually knew I had questions.  Hopefully, Iíll be able to have my questions answered but I thought you might be interested in what she said.

She said that in her studies she has been seeing many children with a mitochondrial disorder and that my son has many of the symptoms.  She indicated that treatment with a natural substance called carnitine might make it possible for my son to reduce or eliminate some of his medications. 

She elaborated on some of the symptoms she noticed in my son but I was quite distracted at the time by my sonís rage.  I think she mentioned excessive weight gain on psychiatric medications (my son is now 4í7Ē and 150 lbs.) as well as thyroid disease (my son has what I think is called subclinical hypothyroid which is not med related Ė his TSH was 7.0 on testing done before medication was given).  She also said that poor response to some medications was another indicator.  She mentioned neurontin in particular.  My son had recently become activated by an increase in his neurontin.

Her mention that carnitine treatment might allow us to decrease some meds got my (and my sonís) hopes way up.  However, most of the lab work she recommended came back in the normal range (I will include it below.) 

Even though a mitochondrial disorder doesnít seem to be a factor in my sonís disease, I thought others might benefit from this information and perhaps be tested if they show symptoms.  I am wondering if you test your patients for this or have ever used carnitine in treatment.  What symptoms might be a sign of a mitochondrial disorder or a carnitine deficiency?  To what medications would someone with a mitochondrial disorder show a poor response?

On another subject, my sonís pdoc wants to prescribe meridia for his weight gain.  Iím somewhat fearful of this since a google search turned up sites related to lawsuits as a result of heart disease allegedly caused by meridia.  Also, it seems this drug has SSRI-like properties and my son has been activated by antidepressants in the past.  What do you think of meridia?

Thanks for your website!
DM

Glucose/W hrs fast
        Glucose                94         (60-105)
        HRS PC                Fasting

AST (SGOT)               26         (11-40)

ALT (SGPT)                28         (3-30)

Lactic Acid                   0.9         (0.5-2.2)

Ammonia                      34         (11-35)

Lipid Profile
        Hours PC                Fasting
**        Triglyceride           140         (33-111)
        Cholesterol                184         (124-200)
**        HDL Cholesterol        39         (40-75)
        Ration Chol/HDL        4.7
        LDL Cholesterol        117         (<130)
        VLDL Cholesterol        28

Carnitine, Total                35         (28Ė83)
Carnitine, Free                 27         (22-66)
Acylcarnitine                      8         (3-32)
AC/FC Ratio                  0.3         (0.1-0.9)

Pyruvic Acid                   0.032         (0.030-0.080)

Insulin Fasting                19         (6-27)

TSH                                2.00         (0.30-4.5)                Lowest itís ever been


Dear Ms. M' -- 

[I got to the end of the following letter before reviewing yours and realizing I was missing the point about the research doc' versus the p'doc.  Rather than rewrite it, though, I think I'll leave it as it is -- in case it applies to some other reader more directly -- and let you apply the ideas to the respective doc's.  Research is research: being a subject in a study may expose you to more risk than a clinician would chose.  Okay, here goes...]


Hold on, I have to get my knee to stop jerking before I can write properly.  Ah, that's a little better; let's see now... Well, I'll tell you how I go about trying to answer something like this.  First thing, let's do a literature search.  Has anybody published anything on carnitine as a treatment for bipolar disorder?  Ok, search
Pub Med, enter "carnitine bipolar" (without the quotes).  

Well, there's some stuff about carnitine deficiency and what happens to people who have that rare condition and are given valproate (Depakote); we knew there was a problem there, that's not new news.  But is there any reported data, anything, a case report or something, to support this approach?  Take a look if you like; I found nothing.. 

Now, sorry, that got my knee going pretty good.  But child psychiatrists have a really tough job.  There's hardly ever any good data to go on for kids.  They have to extrapolate from adult studies, and that isn't always applicable.  And maybe your son's doc is one of the first to get on to something really good, and (like me) she's a clinician who doesn't have time to go write up case reports and get them published.  So, I definitely wouldn't throw out this idea.  

So I looked a bit further.  Let's try a Google search, same "carnitine bipolar" terms.  Hmm, the top one is a letter on this very website!  A woman wrote and asked if carnitine might induce manic symptoms (here's that letter).  

One of the next entries on that Google list is Good & Natural, selling carnitine.  Interestingly, it notes that if you have epilepsy or bipolar disorder, you should consult your doctor before use.  Note sure why, but especially with the epilepsy, it sounds like there's a worry that it might trigger something bad, no?  

So, my knee was going off about treatments for which we have little or no data, and where we may know relatively little about risk as well.  In this case, on searching, we find no information supporting benefit, and a little bit of information supporting risk. 

Therefore, if I didn't know anything more than that, and obviously I don't, I'd be concerned about this approach.  

Okay, now am I playing fair?  What about the stuff I've put on my site about thyroid, and just recently about metabolic syndrome and treatment thereof with Glucophage?  I hope if you read those you'd feel like that data on risk was fairly presented, right alongside the very limited data on potential benefit.  It all comes down to comparing those two, right?  

Finally, I hope you'll check out that section on metabolic syndrome.  It's about weight gain; and mood symptoms; and what there might be to do about that.  And at this point, even though we have no studies except the one that got interrupted 25 years ago (as you'll read about), I think we know much more that will help compare risks and benefits for that approach, than we do about Meridia.   

Your son's cholesterol is not particularly high, but triglycerides are up, HDL is just slightly low, and the insulin is on the high side.  However, by these numbers, unless he has high blood pressure or a very large waist for his size, to go with his HDL being low, he would not meet the official NHLBI criteria for metabolic syndrome, as you'll see referenced on my site.  But surely that set of criteria would have to be revised for kids, so it's not clear -- to me at least -- whether we even know how to "diagnose" metabolic syndrome (more a matter of defining than diagnosing at this point) in kids). 

Careful how you present all this to your son's doc'.  Surely she's trying hard to do what she thinks will help, and she could be right.  So, open vague wondering about supportive data and data on risks is better than saying something like "the internet ask-a-doc said...."  

Dr. Phelps


Published March, 2003
 

 

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