Opinion of Treatment Plan & Dosages?
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Q:  Opinion of Treatment Plan & Dosages?

 
I was on Depakote ER, 2000 mg once a day before bed for 2 years with no problems at all. Now, within the last 3 months the med has stopped working almost entirely, and I have been switched to Trileptal and Seroqel after a manic (not hypomanic) episode with minor psychosis (mild but persistant auditory and visual hallucination, loss of motor coordination). I was told to take 300mg twice a day of the trileptal and that it would be "upped" every week or so. I am a type-II bipolar, with mostly manic episodes, although I have had times where I have been mixed-state for long periods of time, times when I have rapid cycled for months (sometimes in a 10 minute cycle), and I have had 2 or 3 distinct periods of severe depression lasting a year or more with no interruption. I am wondering what the records show for Depakote ER tolerance, and also for trileptal. Also, what is the recommended max dosage for trileptal in a 23 year old male, healthy, 150 pounds. I just want to kno  w what someone else thinks before I go back to my doctor for my next appt. I am still having hypo manic episodes frequently (multiple daily) on the trileptal, and the seroqel brings me down within 15 minutes, but tends to make me fall asleep or be useless. I am prescribed to (2x daily) seroquel 50mg and 1x at bedtime 100mg. Is this normal? Thank you, I need to here from another professional.
 

Dear Jon -- 
Let's see, a bunch of questions there: 

1. what the records show for Depakote ER tolerance, and also for trileptal
My read of the literature at this point is that "tolerance" does not really occur with these medications, but rather the illness seems to advance and require additional medication to maintain the same degree of control.  Sorry, not what you might wish to hear, surely. And it could be wrong.  It's just kind of the
working model.  

You and your doc' have probably already done this, but there should be a search for what might have allowed the illness to progress while you were on medications that had been controlling it.  Not that you can always find something, often (far too often) you can't, it just seems to happen.  But the number one candidate is alcohol or any other street drug use.  Some patients can't get away with even minimal use or they see cycling return.  So if you're using anything, that's gotta go, for starters.  I even wonder about caffeine in this respect in some really sensitive patients (never seen any data about that).  

Other triggers include steroid medications, at least maybe; certainly big doses can do it such as you might get for a severe allergic reaction to something.  Then there's sleep deprivation, like working night shifts, or lots of travel especially across time zones. Those are the ones I see do it most frequently (i.e. induce worsening). 

2. recommended max dosage for trileptal 
2400 mg is the standard recommended max, but most of my patients seem to tolerate only up to about 1800 max before dizziness or cognitive slowing or some such side effect. 

3.  I am prescribed to (2x daily) seroquel 50mg and 1x at bedtime 100mg. Is this normal?
Yep, pretty standard for low dose seroquel, and divided like that is a good strategy if it's sedating.  Of course in your case the strategy isn't working.  You may be going back to the
mood stabilizer list with your doctor.  Good luck on that. 

Dr. Phelps


Published March, 2004
 

 

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