Should I Try Alternatives to Topomax?
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Q:  Should I Try Alternatives to Topomax?

Diagnosed with BP II several years back, am 36yrs. Tried lithium worked well but am a serious endurance athlete and couldn't stand the side effects, lamictal made me so aggressive I rearranged the TV with a baseball bat, without medication the mood cycles are getting closer faster and worse currently trying Topamax (South African naming?) started on 25mg and was completely stoned. Dropped down to 12,5mg for 5 days and back to 25mg for 5days added 12.5 mg 2 days ago and again spent two days totally zonked and out of it. I loose the thread of conversations in mid sentence, numbers are impossible to recall. Am I simply in for a long waiting game or should I be trying alternatives?

Dear Ms. G' -- 
Sounds like you might have been able to tolerate the topiramate (U.S. and South Africa too I gather: Topomax) a little better after going up more slowly, so we can't say for sure that you won't be able to tolerate this medication; perhaps you'll be able to work your way up (usual dose range is 100-150 mg in my experience, sometimes higher, and certainly higher for seizure control). 

However, this medication has been shown in two different randomized trials to be no better than placebo as a mood stabilizer.  It certainly does something, and has helped several of my patients a lot; but it apparently can not routinely be relied upon for mood stabilization in bipolar II or bipolar I. 

Therefore, that leads you back to the list of mood stabilizers.  So far you've had lithium and lamotrigine.  That leaves, on the list of medications well recognized in randomized trials or lots and lots of clinical experience, valproate (divalproex sodium, in the U.S. that's "Depakote") and carbamazepine (U.S. Tegretol and Carbatrol); and more recently olanzapine (U.S. "Zyprexa").  The latter is incredibly good as both short and long term medication but causes weight gain of dangerous proportions in most patients and has been implicated in causing diabetes, so must be used with great caution.  

As you got benefit from lithium, perhaps you could talk with your doctor about taking the highest dose of lithium possible without any side effect problems; and then making up the difference in terms of the symptoms not covered with either Depakote or Tegretol (the former known for weight gain but only at medium to high dose; at lower doses, like just as an adjunct to lithium, much less likely) (and the latter known to have an interaction with lithium that makes people have confusion and tremor and even disturbed gait, though that's not very frequent and is not a reason not to try the combination).  

It is not pretty, as we say in the U.S., but there are clearly alternatives with better evidence for their effectiveness than topiramate (though still with side effect risks and problems, granted).  

Dr. Phelps

Published April, 2004


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