Posted by phidippus on October 1, 2013, at 8:57:15
In reply to Augmenting Bipolar 'Cocktail' with Trodenki XR, posted by LouisianaSportsman on September 24, 2013, at 20:51:00
> Current Psychiatric "Cocktail":
>
> Abilify (aripiprazole)10mg.
> Concerta (methylphenidate ER) 54mg
> Lamictal (lamotrigine) 200mg.
> Lyrica (pregabalin) #60 150mg. [300mg.]
> Pristiq (desvenlafaxine) 50mg.All good, but Lyrica may be overkill. Not sure you should be on Pristiq. That dose of Lamictal is on the low side.
> I would like to discontinue the Lyrica (pregabalin) in place of Trodenki XR (topiramate XR) which unlike Lyrica, is non-scheduled and not abusable.
What are you going to be taking the Topomax for? Anxiety?
>topiramate is an anti-convulsant but it works primarily on sodium channels whereas Lyrica acts exclusively on calcium channels.
Do you know what this means down the line?
>topiramate extended-release capsules would be a great adjunct to my Lamictal.
How so? As a mood stabilizer? Topiramate is fairly useless as a mood stabilizer. I would just go up on the Lamictal, or add something useful, like Trileptal.
>If side effects are too much, I can drop down to 100mg.
It ain't called dopamax for nothing. 100mg will be useless. Most meaningful studies start dosing at 300 mg.
>they will give less side effects since the dose is released over time instead of all at once
Looks good on paper, but in reality, you're going to get side effects at any relevant dose.
>Is there any advantage of using a controlled-release formulation of topiramate over the instant release?
Not having to take it many times a day?
> I am, of course, looking for weight loss of >aripiprazole/pregabalin weight; hownever, that is ot the only intended goal at all.Weight loss is something you need to address therapeutically. ACT comes to mind...
>I have been having mood swings not treated with >the lamotrigine.
Because you're dose is too low.
>I believe augmentation of lamotrigine with a >target dose of 200mg. topiramate
No, not really. Try something with a little better evidence supporting its efficacy, like Carbamazapine.
>Topiramate has been shown to help with anxiety >and bipolar depression of which I am suffering >and, like pregabalin, it antagonizes glutamate.
>I am hoping it will make my mood more stable due to its powerful mood stabilizing mechanism of action.
Powerful? Topiramate is like, 4th line treatment for bipolar disorder. Here's a list of mood stabilizers with proven track records:
Depakote, Trileptal, Carbamazapine, Lithium, Lamictal...Topiramate (Topamax) is not FDA approved for bipolar disorder, either; and a 2006 Cochrane review concluded that there is insufficient evidence on which to base any recommendations regarding the use of topiramate in any phase of bipolar illness.
>It should also fatigue the ability of aripiprazoles weight-gaining mechanism.
Mechanism? If it were only that easy.
>With these reasons in mind, I believe it is the most important medicine to negotiate with at the present time.
Yet, you just overlook...look there...There...Just up your dose of lamictal instead of adding a side-effect conducive medication which has no meaningful data supporting it as a mood stabilizer.
>I am still having depressive episodes on the 50mg.
Of course you are. That dose is as useful as the dopamax. Its not so easy treating bipolar depression. Its better to rely on AAPs and other novel treatments. Have you tried Riluzole? More data exists supporting its efficacy as a mood stabilizer than Dopemax.
>dosage. Also, this dosage is where it starts to effect NE and even DA more potently and acts more as a true SNRI than simply a souped-up SSRI.
Pristiq's effects on dopamine are negligible. The jusry is still out when it comes to norepenephrine and its role on depression.
>I believe that I would benefit from the substitution of Nuvigil (armodafinil) at #60 150mg. BID QAM QPM in replacement of Concerta 54mg.
NUVIGIL IS NOT A TREATMENT FOR ADHD. Really, only stimulants are the only way to treat ADHD effectively. Maybe you have a little depression masquerading as ADHD.
>booster dose is my recommendation. Because aripiprazole has such a high D2 occupancy rate (85% at 10mg.), it drastically reduces the effects of ADHD stimulant drugs such as methylphenidate ER
It doesn't quite work that way. Research on receptor subtypes has shown that the therapeutic effects of stimulants are strongest at D1 receptors. Stimulants are widely considered the first-line treatment recommendation for ADHD because of their high reported success rate. However, atypical antipsychotics have been shown to treat ADHD symptoms. Specifically, risperidone was shown to improve attention and hyperactivity,26 and aripiprazole has been shown to improve cognitive functioning. Basic Dopamine Theory suggests that stimulants and antipsychotics have activity at most DA receptor-subtypes and in most DA pathways. Basic science confirms this. Complex Dopamine Theory suggests possible new insights into mechanisms of action, but further research is needed. Studies on clinical risks and benefits of concurrent use appear promising but often show conflicting data, and significant kinetic side effects have been described. Most physicians are not concerned, but it can be dangerous to ignore potential receptor interactions. Physicians considering the concurrent use of stimulants and antipsychotics should appreciate the following guiding points:
Concurrent use of stimulants and antipsychotics should be accompanied with hesitation and caution because of both theoretical and empirical concerns.
When using a stimulant and a comorbid disorder indicates an antipsychotic, or vice versa, a trial with a non-DA-medication should be initiated first.
Treating side effects of a stimulant with an antipsychotic, or vice versa, may mask symptoms temporarily while worsening the underlying chemical imbalance over the long term.
If using stimulants and antipsychotics concurrently, special caution should be made to taper either class of medication slowly when the other class is being used or when switching from one class to another.
Stimulant-antipsychotic syndrome should be suspected when adverse reactions are seen in the setting of concurrent use, especially following a medication change.
When using stimulants and antipsychotics concurrently, all side effects should be viewed as the product of the interactions of both medications together at their respective doses.
Complex Dopamine Theory suggests that concurrent stimulant-antipsychotic use at low doses may decrease the risk of tolerance and side effects.
Most clinical research on concurrent stimulant-antipsychotic use has been done to assess safety and efficacy despite potential interactions. Studies assessing benefits from their interactions are lacking.
Guidelines for absolute or relative dosing of concurrent stimulant-antipsychotic regimens cannot currently be formulated because of lack of data.
Despite the appropriateness of conservatism with concurrent use, clinical data from aggressive prescribers will be educational.
>Nuvigil, with its unique mechanism of action, >compliments the Abilify better, IMO.How so? The exact mechanism of action is unknown.
>Also, I believe the armodafinil may help with possible side effects of cognitive dulling arising from the use of topiramate.
Not likely. You know what else helps witht cognitive dulling of Topamax? Not taking it.
> New Suggestion for next visit:
>
> Abilify 10mg.Good for mood and keeping your head straight. This can also be increased to improve mood.
> Lamictal 200mg.
A higher dose will improve your mood.
> * Nuvigil #60 150mg. [300mg.] substituted for Concerta 54mg.
Nuvigil is not a subsitute for Concerta.
> * Pristiq 100mg. increase from Pristiq 50mg.
I'd replace this with Rilutek, which shows to be very effective at treating bipolar depression.
> * Trodenki XR #60 50mg. [100mg. target] substituted for Lyrica which was indicated off-label primarily for bipolar depression and anxiety
Useless for bipolar disorder - great indications for anxiety, however.
> Mirapex (pramipexole)
Mood? Has been studied as a treatment for bipolar depression.
> Namenda (memantine)
May confer some mood benefits.
>Gabatril (baclofen)
Useless.
Here are my suggestions:
Abilify 20 mg
Lamotrogine 400 mg
Switch from Concerta to Vyvanse - dex confers mood benefits and helps with anxiety.
How about Wellbutrin instead of Pristiq-much better indications for bipolar depression.
Add Rilutek for depression.Eric
poster:phidippus
thread:1051278
URL: http://www.dr-bob.org/babble/20130930/msgs/1051490.html