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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 10 of 10. This is the beginning of the thread.
Posted by JohnnyS on May 26, 2002, at 23:24:14
Hey Everyone,
Could someone help me with this. So far, this is the status of the new anticonvulsants in psychiatry. Anyone with more informative, please add to it. Thank You.
1. Neurontin: Studies shows placebo better than neurontin for bipolar disorder, company has abandoned FDA approval.
2. Lamictal: One study with mild to moderate efficacy in bipolar depression. I think in phase III study.
3. Topomax: I read on "Psycheducation" web site by Dr Phelps that preliminary studies were poor and that the company is stopping seeking approval by the FDA.
Many doctors still use these meds as first line over lithium and depakote when studies are negative. Does anyone know why this is. Thanks.
JohnnyS
Posted by Ritch on May 27, 2002, at 8:45:33
In reply to New Mood Stablizers Unproven, posted by JohnnyS on May 26, 2002, at 23:24:14
> Hey Everyone,
>
> Could someone help me with this. So far, this is the status of the new anticonvulsants in psychiatry. Anyone with more informative, please add to it. Thank You.
>
> 1. Neurontin: Studies shows placebo better than neurontin for bipolar disorder, company has abandoned FDA approval.Often when a drug is studied for "bipolar disorder" it is being tested soley as an *antimanic* medication (to treat an acute manic episode). There are a lot of other symptoms associated with chronic bipolar disorder that don't involve acute manic spells which Neurontin may be effective at treating, such as anxiety and agitation. Often Neurontin is used in combination with lithium or depakote for those reasons.
>
> 2. Lamictal: One study with mild to moderate efficacy in bipolar depression. I think in phase III study.I think there has been some success with individual patients with treatment-resistant *unipolar* depression as well.
>
> 3. Topomax: I read on "Psycheducation" web site by Dr Phelps that preliminary studies were poor and that the company is stopping seeking approval by the FDA.As with Neurontin, Topamax may be useful in some patients who are also on "first-line" medications.
>
> Many doctors still use these meds as first line over lithium and depakote when studies are negative. Does anyone know why this is. Thanks.
>
> JohnnyS
I think it would be unlikely if a patient who had never been previously diagnosed with bipolar disorder and was experiencing an acute manic episode (for the first time) would be given the above medications. Usually "2nd-line" treatments are used when the patient cannot tolerate Depakote or lithium (for medical reasons, i.e.), or they simply have failed to respond. More often than not I think the "2nd-line" meds are used to augment "first-line" meds. However, I suppose the wisdom of that could be questioned as well.Mitch
Posted by JohnnyS on May 27, 2002, at 9:13:51
In reply to Re: New Mood Stablizers Unproven » JohnnyS, posted by Ritch on May 27, 2002, at 8:45:33
Posted by JaneB on May 27, 2002, at 11:17:13
In reply to New Mood Stablizers Unproven, posted by JohnnyS on May 26, 2002, at 23:24:14
If the second line mood stabilizers don't require blood testing does that mean they aren't as harmful? and if so why not start 2nd line first?
JaneB
Posted by Ritch on May 27, 2002, at 12:08:44
In reply to Re: New Mood Stablizers /another ?, posted by JaneB on May 27, 2002, at 11:17:13
> If the second line mood stabilizers don't require blood testing does that mean they aren't as harmful? and if so why not start 2nd line first?
> JaneBJane,
The newer anticonvulsants generally *are* much less *toxic*. Lithium and Tegretol are probably the most potentially toxic antimanic agents. The upper end of their effective blood levels can be close to toxic levels. Depakote blood monitoring is probably done most often when patients are being treated with very high doses to get their mania under control. I have never had a Depakote blood test-but I have never needed more than 500mg/day, so the likelihood of my Depakote levels being toxic are very small (in fact they would likely be "sub-therapeutic" for someone needing to be treated for an acute manic episode). Pdocs like to prescribe the "newer" meds (antidepressants included), because they *do* tend to have much lower risk of death associated with overdose. You can easily chuck down too much lithium or tricyclics (which includes carbamazepine) or MAOI's and quickly be in very dire circumstances, whereas it would be nearly impossible to die from an overdose on Neurontin (due to its fast elimination and dose-dependent absorption). I suppose if symptoms are mild and relatively non-life threatening a "2nd-line" med being used first would be OK, IF it works! What if it doesn't? Then that person could continue to worsen (lose their job-or worse). Even if the the 2nd-line drug being used first failed, and then a 1st-line drug being used later did in fact work-your time certainly got wasted. However, I don't feel any more comfortable now about the big boxed warning about liver failure on the Depakote insert than when I first saw it years ago-so I understand your concern-I am concerned too!
Mitch
Posted by wendy b. on May 28, 2002, at 10:37:37
In reply to Re: New Mood Stablizers /another ?, posted by JaneB on May 27, 2002, at 11:17:13
> If the second line mood stabilizers don't require blood testing does that mean they aren't as harmful? and if so why not start 2nd line first?
> JaneB
Dear Jane and others,It depends on the symptoms the patient presents to the pdoc. I was started on Neurontin as a "first-line" because my bipolar swings tend to go down instead of up. I didn't need anything as drastic as Depakote or Lithium. Mitch is right, the toxicity issues are very important. My pdoc was aware of this and prescribes neurontin to a lot of bipolars. She thinks it's good to avoid the blood-levels issues if at all possible. If the "second-line" drugs work well for the patient, and they are easier on the body, then they should at least be given a chance.
Neurontin has worked EXTREMELY well for me. I hope Johnny S's posts don't scare people away from taking the "second-line" approach from the start. Everyone does not need Depakote or Lithium if they are bipolar. They are the classicly prescribed meds, but I'm glad I don't have to take either one...
I read in a standard text on bipolar disorder that the reason they found out that Neurontin and some of the other anti-convulsants worked well for mood-swings, was that the people with epilepsy who took Neurontin noticed the dramatic improvement on their moods. And it took off from there. The fact that there are no clinical trials as yet to prove that anti-convulsants work for bipolar symptoms won't prevent me and many others from taking it...
Johnny: regarding the "placebo being better than the drug" reports, I believe they are spurious. There were a couple of discussions about those reports on here a few weeks ago. I tried to look up the threads for you, but don't think they are archived yet, so searching for "placebo" only pulled up threads from February at the latest. I'd suggest going back to the area called "Previous Periods," up above on the main board page, and looking up discussions over the last several weeks. I will also look for it. Several people expressed their reasonings why the reports are questionable in a much better way than I could.
All the best to you and to the other posters on this thread,
Wendy
Posted by Cece on May 30, 2002, at 3:06:27
In reply to New Mood Stablizers Unproven, posted by JohnnyS on May 26, 2002, at 23:24:14
Well, they're used because they do help some people- like me! And I've been through enough drug trials to know a placebo effect from a real effect.
Lamictal is now my primary mood stabilizer (BPII, long history of depression), and it has had undeniable stabilizing and AD effects.
Neurontin works well for me in combination with the Lamictal- the Lamictal is energizing, and the Neurontin is calming. I began Neurontin first and it did not pan out to be enough of a mood stabilizer for me on its own.Topomax apparently does work as a MS for some people, but for most it works best for weight loss. It didn't stabilize me, I did easily lose weight, but I got worse and worse cognitive problems from it and had to stop (regretfully becuz of the weight loss). I have heard that it is now being tested at UCLA as a weight loss med.
Cece
Posted by Leighwit on June 1, 2002, at 19:15:53
In reply to Re: New Mood Stablizers Unproven » JohnnyS, posted by Cece on May 30, 2002, at 3:06:27
Cece and Barbara,
I think that the both of you have both written about cognitive problems as Topomax side effects. Bummer.
I was thinking that Topomax might be a good mood stabilizer for me to research next, since the Lamictal is blowing me up like a water balloon. But cognitive problems aren't very appealing either ~ I happen to like the right side of my brain.
Do you know if Topomax is the only mood stabilizer that has no weight gain profile? (I'm assuming Topomax is virtually risk-free for weight gain since it might actually help people loose weight.) I know Lithium and Remeron (particularly the latter) have high incidence profiles for weight gain. Are there others that I could check out?
Laurie
> Well, they're used because they do help some people- like me! And I've been through enough drug trials to know a placebo effect from a real effect.
>
> Lamictal is now my primary mood stabilizer (BPII, long history of depression), and it has had undeniable stabilizing and AD effects.
> Neurontin works well for me in combination with the Lamictal- the Lamictal is energizing, and the Neurontin is calming. I began Neurontin first and it did not pan out to be enough of a mood stabilizer for me on its own.
>
> Topomax apparently does work as a MS for some people, but for most it works best for weight loss. It didn't stabilize me, I did easily lose weight, but I got worse and worse cognitive problems from it and had to stop (regretfully becuz of the weight loss). I have heard that it is now being tested at UCLA as a weight loss med.
>
> Cece
Posted by Cece on June 1, 2002, at 20:23:18
In reply to Re: New Mood Stablizers UnprovenBarbara » Cece, posted by Leighwit on June 1, 2002, at 19:15:53
As far as I know, Topomax is the only MS that actually causes weight loss. I'm not sure about Neurontin- I think it's been neutral for me.
I don't personally know of anyone who hasn't lost weight on Topomax- my niece who is BPI lost 50# she had gained on other meds, but eventually got conitive problems also. They don't seem to set in right away- I was okay for a few months until they became noticeable, and they progressed. I was taking 100mg/day. Last year, I thought I would see if I could take a small dose, 25mg, and get the good effects (weight) without the bad, but got the cog problems right off. So I guess you become sensitized to it in some way.
I lost the weight without changing my eating habits. I think that Topomax works (but not positive) by raising the 'set point'- the point at which the body decides that it needs to store fat rather than burn it. I think that the ones that cause weight gain do the reverse. Anyone know for sure?
No recourse for the fluid retention? Diuretics?
Cece
Posted by Leighwit on June 3, 2002, at 11:43:42
In reply to Re: New Mood Stablizers UnprovenBarbara » Leighwit, posted by Cece on June 1, 2002, at 20:23:18
> As far as I know, Topomax is the only MS that actually causes weight loss. I'm not sure about Neurontin- I think it's been neutral for me.
>
> I don't personally know of anyone who hasn't lost weight on Topomax- my niece who is BPI lost 50# she had gained on other meds, but eventually got conitive problems also. They don't seem to set in right away- I was okay for a few months until they became noticeable, and they progressed. I was taking 100mg/day. Last year, I thought I would see if I could take a small dose, 25mg, and get the good effects (weight) without the bad, but got the cog problems right off. So I guess you become sensitized to it in some way.
>
> I lost the weight without changing my eating habits. I think that Topomax works (but not positive) by raising the 'set point'- the point at which the body decides that it needs to store fat rather than burn it. I think that the ones that cause weight gain do the reverse. Anyone know for sure?
>
> No recourse for the fluid retention? Diuretics?
>
> CeceCece,
I'm not sure why the internist didn't mention diuretics. I guess I could mention that as a possbility to the Pdoc, but I'm not sure that diuretics are good for your kidneys ~ I know that in the past, I've been told diabetics shouldn't take them, but I cannot specifically recall the precise reason.
Laurie
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