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Dr. Bob is Robert Hsiung, MD,
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Posted by phidippus on September 5, 2015, at 14:44:34
In reply to Re: AAPs as mood stabilizers/failed traditional » phidippus, posted by Sheilac on September 5, 2015, at 7:18:31
Mood and Bipolar Disorders. Levetiracetam (Keppra)affects different parts of the brain, including the hippocampus and the amygdala, which are involved in mood disorders.[9,10,94-96] Studies have shown that increased levels of hippocampal Y-1- and Y-5-like receptors might be responsible for mood-stabilizing properties of levetiracetam.[10] Levetiracetam, both as add-on and as monotherapy, has shown its efficacy in a broad spectrum of bipolar disorders.
Bersani[97] investigated the potential efficacy of levetiracetam in outpatients affected by bipolar spectrum disorders as an add-on therapy to previous pharmacologic treatments. Twenty patients, 13 men and 7 women, were enrolled in this pilot study. These patients received oral levetiracetam 500 mg twice daily for 60 days. Fifteen patients completed the study, and for all of these patients the BPRS and the Bech-Raphaelsen scale of mania scores showed a rapid decrease following levetiracetam add-on therapy; this effect was significant at day 60. The tolerability of levtiracetam was assessed by the dosage record and treatment-emergent symptom scale. Five patients dropped out during the study, one because his symptoms worsened and the others for reasons independent of treatment response. The rest of the patients tolerated levetiracetam therapy without significant adverse effects. This study was the first to show the positive effect of levetiracetam in manic syndrome, including mood and behavioral symptoms.[97]
In an open-label trial, 34 patients with treatment-refractory bipolar I disorder (13 depressed, 7 manic, and 14 cycling) were enrolled.[92] These patients received 500-1000 mg of levetiracetam titrated to a target dosage of 2000 mg/day. The dosage was increased to 3000 mg/day as needed. Levetiracetam was an add-on therapy for eight weeks. The patients were rated weekly or once every other week with the Young Mania Rating Scale (YMRS), the Inventory for Depressive SymptomatologyClinical version, and the Clinical Global Impressions scale for use in bipolar illness for severity of mania, depression, and overall illness. A 31% remission rate was reported in patients who were depressed at baseline and who received levetiracetam as an add-on therapy. A 44% remission rate was noted in patients with mania at baseline. Four patients dropped out within the first week of treatment for administrative reasons, drug intolerance, or mood worsening. Another eight patients dropped out before week 3 because of lack of efficacy. Only 1 patient experienced psychosis. This was a high early-withdrawal rate for this open-label study. Moreover, severely depressed patients did not show any good response ( Table 4 ).
Grunze et al.[93] conducted an open-label study in 10 patients with a history of bipolar I disorder who were in an acute manic state. Levetiracetam was used as an add-on therapy with off-and-on design. All patients were treated with haloperidol 5-10 mg/ day. Levetiracetam was added until day 14, then discontinued, and reintroduced at day 21. The maximum dosage of levetiracetam used was 4000 mg/day. The mean dosage of levetiracetam was 3125 mg/day. The YMRS was used to assess the psychopathologic changes. After a mean decrease of the YMRS scores from 29.6 to 17.2 during the first on phase, manic symptoms worsened during the off period and ameliorated again during the second on phase, with a decrease of the mean YMRS score to 14.7 at the end of the study. At day 14, only 2 patients responded compared with 7 at the end of the study at day 28. Levetiracetam showed some additional antimanic effects in this study. The important adverse effects noted in this study were sedation (3 patients), dizziness (1 patient), and asthenia (1 patient). The abrupt discontinuation of drug caused no withdrawal effects except worsening of manic symptoms ( Table 4 ).[93]
Levetiracetam has a potential role in treating refractory bipolar patients with different comorbidities that are difficult to manage even with multiple medications. Kaufman[98] described a 21-year-old white woman with treatment-resistant, rapid-cycling, bipolar disorder who did not respond to 15 different psychotropics. She responded well to levetiracetam monotherapy, which was started at 1000 mg at bedtime and then increased to 2500 mg at bedtime. She remained without bipolar features during 1 year of maintenance treatment, except for one week during which she was noncompliant.[98]
The results of these studies suggest the need for further controlled trials to see the efficacy and tolerability of levetiracetam in patients with different mood and bipolar disorders. It is premature to recommend the use of levetiracetam in patients with these mood disorders in routine clinical practice.
Eric
Posted by Sheilac on September 5, 2015, at 15:05:49
In reply to Re: AAPs as mood stabilizers/failed traditional » Sheilac, posted by phidippus on September 5, 2015, at 14:44:34
Thank you so much Eric. I'm going to really talk to my doctor about this.
I've responded well to other anticonvulsants, I've just had a few bad side effects which caused me to stop them. Possibly Keppra, could work.
I'll never stop looking for the right add-on.
Posted by Sheilac on September 5, 2015, at 15:36:35
In reply to Re: AAPs as mood stabilizers/failed traditional » Sheilac, posted by phidippus on September 5, 2015, at 14:44:34
Are there any other meds I should look at?
I have a terrible bladder issue call interstitial cystitis (very painful bladder, urinary frequency, etc.) some of the medications I've tried have side effects of cystitis, like Depakote or Topamax.
Trileptal just causes painful, stiff muscles & joints. I can take small doses and it works great for anxiety, but higher doses are painful.
Both Depakote & Topamax worked great for me mentally, but caused terrible cystitis. Lamictal & Wellbutrin made me manic. Lamictal also caused ulcers in my mouth & on my gums. It was terrible. Lithium caused a thyroid nodule to grow (which had to be biopsied).
I'm kinda hard to treat. For some reason Geodon is awesome for me. No side effects. Abilify made me fat, risperdal caused rediculous swelling.
I feel like I've tried everything, but that can't be possible. I will mention Keppra, but I'm interested in anything else that might be an option.
Thanks for your brain power!
Posted by phidippus on September 5, 2015, at 16:33:54
In reply to Re: AAPs as mood stabilizers/failed traditional » phidippus, posted by Sheilac on September 5, 2015, at 15:36:35
Geodon is working well for you. Can you tell me what symptoms you are still having that you would like to treat?
Eric
Posted by Sheilac on September 5, 2015, at 17:03:06
In reply to Re: AAPs as mood stabilizers/failed traditional » Sheilac, posted by phidippus on September 5, 2015, at 16:33:54
Geodon at 160mg is great for me, but I still have some anger, short fuse issues. It's better now that I've gone from 120mg to 160mg, but still not as "stable" and even tempered as I would like to be.
I don't care if I'm a little goofy at this point, something more would be worth it. Klonopin is like eating M&Ms, 1mg of Klonopin just doesn't cut it.
Posted by phidippus on September 5, 2015, at 17:48:01
In reply to Re: AAPs as mood stabilizers/failed traditional » phidippus, posted by Sheilac on September 5, 2015, at 17:03:06
The irritability and anger issues may be untreated mania. You're looking for an agent that will calm you down and round those edges. You mention you add Trileptal to calm things a little and that works but you get unwanted side effects. I know of a couple of agents that might work to treat your slight mania like Trileptal:
Keppra - has been shown to be an effective mood stabilizer and has especially strong anti-manic effects. Also has some anxiolytic properties.
Zonegran - Can be useful as a mood stabilizer, but especially useful in treating bipolar depression.
Verapamil - High doses of this calcium channel blocker have shown to have mood stabilizing properties.
Nimodipine - may have particular benefits for those diagnostic subclasses of bipolar disorder most resistant to therapy, e.g., ultra-rapid-cycling bipolars and brief recurrent depressions.
These agents may help to take the edge off. You mentioned in the past Zyprexa was very helpful for you. It wouldn't hurt to combine the Geodon with the Zyprexa in a low dose.
Eric
Posted by Sheilac on September 5, 2015, at 19:04:51
In reply to Re: AAPs as mood stabilizers/failed traditional » Sheilac, posted by phidippus on September 5, 2015, at 17:48:01
Those sound like great options for me to discuss with my doc.
I did love zyprexa, only used a small dose for about 10 days. I just wonder about using 2 AAPs at one time?
I wonder also how low I can go without weight gain on it.
Posted by Christ_empowered on September 6, 2015, at 8:13:43
In reply to Re: AAPs as mood stabilizers/failed traditional » phidippus, posted by Sheilac on September 5, 2015, at 19:04:51
Sometimes, 2 AP/AAP drugs are used together. I think its fairly common in schizophrenia and schizoaffective, less so w/ bipolar I.
Anyway, over the long haul, probably not the best idea, but for short term use, I can see it being helpful. Me, I take 30mgs/Abilify and then when/if I feel agitated, I take a low dose of risperidone on top, at night. I only do that for a little while and then I stop.
Posted by phidippus on September 6, 2015, at 20:37:45
In reply to Re: AAPs as mood stabilizers/failed traditional » phidippus, posted by Sheilac on September 5, 2015, at 19:04:51
There really isn't a problem with using two AAPs at once. I've known many patients who have been on two antipsychotics at once-my favorite example is this one gentleman who had bipolar disorder and temporal lobe epilepsy. Besides the load of anticonvulsants he was on, he was also on haloperidol AND clozaril, two of the most powerful antipsychotics available.
I imagine the Geodon is working well to treat your symptoms from the bottom up-it can be remarkably effective as an antidepressant. But it might activate you a little. Adding a little Zyprexa might calm things down-Zyprexa has no antidepressant qualities and will kind of bring down things a bit. You can start in 5mg increments and see how you respond.
Since you have problems with conventional mood stabilizers, treating your illness with two aaps may be the best way to go.
Eric
Posted by Sheilac on September 7, 2015, at 6:45:17
In reply to Re: AAPs as mood stabilizers/failed traditional » Sheilac, posted by phidippus on September 6, 2015, at 20:37:45
Would going any higher than my current 160mg of Geodon help take the edge off? I'm BP.
Posted by Lamdage22 on September 7, 2015, at 7:30:29
In reply to Re: AAPs as mood stabilizers/failed traditional » phidippus, posted by Sheilac on September 7, 2015, at 6:45:17
You sure are on a lot of stuff and you wanna try even more stuff.
I dont know if it would be a good thing if your doctor cooperates with this.
Posted by Lamdage22 on September 7, 2015, at 7:36:10
In reply to Re: AAPs as mood stabilizers/failed traditional, posted by Lamdage22 on September 7, 2015, at 7:30:29
Can you share what is angering you?
Posted by Sheilac on September 7, 2015, at 9:38:47
In reply to Re: AAPs as mood stabilizers/failed traditional, posted by Lamdage22 on September 7, 2015, at 7:36:10
Usually my husband stresses me out because he is quick to temper (he takes risperdal) and my mother has terminal cancer and I'm one of her caregivers. It's very stressful and sometimes my stress makes me lose my temper or blow or become overly irrational. Also, to add to my stresses, my husband has decided we are moving again (2nd time this year), I've had 2 surgeries and I live in almost constant pain when my Interstitial Cystitis flares up.
I've been through years of counseling, yoga, deep breathing, meditation, but Geodon has really helped. Klonopin used to help, but not so much anymore. I noticed when I was taking Depakote (which flared my IC) Klonopin worked better. Unfortunately, I've failed anticonvulsants. Cross them off my possible med list.
It is imperative that I basically keep it together. Im not trying to drug myself into being constantly numb, I'm just trying to keep my BP in check and react like any other person would. I can't start screaming at a bad driver in the grocery store parking lot, or become so enraged I want to physically attack someone. That's just wrong.
Don't get me wrong, I have my times when I react correctly to the stresses, like crying, but my BP makes stress particularly hard to handle sometimes.
Posted by Sheilac on September 7, 2015, at 9:43:22
In reply to Re: AAPs as mood stabilizers/failed traditional, posted by Lamdage22 on September 7, 2015, at 7:30:29
Actually, I'm only taking 160mg of Geodon and 2mg of Klonopin and 10mg of Adderall XR. I don't think I'm on a lot of meds.
I've had to drop Trileotal (again) due to the edema and chronic muscle & joint pain. I've basically failed all the anticonvulsants. I react pretty well to the AAPs. I've failed both Lithium & Depakote as mood stabilizers.
It's tough to rely on 1 AAP as my antidepressant AND mood stabilizer.
I guess my life would be a lot easier if I could just take a mood stabilizer.
Posted by phidippus on September 7, 2015, at 13:36:56
In reply to Re: AAPs as mood stabilizers/failed traditional » phidippus, posted by Sheilac on September 7, 2015, at 6:45:17
I've pushed Geodon to 240 mg and didn't notice a heck of a lot of difference but that was with lithium. If you push it that high it might make more of a difference for you.
Eric
Posted by phidippus on September 7, 2015, at 14:35:10
In reply to Re: AAPs as mood stabilizers/failed traditional » Lamdage22, posted by Sheilac on September 7, 2015, at 9:38:47
I'm here for you. I won't ever give up on you.
Eric
Posted by phidippus on September 7, 2015, at 14:37:09
In reply to Re: AAPs as mood stabilizers/failed traditional » Lamdage22, posted by Sheilac on September 7, 2015, at 9:43:22
Have you considered Clozaril?
Eric
Posted by Sheilac on September 7, 2015, at 16:31:12
In reply to Re: AAPs as mood stabilizers/failed traditional » Sheilac, posted by phidippus on September 7, 2015, at 13:36:56
I'm not sure what the next push up from 160mg is, I was thinking pushing to 180mg, or even 200mg.
Posted by Sheilac on September 7, 2015, at 16:36:44
In reply to Re: AAPs as mood stabilizers/failed traditional » Sheilac, posted by phidippus on September 7, 2015, at 14:37:09
No, I've never heard of Clozaril. I have a feeling my pdoc will want to push Geodon higher. Which in fine with. But adding a little of something else shouldn't be out of the realm.
Geodon has been a very reliable med for me for years, at varying doses. I didn't really find stability until I hit 120mg. I'm even better at 160mg. Maybe a little higher would be great. We'll see.
Posted by Sheilac on September 7, 2015, at 16:41:03
In reply to Re: AAPs as mood stabilizers/failed traditional » Sheilac, posted by phidippus on September 7, 2015, at 14:35:10
Thanks, Eric. I appreciate the input and helping me think of things to discuss with my pdoc. I'm never giving up either. I have no choice. I know for sure that I must always be on medication and stay as stable as possible to continue being a contributing member of society. I'm not a quitter, even on my darkest most stressful days.
Thank you for your support! It means a lot!
Posted by phidippus on September 7, 2015, at 16:47:46
In reply to Re: AAPs as mood stabilizers/failed traditional » phidippus, posted by Sheilac on September 7, 2015, at 16:36:44
The only thing to be careful with is it can cause QT prolongation. Have your doctor do an EKG when you move up to a higher dose.
Eric
Posted by Lamdage22 on September 8, 2015, at 6:47:37
In reply to Re: AAPs as mood stabilizers/failed traditional » Sheilac, posted by phidippus on September 7, 2015, at 16:47:46
I am sorry you have been through so much trouble.
Well, you are on uppers and downers at the same time, thats what i meant with "a lot".
Posted by Lamdage22 on September 8, 2015, at 6:49:41
In reply to Re: AAPs as mood stabilizers/failed traditional, posted by Lamdage22 on September 8, 2015, at 6:47:37
Check the side effects and risks and decide if its really worth it for you.
Posted by Sheilac on September 8, 2015, at 11:17:13
In reply to Re: AAPs as mood stabilizers/failed traditional, posted by Lamdage22 on September 8, 2015, at 6:47:37
By uppers and downers you mean the Adderall and Geodon?
Posted by Lamdage22 on September 9, 2015, at 6:03:27
In reply to Re: AAPs as mood stabilizers/failed traditional » Lamdage22, posted by Sheilac on September 8, 2015, at 11:17:13
Yes but only based on my personal experience. I realize that you may be different.
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