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topamax for weight loss
okay anticonvulsant bipolar medications. nowthe ones that are in bold treat mania. topamax and neurontin don't work but they are usedfor other purposes with bipolar. and lamictal which is an anticonvulsant does not treatmania it treats depression. we're still talking about treating manicc episodes we're talkingabout these. now tegretol is a very problematic drug to use for lots of reasons. side effectwise it's a problem. it causes birth defects.
topamax for weight loss, but actually it also interferes with its ownmetabolism. so it has an effect on the liver function so you have to frequently do dosageadjustments to deal with the fact that it's being metabolized differently over a periodof time. equetro is a sustained release version of this and it has fewer drug interactionsit's a little bit better side effect wise
but typically it's not gonna be the firstdrug because it's more problematic. so if you look at anticonvulsants that treat mania,depakote is really gonna be the one used most. if you look at most of these drugs they causeproblems, the exception is lamictal. we'll talk about that after our break. lamictalcan cause rashes but tends to have very few side effects. it's really the only bipolarmedication that has very very few side effects except for rash. then depakote, we'll lookat this slide and take a break. if you look at head to head studies it seems to be aseffective as lithium for classic euphoric mania. the advantage is thatit's somewhat better tolerated than lithium okay. they actually have similar side effectsin some respects but it's a little bit better
tolerated. it has been used although the researchdoesn't strongly support this but it may treat rapid cycling. it clearly is the best medicineas i mentioned before for dysphoric mania. let me just mention something and that islithium is used a lot in other countries and not as much in the united states. i may havementioned this in our last class i don't remember, but only 30% of people with bipolar in theunited states have ever tried lithium and the experts are saying that's a real mistake.because it's a very good bipolar drug and also as i mentioned in our last class it'sthe one drug that has a huge impact in reducing suicide rates. remember that/ seven fold decreasein suicides. so if you look at patterns of practice in the united states you're gonnaget a lot more people put on depakote than
lithium but that is a prescribing bias that'snot shared in other parts of the world like europe, england, australia and so forth wherethey use a lot of lithium. but the other advantage of depakote and then we'll take our break,is all these antimanic drugs take about a week and a half to really work now you canknock someone out with antipsychotics, you can knock them out with tranquilizers to getrid of the severe agitation but really it takes about a week and a half before it reallytargets the grandiosity and decreased need for sleep and flight of ideas and all thatkinds of stuff. with depakote if you get real aggressive in the dosing you can turn thecorner in about four days. ok. so i think that may be for better or for worse. i thinkthat in a managed care environment the reason
it's used a lot because it's 'let's get thesepeople out of the hospital as quickly as possible and we can get them out quicker with depakote.'but what's the other side of the coin? we talked about this before, you knock peopleover with side effects and in the long run they may be less compliant with medicationtreatments so it's a two edged sword okay. now if it seems like we're spending a disproportionatelylarge amount of time talking about bipolar, the reason for that is one is it's complicatedbut the other thing two is probably in psychiatry this is where most damage occurs to humanbeings it's inappropriate diagnoses and inappropriate treatment. ok so that's one reason, go fortwenty minutes and we'll take a lunch break. depakote levels here, like with lithium it'snot the amount that you take that matters
as much as levels so you have to monitor theblood levels with lithium likewise with depakote. with depakote when you take depakote a wholelot of that binds with proteins in the blood like albumin for instance. and when it's boundto the protein it can't get into the brain. so unless you have a level of at least 50,100% of depakote is locked onto blood proteins and can't get into the central nervous system.and once you exceed that you have what are called free molecules that are floating aroundin the bloodstream not bound to proteins and that's what crosses into the brain. the reasoni mention this is i've seen over the years and mostly these are people, kids teenagersand they're not doing very well on their medicine. and i'll ask 'well, what was their latestdepakote level?" and i've been told, 'well,
they haven't really taken any depakote levelsrecently." and it's like, what? or "well, it was forty." well i think i have an ideawhy it isn't working. because it's not getting in the brain. it has to be within this rangehere. in addition to the potentially problematic sometimes dangerous side effects this is alsosomething that's a really big deal and it's polycystic ovaries. nowdepakote was used for a number of years prior to being used in psychiatry because it treatsepilepsy. now in women under the age of twenty, if they're not monitored carefully they candevelop polycystic ovaries which if allowed to go on for very long can cause permanentinfertility. and this unfortunately was discovered after it'd been used years and years aftertreating kids with epilepsy and then they
end up later and can't have kids and it'sjust absolutely horrible outcome. now it says women under the age of twenty, 80% can developpolycystic ovaries. after the age of twenty the rate drops down to 13% so it's not zero.so here's what has to happen. and that is if you have preadolescent girls who are takingdepakote you do a sonogram at the very beginning of treatment and you repeat this two timesa year. and i certainly don't know the particulars that they look for but radiologists absolutelycan detect changes in the ovaries that detect 'uh oh we're starting to move in that direction,'so you stop the depakote and move on to a different medication. after puberty though,weight gain and irregular menses. i want to add something that may be more common. it'scalled hirsutism and it's abnormal growth
of hair. so you get like 16, 17 year old oreven a 33 year old woman starts to get excessive facial hair or hair on their chest. so weightgain, irregular menses or abnormal hair is a red flag that they may've developed polycisticovaries and you get it checked out and you change the medicine. and my great concernhere is all these kids getting put on depakote for all kinds of reasons and not being monitoredcarefully. especially inner city kids and kids who don't have good health insurance,that kind of stuff. now topamax they thought for awhile well maybe we can add this to thelist of drugs to treat mania but it really doesn'tseem to be very effective. but it's frequently given as an add-on drug. remember i said mostpeople that are successfully treated take
4 drugs? it's not unusual that this wouldbe an add on drug. and mainly because of the firsts three things up here. you have highrates of binge eating disorder in bipolar disorder. high rates of obesity. and a otof the drugs will cause weight gain and so this drug is one of the only opsychiatricdrugs that causes really substantial weight loss. most people that are taking topamaxare losing a pound a week without dieting, without increasing their exercise. now ifyou happen to be taking depakote or lithium or zyprexa, sometimes people are putting ona half a pound or a pound a week and topamax so it makes it weight neutral. so they'renot losing weight but they're not gaining weight. now i don't know if this is true ornot there's been some jokes about people going
into their primary care doctor and fakingbeing bipolar so they could get topamax so they could lose weight. a pound a week withoutdieting that sounds appealing for many people. it treats pain, fda approved for migraineprophylaxis. the rate of migraine headaches in bipolar patients is three times the rateof the general population so it's always nice to get a drug that kills several birds withone stone. also there's some studies suggesting that people in recovery from alcoholism thatit maintains longer periods of abstinence for people that are taking topamax. the badthing about topamax is that even in low doses it can cause cognitive problems mainly memoryproblems. here we're talking about new learning, "i can't remember where i parked my car,"you know that kinda thing. and sometimes it's
substantial. again this is i'm sure a joke,but they say the reason people are losing a pound a week on topamax is that they forgetwhere the refrigerator is. because of the cognitiveimpairment people jokingly call it 'dopeamax.' makes you dopey. okay neurontin doesn't workat all to treat mania, it really does have a place though in treating bipolar. last timearound we talked about there's a lot of comorbidity and anxiety disorders are seen very frequentlyin about half the people who have bipolar. i think i mentioned this last class but anxietydisorders and substance abuse, if they're comorbid with bipolar if you don't treat those,the outcome in general is a lot more poor. so you've really got to aggressively treatthe bipolar but also treat the comorbidities.
the problem though is that the drugs thatwork best for treating anxiety are antidepressants. in fact as we're going to see antidepressantsmay be better at treating anxiety disorders than they are at treating depression. butwhat do antidepressants do? they aggravate bipolar. so neurontin can be used to treata whole array of anxiety disorders with the exception of ocd. ocd is absolutely clearlydue to inadequate serotonin function and neurontin does not have an impact on increasing serotonin.
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