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(5/24/00 11:04 pm)
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Data Lacking for Newer Drugs for Bipolar Disorder
Taken from Medscape
TUCSON, ARIZ. -- Scientific data cannot justify some of the approaches being used to treat bipolar disorder patients.
This is particularly true when it comes to prescribing newer anticonvulsants alone or in conjunction with traditional drugs.
"If we're practicing good, rigorous medicine, we should go to the farther-out treatments later on. [We should] have more conversations with the patient and document why we're doing it," said Dr. Alan J. Gelenberg, professor and head of psychiatry at the University of Arizona in Tucson.
In practice, many psychiatrists aren't waiting too long to see whether drugs like lithium and divalproex are working in their patients with bipolar disorder before they jump to alternatives such as gabapentin, lamotrigene, or topiramate for main-line treatment of the disorder, he maintained.
It's a practice he warns against.
Data are scanty or nonexistent that would suggest these drugs are efficacious in terms of long-term maintenance of bipolar patients, he said at a psychopharmacology conference sponsored by the University of Arizona.
Gabapentin. Gabapentin (Neurontin, Parke-Davis) is quite safe, and since it is not metabolized by the liver, it has few drug interactions and requires no monitoring of blood levels.
"The bad news is, it doesn't seem to work in bipolar disorder patients," said Dr. Gelenberg.
Several negative controlled studies have been completed but have not been published, he noted.
"People who are working in this area think [the potential of gabapentin in bipolar disorder] is trending negative," the psychiatrist said.
If a patient is on gabapentin and appears to be benefitting, Dr. Gelenberg would not advise stopping the drug, but he said he would be reluctant to turn to it unless and until clinical studies show it has some efficacy.
Lamotrigene. Early evidence suggests lamotrigene (Lamictal, Glaxo Wellcome) may in fact have some efficacy in treating patients with bipolar depression, said Dr. Gelenberg.
The drug also carries a weightier risk profile, since it can trigger life-threatening cutaneous reactions such as Stevens-Johnson syndrome or toxic epidermal necrosis.
Will it be an effective drug or adjunct for maintenance?
The studies haven't been done to answer that question.
"We're going to be doing a lot of shrugging. Ask me in a year or ask me in 2 or 3 years," he said.
Topiramate. Topiramate, (Topamax, Ortho-McNeil Pharmaceuticals) like the others, is approved by the Food and Drug Administration as an adjunct in treating partial seizures in patients who have epilepsy.
"I have no idea whether it has efficacy for bipolar disorder," Dr. Gelenberg commented.
All of the studies suggesting topiramate might be a good choice for treating bipolar disorder have been small series, case studies, or anecdotal reports.
"The good news is that it really does seem, in at least half of the patients who take it, to promote weight loss," he said. "That makes me a little bit more interested in using it."
Dr. Gelenberg noted that many bipolar disorder patients endure weight gain as a side effect of medication, so that any drug counteracting that effect is worthy of further study.
Still, topiramate has side effects of its own, including fatigue and mental sluggishness.
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