Question:
Some Personal Comments Upon the Recent Article on Lamictal and Neurontin?
Answer:
Two new anticonvulsants, Lamictal (lamotrigine) and Neurontin
(gabapentin), may be valuable additions to the bipolar armamentarium, Dr.
Norman Sussman said at a psychopharmacology update sponsored by New York
University.
These agents may be useful both as primary treatment in refractory cases
and as add-on drugs, said Dr. Sussman, director of the Psychopharmacology
Research and Consultation Service at Bellevue Hospital Center in New York
City.
Lamotrigine appears to be "an excellent antidepressant, particularly in
bipolar illness," and it is less likely than other agents to induce mania
or rapid cycling. "It remains to be seen how well it controls mania," he
said.
The evidence for its efficacy comes entirely from open-label studies and
case studies. In one series of seven rapid-cycling patients (six with
bipolar disorder, one with schizoaffective disorder), the response to
lamotrigine was "dramatic" in two patients, moderate in two, and absent
in two. One patient discontinued the drug due to nausea.
A study of 22 depressed bipolar patients who were refractory to other
treatment found that 16 responded to lamotrigine by the end of 4 weeks of
treatment, and none switched into mania.
In a recently published series of 16 patients with refractory bipolar I
or II disorder, half had a good response to lamotrigine; all of the
responders had been in a depressed or mixed phase. Mania was precipitated
in two patients, however.
Lamotrigine is generally well tolerated, but it may interact with other
anticonvulsants like carbamazepine and divalproex. A significant drawback
is the risk of rash, which can progress to Stevens-Johnson syndrome.
"Because it can precipitate a life-threatening condition, it's not a drug
I'd use until I've exhausted other alternatives," Dr. Sussman said.
The risk is dose related and may be minimized by a cautious, gradual
escalation of the dose over several weeks, with prompt discontinuation if
rash develops, he said.
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The mood effects of gabapentin were first observed in the treatment of
epilepsy. Pooled data for 705 patients with refractory seizures found
that improvements in mood, cognition, and social function were common
when gabapentin was added to other drugs. Nearly half of patients on
gabapentin reported enhanced well-being, versus 29% of patients on
placebo.
In a retrospective study of 73 patients with bipolar I or II disorder,
bipolar disorder not otherwise specified, or schizoaffective disorder, 67
had a positive response. Cycling ceased in all who remained on the drug,
and 23 reported improved mood, Dr. Sussman said.
In an open-label study of gabapentin in nine patients with bipolar I or
II disorder who were unresponsive to other mood stabilizers, seven had
moderate improvement after 1 month; another patient showed improvement
after 3 months on gabapentin. In a 6-week study of gabapentin in 15
patients with refractory bipolar depression, improvement was marked in 5
and partial in 3. No patient developed manic symptoms, he said.
Results of other case studies have suggested that gabapentin may be
useful in patients with sleep disorders, anxiety, and Parkinson's
disease. Improvements, sometimes dramatic, also have been seen in
attenuation of craving in cocaine addicts and in behavior control; for
the latter, gabapentin was helpful in the case of a 13-year-old with
temper tantrums, screaming fits, and violent mood swings. I'm sorry that you had such a negative experience! Some pdocs just don't
seem to realize that the way a med is taken is often as important as the
med itself. They just read the PDR and go with that. And wonder why they
don't see the positive results that others do.
What dose of Neurontin are you currently taking? How effective has it
proved so far for you?
I am currently working my way up to 3200 mg. Taking it very slowly, and the
goal is to take it 4 times a day. My current pdoc is great and very open to
what I read on websites. I told him of your Neurontin protocol and since
I am having trouble with some cycling, sleep deprivation and depression, he
told me to go with the 4 doses a day. Neurontin has been a lifesaver for me. My Depakote alone just wasn't doing the
trick. I also take 60 mg. of Parnate and hope to decrease that once I work up
to 3200 mg. of Neurontin.
You are right about pdocs using the PDR recommendations. That's what got me
into trouble. I really recommend after my experience working up slowly...an
additional pill every 4 to 5 days. Otherwise, mania will show it's ugly head
again.
The first couple of weeks I was on Neurontin, it did help me with my
shoulder pain from FMS/MPS. But then all my muscles starting aching
(particularly in my lower back)! My Neurologist had prescribed the dose
he takes for his neck pain (600 mg 2 times daily). This proved to a big
overdose for me. I slowly reduced my Neurontin dosage from 1200 mg/day to
200 mg/day. I remained mentally rock stable from the moment of taking my
very first capsule! My increase in cognition was also nothing short of
miraculous! But my back pain became truly debilitating. :-( So I am now off Neurontin (hopefully temporarily!) until my muscular pain
disappears or at least greatly diminishes. Then I plan on resuming
Neurontin EXTREMELY slowly so as to hopefully not to again exacerbate my
muscular pains. I am currently taking Relafen and Naproxen for pain.
Neurontin proved to be a devil's bargain for me. It had the best mental
properties by far of any of the dozens of psychoaffective meds I have
taken over the years. I was able to slowly reduce my antidepressant
(Effexor) from 300 mg/day to only 50 mg/day when I was on Neurontin. I am
now taking 25 mg 4 times daily of Effexor. The antidepressive effects of
Neurontin proved to be very powerful for me. That is why I caution people
about starting Neurontin VERY slowly in order to prevent them from being
sent into (hypo)mania. The same advice is also true for Lamictal.
IMO all too many of us with BP are being overdosed with Neurontin and
Lamictal because doctors are not aware of how to prescribe these
remarkable new meds for those who prove to be extremely sensitive to
their antidepressive effects. Due to Neurontin's very short half life, it
definitely should be taken a minimum of 4 times per day in equal doses.
Since the PDR doesn't mention this important fact, some people are
unfortunately experiencing induced ultra-rapid cycling. Thus they
conclude that Neurontin (or Lamictal) are not for them. The problem is
one of taking it not frequently enough and/or at too high a dosage.
I do not regret my experiences with Neurontin. I felt "normal" for the
first time since 1984. My IQ jumped at least 25-50 points back to where
it used to be. My Klutz Factor significantly decreased. My memory and the
clarify of my thinking processes greatly improved. But is my marvelous
mental improvement worth the price of truly intolerable back pain? Only
time will reveal the answer to that question.
Another person's muscular condition may well be totally unaffected by
Neurontin. But no one can say for sure a priori. In my opinion it is
definitely worth a try. But as with all meds there are no guarantees.
YBMV. However nothing ventured, nothing gained.
