Bipolar disorder topiramate

Pharmacotherapy is the cornerstone of acute and maintenance treatment of bipolar disorder. Mood-stabilizing drugs are the usual first-choice treatments and include lithium, divalproex, carbamazepine, and lamotrigine. Atypical antipsychotics other than clozapine are also approved for treatment of acute mania. Lithium, lamotrigine, olanzapine, and aripiprazole are approved for maintenance therapy. Drugs used with less research support and without Food and Drug Administration (FDA) approval include topiramate and oxcarbazepine. Benzodiazepines are used adjunctively for mania. 

H., and Levin, H. (1999) Topiramate as add-on treatment for patients with bipolar disorder. Bipolar Disord 1 42-53. 

Virtually all anticonvulsants are or have been of interest for the treatment of bipolar disorder. However, the importance of controlled data cannot be understated. For example, gabapentin, an anticonvulsant that initially received much attention as a potential mood stabilizer, was compared with placebo and did not appear to stabilize mood (Frye et al. 2000 Pande et al. 2000). Similar negative results were seen with topiramate in placebo-controlled trials for the treatment of mania. Although these medications might be useful adjuncts in some patients, given the currently expanded pharmacopoeia of medications with positive controlled trial data in bipolar disorder, we do not recommend the primary use of agents that have only case reports as an evidence base or controlled studies with predominantly negative results. 

Other agents with anticonvulsant properties that may be of use m the treatment of bipolar disorder include topiramate, gabapentin, tiagabine and carbamazepine (Janicak et al., 2001). 

Recently, Calabrese (240) reviewed the use of topiramate in bipolar disorder and also presented the results of two additional studies. He noted that, thus far, topiramate had been studied in 12 open clinical trials involving a total of 224 patients, mainly in manic and mixed states, and generally as an augmentation strategy. 

Calabrese JR. Update on the use of topiramate in bipolar disorder. Presented at the American Psychiatric Association 2000 Annual Meeting, Chicago, May 13-18, 2000. 

Another group of mood-stabilizing drugs that are also anticonvulsant agents have become more widely used than lithium. These include carbamazepine and valproic acid for the treatment of acute mania and for prevention of its recurrence. Lamotrigine is approved for prevention of recurrence. Gabapentin, oxcarbazepine, and topiramate are sometimes used to treat bipolar disorder but are not approved by FDA for this indication. Aripiprazole, chlorpromazine, olanzapine, quetiapine, risperidone, and ziprasidone are approved by FDA for the treatment of manic phase of bipolar disorder. Olanzapine plus fluoxetine in combination and quetiapine are approved for the treatment of bipolar depression. 

Vieta E, Sanchez-Moreno J, Goikolea JM, Colom F, Martinez-Aran A, Benabarre A, Corbella B, Torrent C, Comes M, Reinares M, Brugue E. Effects of weight and outcome of long-term olanzapine-topiramate combination treatment in bipolar disorder. J Clin Psychopharmacol 2004 24 374-8. 

Chen CK, Shiah IS, Yeh CB, Mao WC, Chang CC. Combination treatment of clozapine and topiramate in resistant rapid-cycling bipolar disorder. Clin Neuropharmacol 2005 28 136-8. 

A 24-year-old woman with a history of bipolar disorder and binge eating had a history of isolated panic attacks 8 years before and the attacks subsided 14 days after topiramate withdrawal (627). 

A 41-year-old woman with a diagnosis of bipolar disorder developed severe suicidality when topiramate was added to her previous treatment (carbamazepine and levothyroxine) for mood stabilization (649). 

Topiramate is itself a second-line augmenting agent for numerous other anticonvulsants, lithium, and antipsychotics in treating bipolar disorder... 

Lack of convincing efficacy for treatment of bipolar disorder suggests risk/benefit ratio is in favor of discontinuing topiramate in bipolar patients during pregnancy... 

Atypical antipsychotics may be preferable to topiramate if treatment of bipolar disorder is required during pregnancy... 

Chengappa KR, Gerstion S, Levine J. The evolving role of topiramate among other mood stabilizers in the management of bipolar disorder. Bipolar Disord. 2001 3 215-232. 

Suppes T. Review of the use of topiramate for treatment of bipolar disorders. J Clin Psychopharmacol 2002 22 599-609. 

Topiramate is an antiepileptic medication also used in an off-label capacity to treat migraine headaches and bipolar disorders. 

McElroy SL, Suppes T, Keck PE, Frye MA, Denicoff KD, Altshuler LL, Brown ES, Nolen WA, Kupka RW, Rochussen J, Leverich GS, Post RM. Open-label adjunctive topiramate in the treatment of bipolar disorders. Biol Psychiatry 2000 47(12) 1025-33. 

Certain anticonvulsants developed initially for the treatment of epilepsy, such as topiramate and zonisamide, have been found to have a beneficial effect in mood disorders, particularly bipolar disorder. In addition, patients treated with these compounds lose weight. They were therefore seen as potential therapeutic agents for use in obese patients with BED. 

The place in therapy of the newer anticonvulsants, such as gabapentin, levetiracetam, tiagabine, topiramate, and zon-isamide, is controversial. Many clinicians consider these agents to be less effective than established mood stabilizers based on initial studies and avoid them for monotherapy in bipolar disorder. 

I Preliminary open observations of adjunctive topiramate treatment suggest that it may have antimanic or anticychng effects in some patients with bipolar disorder including those who are treatment resistant. 

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