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Augmenting Bipolar 'Cocktail' with Trodenki XR

Posted by LouisianaSportsman on September 24, 2013, at 20:51:00

Current Psychiatric "Cocktail":

Abilify (aripiprazole)10mg.
Concerta (methylphenidate ER) 54mg
Lamictal (lamotrigine) 200mg.
Lyrica (pregabalin) #60 150mg. [300mg.]
Pristiq (desvenlafaxine) 50mg.


296.80 Bipolar Disorder NOS
314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type


I would like to discontinue the Lyrica (pregabalin) in place of Trodenki XR (topiramate XR) which unlike Lyrica, is non-scheduled and not abusable. I do not want to be taking two medications (Abilify and Lyrica) that cause significant weight gain. I do not expect the topiramate to be a direct replacement for pregabalin, obviously. Like pregabalin, topiramate is an anti-convulsant but it works primarily on sodium channels whereas Lyrica acts exclusively on calcium channels. I believe topiramate, initiated in the form of Trokendi XR (approved August 2013 as the only controlled-release form of topiramate not combined with phentermine) at #60 100mg. topiramate extended-release capsules would be a great adjunct to my Lamictal. I will suggest prescription of #60 100mg. (the initial dose for bipolar disorders and the mean dose for bipolar disorders according to one study = 210.5 mg/day). If side effects are too much, I can drop down to 100mg. since I was prescribed 100mg. pills. I believe the controlled-release pills might be advantageous because they will give less side effects since the dose is released over time instead of all at once, and it eliminates any need for BID dosing due to a more consistent peak plasma concentration. Is there any advantage of using a controlled-release formulation of topiramate over the instant release? I am guessing there might be. Only a theory. Also, I have noticed in some literature that when lamotrigine was transferred to another anticonvulsant, it was automatically titrated at the target dose of the alternative anticonvulsant. I also have a high tolerance of all psychoactive medications which my pdoc and I both agree on, and we frequently begin titrating at the higher doses of medications; therfore, I think a fast titration is feasible.

I am, of course, looking for weight loss of aripiprazole/pregabalin weight; however, that is not the only intended goal at all. I have been having mood swings not treated with the lamotrigine. I believe augmentation of lamotrigine with a target dose of 200mg. topiramate (average dosage for bipolar according to another study was 245mg. QD) would be beneficial. I do not want to exceed the dosage that gets the job done as cognitive side effects are dose-dependent. I did not experience cognitive dulling from pregabalin nor any other psychoactive medication and hopefully it will be the same case with potential topiramate. Pregabalin works well and hopefully so will topiramate. Topiramate has been shown to help with anxiety and bipolar depression of which I am suffering and, like pregabalin, it antagonizes glutamate. I am hoping it will make my mood more stable due to its powerful mood stabilizing mechanism of action. It should also fatigue the ability of aripiprazoles weight-gaining mechanism. With these reasons in mind, I believe it is the most important medicine to negotiate with at the present time.

Additionally, I believe that the dosage of Pristiq should be increased to 100mg (300mg. venlafaxine). I am still having depressive episodes on the 50mg. dosage. Also, this dosage is where it starts to effect NE and even DA more potently and acts more as a true SNRI than simply a souped-up SSRI.

I have taken Nuvigil in the past and it has since been replaced by a gambit of ADHD stimulants. I believe that I would benefit from the substitution of Nuvigil (armodafinil) at #60 150mg. BID QAM QPM in replacement of Concerta 54mg. Nuvigil is safely taken at this dosage. Like Concerta, Nuvigil does not provide adequate all-day relief. A 150mg. tablet taken in the morning with a 150mg. booster dose is my recommendation. Because aripiprazole has such a high D2 occupancy rate (85% at 10mg.), it drastically reduces the effects of ADHD stimulant drugs such as methylphenidate ER. Nuvigil, with its unique mechanism of action, compliments the Abilify better, IMO. Its abuse-potential is also much, much lower. The Nuvigil is an absolute *must* combined with the Abilify as it causes me to want to sleep during the daytime, but this may be the Pristiq. Also, I believe the armodafinil may help with possible side effects of cognitive dulling arising from the use of topiramate.

New Suggestion for next visit:

Abilify 10mg.
Lamictal 200mg.
* Nuvigil #60 150mg. [300mg.] substituted for Concerta 54mg.
* Pristiq 100mg. increase from Pristiq 50mg.
* Trodenki XR #60 50mg. [100mg. target] substituted for Lyrica which was indicated off-label primarily for bipolar depression and anxiety
(asterisk indicates a change)

Augmentation Ideas, in order of most promising, for future visits if above regimen does not succeed:

Mirapex (pramipexole)
Namenda (memantine)
Gabatril (baclofen)

Any thoughts? Ideas?

Thank you!!




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