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psychiatric illness:
Bipolar disorder. Multiple studies have found that AEDs are efficacious
for treating bipolar disorder. Carbamazepine, valproate (divalproex), and
lamotrigine have the most evidence supporting their use (Table 1, page 52).
For an extensive bibliography of studies supporting AEDs for bipolar disorder and other psychiatric illnesses, see this article at CurrentPsychiatry
com. Carbamazepine and valproate are FDA-approved for treating acute
manic or mixed episodes associated with bipolar I disorder in adults,
and may be beneficial for maintenance treatment. Lamotrigine is FDAapproved for maintenance treatment of bipolar I disorder in adults; however, it lacks efficacy for mania and acute bipolar depression.1 The use
of newer AEDsincluding gabapentin, levetiracetam, oxcarbazepine,
tiagabine, topiramate, and zonisamidefor bipolar disorder is not recommended because evidence is limited or inconclusive.
continued
Current Psychiatry
Vol. 9, No. 12
51
Table 1
Antiepileptic
selection
Medication
Mania
Depression
Maintenance
Major
depressive
disorder
Carbamazepine
(aggression,
impulsivity)
(adjunct to
clozapine)
(aggression,
impulsivity)
Lamotrigine
Valproate
Gabapentin
Levetiracetam
Oxcarbazepine
Clinical Point
Tiagabine
When prescribing
carbamazepine, be
aware of potential
drug-drug
interactions with
antipsychotics
Topiramate
Zonisamide
52
Current Psychiatry
December 2010
Source: For an extensive bibliography of studies that support these recommendations, see this article at CurrentPsychiatry.com
port the practice, AEDs commonly are combined with antipsychotics to treat patients
with schizophrenia.3,4 Clinicians who prescribe carbamazepine should recognize the
potential for drug-drug interactions with
antipsychotics (ie, increased metabolism of
antipsychotics caused by cytochrome P450
[CYP450] 3A4 induction).
: strong evidence supporting efficacy; : moderate evidence supporting efficacy; : weak evidence supporting efficacy
ONLINE
ONLY
Schizophrenia
Table 2
Possible medication(s)*
Benzodiazepine withdrawal
Carbamazepine, valproate
Topiramate, zonisamide
Bulimia nervosa
Topiramate
Drug dependence/abstinence
Pregabalin, tiagabine
Obesity
Panic disorder
Valproate
Lamotrigine
Social phobia
Gabapentin, pregabalin
*Based on small randomized controlled trials, open-label trials, or case reports. Further investigation in large systematic
trials is needed
lamotrigine, tiagabine, and valproate.8 Peripheral edema with these agents generally has not been linked to cardiovascular
complications in healthy adults. Carba
mazepine and pregabalin may cause conduction abnormalities and should be used
with caution in patients with underlying
electrocardiogram abnormalities.8
Chronic carbamazepine use results in
elevated plasma homocysteine and serum lipoprotein concentrations, which are
biomarkers of cardiovascular disease.9 If
clinically appropriate, switching from carbamazepine to a non-inducing AED (ie,
lamotrigine) may ameliorate such effects.
Chronic valproate use has been associated
with increased plasma homocysteine levels; increases in serum lipoproteins may
parallel valproate-induced weight gain.9
CNS effects. Common acute neurologic effects of AEDs include somnolence, dizziness,
and ataxia. The incidence of these effects
vary by agent; gabapentin and zonisamide
appear to be the most sedating.8 However,
in general these effects occur at the start of
treatment and abate within a few days with
continued treatment or dosage reduction.
Starting at a low dose and slowly titrating
may help prevent neurologic adverse effects.8 Peripheral neurologic effectsspecifically paresthesiasare primarily associated
with topiramate and zonisamide and may be
attributed to carbonic anhydrase inhibition.8
Clinical Point
Neurologic
adverse effects
of antiepileptics
generally occur
at the start of
treatment and abate
within a few days
Current Psychiatry
Vol. 9, No. 12
53
Table 3
Comparative
effect on
cognition
Compared with
Carbamazepine
Topiramate
Carbamazepine, topiramate
Gabapentin
Topiramate
Carbamazepine, oxcarbazepine
Carbamazepine, topiramate
Lamotrigine
Levetiracetam
Oxcarbazepine
Carbamazepine, valproate
Pregabalin
Levetiracetam
Tiagabine
Topiramate
Carbamazepine
Antiepileptic
selection
Lamotrigine
Valproate
Gabapentin
Clinical Point
A predictor of
cutaneous reactions
to lamotrigine
is concomitant
valproate use
without lamotrigine
dosage adjustment
ONLINE
ONLY
Topiramate
young age.12
A history of AED-induced rash also increases risk. For example, patients with a
history of rash with carbamazepine are at
risk for rash with oxcarbazepine because
of cross-reactivity.
Any AED-induced skin rash may progress to a fatal reaction, such as toxic epidermal necrolysis or Stevens-Johnson
syndrome. Carbamazepine and lamotrigine are most strongly associated with these
severe reactions.12 Patients who exhibit
painful rash, fever, enlarged lymph nodes,
malaise, and mucosal involvement may be
at risk for a more severe disease course.12 If
a patient taking an AED develops a rash,
immediately stop the drug and perform a
thorough risk-benefit analysis before considering re-initiation.
62
Current Psychiatry
December 2010
men.13,14 Decreased platelet count is common with valproate, but coagulation dysfunction may not be present until counts
fall below 50,000/mL. Carbamazepine is
associated with leukopenia, which usually occurs in early treatment and resolves
without dosage adjustments; however,
this agent carries a black-box warning for
risks of agranulocytosis and aplastic anemia. Similar postmarketing findings have
been reported with lamotrigine.8 Baseline
hematologic testing and monitoring is recommended.
petite and body weight. Weight gain is common with valproate and pregabalin, but may
occur with carbamazepine and gabapentin
as well.8 Weight gain does not appear to be
dose-related and may be minimized by diet
and exercise. Lamotrigine and levetiracetam do not appear to affect weight, whereas
weight loss and anorexia have been reported
with topiramate and zonisamide.8
Hyponatremia and syndrome of inappropriate antidiuretic hormone secretion
have been reported with both carbamazepine and oxcarbazepine; the incidence is
higher for oxcarbazepine. For both agents,
hyponatremia risk is highest in elderly patients.12 Valproatealone and concomitant
with topiramatemay elevate ammonia
levels, but monitoring generally is necessary only in symptomatic patients. Topiramate and zonisamide increase the risks of
hyperchloremic, nonanion gap metabolic
acidosis and hypohidrosis; serum bicarbonate should be monitored at baseline
and as clinically indicated.12,15
ciated with aggressive behavior, irritability, and increased anxiety and depression,
which usually occur soon after drug initiation.8 Similarly, topiramate use is associated with affective and psychotic symptoms.
Carbamazepine, gabapentin, lamotrigine,
oxcarbazepine, and valproate have been
associated with a decreased risk of psychiatric adverse effects compared with the
overall incidence among AEDs.8
An FDA analysis suggested patients receiving AEDs have an elevated risk of suicidal ideation or behaviors, regardless of the
indication.16 However, the data for increased
suicidality are better supported for epilepsy
patients than for those with a psychiatric
diagnosis. The increased risk was noted as
early as 1 week after initiating an AED and
extended up to 6 months. The findings generally were consistent across demographic
subgroups and AEDs.16 However, a recent
study suggests the risk of suicidal acts or
violent death is lowest with topiramate compared with gabapentin, lamotrigine, oxcar-
Clinical Point
Valproate-induced
hepatotoxicity may
have acute onset and
hepatic dysfunction
may progress despite
discontinuing the
drug
Introduction by
Table 4
Antiepileptic
selection
Clinical Point
Explain to patients
taking topiramate
or zonisamide that
increasing their
fluid intake will
significantly reduce
kidney stone risk
Medication
Comment(s)
Carbamazepine
Patients screening positive for the variant HLA-B1502 allele are at an elevated risk
of developing Stevens-Johnson syndrome or toxic epidermal necrolysis. All patients
of Asian descent should be screened22
Gabapentin
Associated with weight gain, edema, and sedation; no reported effects on liver
function tests
Lamotrigine
Levetiracetam
Oxcarbazepine
Pregabalin
Tiagabine
Elevated risk of seizures and status epilepticus when used in non-seizure patients
Topiramate
Valproate
Zonisamide
ONLINE
ONLY
64
Current Psychiatry
December 2010
Therapeutic monitoring
Therapeutic serum drug concentration
monitoring can help evaluate toxicity,
medication adherence, and effects of po-
Available online
Clinical Point
Therapeutic serum
drug concentration
monitoring can
help establish target
drug concentrations
specific to your
patient
CME REVIEWER
Christoph U. Correll, MD
Professor of Psychiatry
and Neuroscience
University of Cincinnati College
of Medicine
Cincinnati, Ohio
Medical Director
Recognition and Prevention
(RAP) Program
The Zucker Hillside Hospital
Associate Professor of Psychiatry
Albert Einstein College
of Medicine
Bronx, New York
FACULTY
Joseph F. Goldberg, MD
Associate Clinical Professor
of Psychiatry
Mount Sinai School of Medicine
New York, New York
FREE
1.0 CM
E
credit
Available at CurrentPsychiatry.com
Click on Supplements/CME
This activity is supported by an educational grant from Janssen, Division of OrthoMcNeil-Janssen Pharmaceuticals, Inc, administered by Ortho-McNeil-Janssen Scientific
Affairs, LLC. It was peer reviewed by Current Psychiatry.
Related Resources
McElroy SL, Keck PE, Post RM, eds. Antiepileptic drugs to
treat psychiatric disorders. New York, NY: Informa Healthcare USA, Inc.; 2008.
Antiepileptic
selection
Oxcarbazepine Trileptal
Pregabalin Lyrica
Tiagabine Gabitril
Topiramate Topamax
Valproate (Divalproex)
Depakote, Depakote ER
Zonisamide Zonegram
Disclosure
Clinical Point
Carbamazepine
and valproate
require serum drug
concentration
monitoring to
prevent adverse
effects
Bottom Line
66
Current Psychiatry
December 2010
Table
Carbamazepine
4 to 12 g/mL
Valproate (divalproex)
50 to 125 /mL
Supratherapeutic presentation
Current Psychiatry
Vol. 9, No. 12