Carbamazepine and Oxcarbazepine in psychiatry

[thelastpsych]

I've seen other providers use these two drugs for a varying of conditions unrelated to epilepsy, such as aggression in adults, alcohol use disorder, manic episodes. As far as I can tell, it can be used as a 3-4th line in bipolar disorder, after the usual agents such as lithium/valproate/... have been tried.

I'm always a bit skeptical of these two drugs in psychiatry, especially with it's not so tame side effects profile and monitoring. Do you guys use it? What have been your experiences?

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[Sushirolls]

Even when I was doing more IP and had higher acuity patients in years past, I avoided them. Gravitated more towards antipsychotics.
When in residency I didn't really see much response from them, not impressed, and not worth the other CYP observations.

 

[Merovinge]

Trileptal is pretty well tolerated but likely less effective than Tegretol for psychiatric conditions (which is saying something as Tegretol is already not great). I have no problem considering it for affective lability/aggression in the child-adolescent space as the side effect profile is much more favorable to the antipsychotics and somewhat better than VPA. We have very little data on DMDD where it is reasonable to consider as well as patients with pre-syndromal bipolar spectrum illness or frank bipolar disorder in youth. I prescribed it a few times in a year when doing full-time outpatient to give a sense for it's overall utility, but not a medication I would just completely ignore.

P.S. Always check a BMP if you get significant fatigue, I have caught a few significant hyponatremia cases over the years from Trileptal. Don't rx a med with a known side effect and not f/u if you see signs of it.

 

[Celexa]

I've had several pts who responded well to carbamazepine for bipolar, and some find it much more tolerable than antipsychotics or lithium. Had at least one patient who was on it for seizure, switched off to something else, and oops turns out that carbamazepine was definitely also doing some heavy lifting treating the mood disorder. I've also seen multiple patients rapidly becomes hyponatremic upon initiation, and its got interactions as noted, so it's not my favorite but I think it is an important tool to keep in mind.

Never had or seen success with oxcarb.

 

[TexasPhysician]

I have multiple patients current on oxcarb for irritability/aggression issues with good response.

 

[Stagg737]

Trileptal is pretty well tolerated but likely less effective than Tegretol for psychiatric conditions (which is saying something as Tegretol is already not great). I have no problem considering it for affective lability/aggression in the child-adolescent space as the side effect profile is much more favorable to the antipsychotics and somewhat better than VPA. We have very little data on DMDD where it is reasonable to consider as well as patients with pre-syndromal bipolar spectrum illness or frank bipolar disorder in youth. I prescribed it a few times in a year when doing full-time outpatient to give a sense for it's overall utility, but not a medication I would just completely ignore.

P.S. Always check a BMP if you get significant fatigue, I have caught a few significant hyponatremia cases over the years from Trileptal. Don't rx a med with a known side effect and not f/u if you see signs of it.

I've had several pts who responded well to carbamazepine for bipolar, and some find it much more tolerable than antipsychotics or lithium. Had at least one patient who was on it for seizure, switched off to something else, and oops turns out that carbamazepine was definitely also doing some heavy lifting treating the mood disorder. I've also seen multiple patients rapidly becomes hyponatremic upon initiation, and its got interactions as noted, so it's not my favorite but I think it is an important tool to keep in mind.

Never had or seen success with oxcarb.

My experience has been somewhat the opposite. I've only ever seen 1-2 patients where carbamazepine was effective AND tolerable. Not to mention the side effect profile is like taking the worst of everything else and combining it into one med (SJS, thrombocytopenia, agranulocytosis, hyponatremia, etc). Most of the time it doesn't really work and when it does there's the whole self-induction thing that gets tricky.

I've had numerous patients who have found oxcarbazepine helpful and tolerated it just fine. These patients are mostly adults with IDD or developmental problems where the Trileptal helps their agitation when SGAs either weren't effective or had significant side effects. However, I have also had a couple of bipolar patients where oxcarb was just the right med for them including one who had previously been at the state forensic hospital for 18+ straight months at one point.

I'll reach for oxcarb over carbamazepine pretty much every time, but I also don't treat kids so little caveat there.

 

[michaelrack]

these days I am doing mostly IP C and A psychiatry (ages 10-17). For bipolar and for DMDD with severe mood lability or aggression, I tend to use VPA or abilify in boys; and trileptal or abilify in girls. I also use a fair amount of seroquel, especially if there is a PTSD component. Some of my colleagues like to use VPA in both sexes, but its teratogenicity makes me nervous in girls. Trileptal is hit or miss in my experience.

 

[comp1]

VA, so I rarely have to worry about teratogenicity, but I don't like these meds. They seem poorly tolerated and dangerous in overdose. At least with depakote it's harder to OD on because the tablets are so massive.

 

[Merovinge]

these days I am doing mostly IP C and A psychiatry (ages 10-17). For bipolar and for DMDD with severe mood lability or aggression, I tend to use VPA or abilify in boys; and trileptal or abilify in girls. I also use a fair amount of seroquel, especially if there is a PTSD component. Some of my colleagues like to use VPA in both sexes, but its teratogenicity makes me nervous in girls. Trileptal is hit or miss in my experience.

I'd look to Latuda a lot more these days with it being generic and available for basically any kids. Sucks needing to take with food but otherwise a good medication.

 

[ObsequiousAplomb]

I have never started carbamazepine for a patient before. None of my attendings in residency were comfortable with its use in the modern era, even the ones who were practicing since the 1960s.

I never cared much for Trileptal until a close friend had success with it. He has bipolar disorder and tried Invega, Ability, Zyprexa, Latuda, lithium, Depakote all in various combos for years with only 6-12 months between manic episodes. His NP was at a loss and gave him Trileptal monotherapy. He has only had two hypomanic episodes in the past 6 years.

Even knowing that success story, I've still never prescribed it. Unlike the people in this thread who do use it, I only treat adults.

 

[clozareal]

I don't like them because they don't usually work. Oxcarbazepine is a worse mood stabilizer and higher risk of hyponatremia than carbamazepine. Carbamazepine has it's own issues with its autoinduction, but I will use it more than oxcarb. I usually prefer carbamazepine over Depakote given the reproductive issues not only with women, but now we're discovering with men too. My favorite mood stabilizer is lithium. No hard and fast rules for me with regards to these medications though as I'll use them down the line for treatment resistance/intolerance of alternatives.

 

[calvnandhobbs68]

these days I am doing mostly IP C and A psychiatry (ages 10-17). For bipolar and for DMDD with severe mood lability or aggression, I tend to use VPA or abilify in boys; and trileptal or abilify in girls. I also use a fair amount of seroquel, especially if there is a PTSD component. Some of my colleagues like to use VPA in both sexes, but its teratogenicity makes me nervous in girls. Trileptal is hit or miss in my experience.

Yeah I never really use depakote in general but I really never use it for girls....I'd use lithium over depakote because there is actually less of a teratogenicity risk. If you're using it for bipolar, lithiums a better option anyway and there are sources that clearly state that VPA should only be used in females of childbearing age "when all other options have been exhausted".

Is Valproate Reasonable?

www.ncbi.nlm.nih.gov

There was some forensic case we went over in residency where basically someone got raked over the coals for not clearly discussing and documenting the teratogenicity risk of depakote every appointment and reviewing birth control, folic acid every appointment for a young woman who then had a kid with a neural tube defect.

 

[Merovinge]

VPA in childbearing aged females (particularly minors) ONLY if implantable form of birth control is documented and you have an extensive discussion around this being probably the single worst medication on Earth to be on for a woman who happens to get pregnant. It's efficacy is way too fringe to rx VPA into teenage girls unless you are in a near apocalyptic situation and even then get ready for a 10% at best response rate. There are no called strikes in prescribing, almost never a reason you need to go down the VPA path in adolescent females.

 

[Merovinge]

I have never started carbamazepine for a patient before. None of my attendings in residency were comfortable with its use in the modern era, even the ones who were practicing since the 1960s.

I never cared much for Trileptal until a close friend had success with it. He has bipolar disorder and tried Invega, Ability, Zyprexa, Latuda, lithium, Depakote all in various combos for years with only 6-12 months between manic episodes. His NP was at a loss and gave him Trileptal monotherapy. He has only had two hypomanic episodes in the past 6 years.

Even knowing that success story, I've still never prescribed it. Unlike the people in this thread who do use it, I only treat adults.

Had a CEO of a medium sized company stable on Tegretol monotherapy, had not had an episode in like 8 years (previous hx of hospitalization and marked dysfunction). Guy came like clockwork to a resident clinic every 3 months to get his refill. Have never seen anyone since have such a good response but this is why we need as broad array of options as the evidence can support. I don't like the meds but I sure won't rule them out in all cases.

 

[Stagg737]

Agree with much of thread. To clarify my previous post, both these meds are minimum 4th line options for me. It is exceptionally rare for me to use them for reasons other than agitation in IDD populations to the point that I barely even feel comfortable prescribing carbamazepine at all.

 

[Celexa]

Agree with much of thread. To clarify my previous post, both these meds are minimum 4th line options for me. It is exceptionally rare for me to use them for reasons other than agitation in IDD populations to the point that I barely even feel comfortable prescribing carbamazepine at all.

Yes, the important point is that they are 4th line options in almost all cases but 4th line options matter! They still have a chance of being the thing that stabilizes a patient and returns them to function. We don't have such a wealth of treatments in psychiatry that we can afford to discount even very imperfect medications with the potential to help.