Lyrica vs. Gabitril vs. neither?

[ratched]

Outpt psychopharm question for everyone..... has anyone had experience with Lyrica and/or Gabitril in conjunction w/Neurontin? I realize that, mechanistically, there is some degree of redundancy here, but I'm curious about peoples' experiences (if any).

I have a tx-refractory pt who suffers from GAD, double depression, active bulimia nerv who's getting a partial response from Effexor 300, low dose Ativan, Neurontin (total daily dose of 2100 mg) -- currently, she has daily bursts of ++anxiety, and b/p behaviors. For various reasons (rel to past med trials and fear of future wt gain), we cannot raise the benzo, initiate an atypical (which would be my first choice), or go near SSRIs (including Prz which has been tried by prior treater to no success).

Neurontin was the new kid on the block, and she had quite good results initially, but these have unfortunately waned. So, that's why I'm thinking of going down the Lyrica/Gabitril road. Any thoughts would be welcomed.....

(also, in case you're wondering, she's fully engaged in psychotherapy; not willing to do a more behaviorally-based ED psychotherapy however)

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[Chrismander]

Outpt psychopharm question for everyone..... has anyone had experience with Lyrica and/or Gabitril in conjunction w/Neurontin? I realize that, mechanistically, there is some degree of redundancy here, but I'm curious about peoples' experiences (if any).

I have a tx-refractory pt who suffers from GAD, double depression, active bulimia nerv who's getting a partial response from Effexor 300, low dose Ativan, Neurontin (total daily dose of 2100 mg) -- currently, she has daily bursts of ++anxiety, and b/p behaviors. For various reasons (rel to past med trials and fear of future wt gain), we cannot raise the benzo, initiate an atypical (which would be my first choice), or go near SSRIs (including Prz which has been tried by prior treater to no success).

Neurontin was the new kid on the block, and she had quite good results initially, but these have unfortunately waned. So, that's why I'm thinking of going down the Lyrica/Gabitril road. Any thoughts would be welcomed.....

(also, in case you're wondering, she's fully engaged in psychotherapy; not willing to do a more behaviorally-based ED psychotherapy however)

In my experience Lyrica is better than gabapentin for anxiety. It makes no sense to combine neurontin and lyrica. Lyrica is much better absorbed than gabapentin. Gabapentin has an active transporter in the gut that saturates, meaning there's a max dose beyond which you don't get much more into the system. The downside of Lyrica is substantial weight gain. I had a patient (already quite obese though) gain nearly 50 pounds on it, though it really improved her GAD and panic.

 

[billypilgrim37]

What very rich planet do you folks live on that your insurance companies will pay for Lyrica or Gabitril for anxiety? We have to launch all out assaults to get the insurance companies to pay for their approved indications, nevermind anxiety.

 

[whopper]

Although the data supports that Lyrica is superior to Gabapentin, I tend to shy away from it because there are several clinical reports that it has been used as a substance of abuse.

I do have one patient, only one where I have him on both meds. This patient has severe PTSD from being struck by lightening, chronic pain in his arm from the lightening, and panic disorder, was tried on 3 SSRIs and 2 SNRIs, all with buspirone augmentation with no benefit. When I first met him, his prior psychiatrist zonked him out on megadoses of Clonazepam and Valium (yes both--that doctor is an idiot) to the point where he could barely stand. My justification is he reached the maximum dosage of Gabapentin (3600 mg a day), had a tremendous benefit, I'm talking tremendous. I was able to completely wean him off of his Clonazepam, the Gabapentin caused no side effects, and he was now anxiety free most of the day unless there was a lightening storm (that actually occurs quite often in these parts. I even recommended he consider moving because during the summers here, we get them sometimes daily. Touchdown Jesus was in these parts.) He also had a pain benefit. He now only takes Valium on days where there's a lightening storm and outside the summer, it barely occurs here.

He still had some anxiety and adding Lyrica did further help in this regard. The dosage added was low. IMHO there's no need to put someone on both unless the max dosage of one is reached.

 

[F0nzie]

...I need to start pushing the Gabapentin past 1200mg for anxiety before giving up on it. I've had 1 patient tell me it made his anxiety worse.

 

[dl2dp2]

Did you think about Abilify or Geodon? Not as much WT gain concerns.

Echoing previous posts, Gabapentin in itself has some abuse potential. The trials really haven't shown it to be particularly efficacious. Lyrica seems like a real anxiety drug, but yeah, I can't believe insurance would pay for it.

Other options: busprone...TCA/mirtazapine (likely no good for WT gain), Depakote/topamax (one of the unorhtodox Stahl suggestions, WT gain too), MAOIs (selegeline patch? -> it causes weight LOSS!), naltrexone (this is a weird one, I know, this is something one of the addiction attending mentioned to me--people on bup DEF get less anxious, but hard to tell what's what in suboxone maintainance/alcoholism)

The other thing you might consider is if this "anxiety" and "b/p behaviors" might respond to lithium, though strictly lithium has no action to anxiety per se., but it's a good drug for young women who want to stay thin, correct? Is the anxiety related to affective dysregulation, which could potentially respond to lithium?

 

[Chrismander]

Did you think about Abilify or Geodon? Not as much WT gain concerns.

The other thing you might consider is if this "anxiety" and "b/p behaviors" might respond to lithium, though strictly lithium has no action to anxiety per se., but it's a good drug for young women who want to stay thin, correct? Is the anxiety related to affective dysregulation, which could potentially respond to lithium?

How is lithium a good drug for young women who want to stay thin? It causes weight gain as well...

 

[billypilgrim37]

How is lithium a good drug for young women who want to stay thin? It causes weight gain as well...

It helps them stay thin because the law suit they slap against you when their baby has any birth defect will help them afford liposuction.

 

[firedoor]

I have a tx-refractory pt who suffers from GAD, double depression, active bulimia nerv who's getting a partial response from Effexor 300, low dose Ativan, Neurontin (total daily dose of 2100 mg) -- currently, she has daily bursts of ++anxiety, and b/p behaviors.

Please clarify, expand.

 

[whopper]

I've had 1 patient tell me it made his anxiety worse.

I've mentioned in several threads that I've used gabapentin to treat anxiety, but of course, like with all meds, it doesn't work in all, some people do get side effects. I've also ready that there are some abuse cases with it though that potential, at least anecdotally appears to be worse with Lyrica.

If someone had treatment resistant anxiety, I would consider that it's possibly ADHD left undiagnosed. As I've written several times, I've had a subset of patients that complain of anxiety, get a TOVA, the TOVA is (+) for ADHD and then ADHD treatment actually helps them relieve their anxiety.

 

[dl2dp2]

How is lithium a good drug for young women who want to stay thin? It causes weight gain as well...

I should clarify. it is, or may be, a good drug for a young woman who wants to stay thin who has a bipolar spectrum/BPD spectrum disorder with significant affect dysregulation, where you strongly suspect that there's rationale for a mood stablizer. Most of the other mood stabliziers have much worse birth defects, and while lithium does cause weight gain, it's not nearly as bad as depakote, and does not cause hirsuitism and other vanity related side effects.

Whopper made an excellent point that I forgot about. Sometimes stimulants "paradoxically" treat anxiety in unrecognized ADHD patients--I've seen a couple on the adolescent unit.