Trileptal (oxcarbazepine)

[Smilemaker100]

Trileptal is normally prescribed as an anti-convulsant. I was wondering what the psychiatrists/residents on this board think about this drug's success as a mood stabilizer for the treatment in manic depression versus that of valproic acid (also an anti-convulsant prescribed as a mood stabilizer).

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[Anasazi23]

Oxcarbazepine is essentially a "second generation" version of carbamazepine that has similar efficacy in the treatment of epilepsy but lacks toxic metabolites and has fewer side effects. There's not much data on the efficacy of Trileptal in bipolar but it is generally presumed to be efficacious for bipolar and has been endorsed as a replacement for carbamazepine in current APA guidelines. There are a few studies comparing Trileptal to lithium in the manic phase and in both phases of BD as an add-on agent, with good results.

Your question asks about Trileptal vs. valproic acid. It could be conceivably compared to any of the other label or off-label anticonvulsants used in psychiatry (ie. topamax). It is generally seen as a second line agent for those refractory to valproate, who are obese, are unwilling to get regular blood tests, or have hepatic disease, increased LFTs, HIV, neuropathic pain.

It has potent 2C19 inhibition, and can increase phenytoin levels by up to 40%, and like many other agents, can inactivate oral contraceptives. It can also decrease the levels of some Ca channel blockers.

My personal experience with has had relatively good success, though I find that it does not tend to work as quickly as VPA or lithium, and that people decompensate very quickly when finally stabilized on it if they stop taking it. I guess the same could be said of other mood stabilizers, however.

 

[joanithan]

Caution should be taken before extrapolating efficacy for this drug from the data supporting efficacy of Tegretol. In fact, to the best of my knowledge, there is little or no data to support the role of this drug as a first line mood stabilizer. There are very few drugs, particularly AED's, for which there is data to support their use as mood stabilizers. The only drugs with very good data to support their uses as prophylaxis against mania are Lithium, Tegretol (limited), and some older neuroleptics. Although there is a role for other drugs in bipolar disorder (e.g., there is data to support Lamotrigine as a good anti depressent for patients with BPAD in that it does not appear to flip BPAD patients to mania, as many pure antidepressants do), there are very few drugs that are "complete" mood stabilizers. It is important to note also that Li has been substantiated independently to be an antidepressant in unipolar depression. I believe that there is only one study comparing Li to Depakote as mania prophylaxis, and in that study, neither Li nor VA were statistically superior to placebo for this purpose. Nevertheless, there is copious data to support this role for Li in other excellent studies. Most of the information you hear today about medicicnes is anedocdotal. Although some of the drug companies would like to suggest the 2nd generation neuroleptics are appropriate mood stabilizers, I do not believe there is a single randomized double blind placebo study that has been published to substantiate this. Specifically, to the best of my knowledge, there is no data to support these drugs as mania prophylaxing medicines.
Hope this helps, and I hope that if I have missed a study, someone will set me straight. I do not want misinform anyone. Best wishes.

 

[Anasazi23]

Here's a summary table of some Trileptal studies...most appear efficacious in various respects. I've got another patient on it now....appears to be helping quite quickly.

http://www.bipolarnews.org/pdfs/Oxcarbazepine%20in%20Mood%20Disorders.pdf

 

[joanithan]

Here's a summary table of some Trileptal studies...most appear efficacious in various respects. I've got another patient on it now....appears to be helping quite quickly.

http://www.bipolarnews.org/pdfs/Oxcarbazepine%20in%20Mood%20Disorders.pdf

Thank you for the excellent list of resources. It is significant to note that, as mentioned, unfortunately there is not a randomized controlled study as to the efficacy of Trileptal to delay manic episodes, meaning it is not adequate for monotherapy. The Cabrera study is interesting, but was not controlled and had an extremely small n. It is hoped that Trileptal will be shown to have this use in the future, as our armamentarium is still quite small (despite numerous reviews suggesting the contrary).