Your experience with Oxcarbazepine for Bipolar Disorder and other off label uses.

[Iparksiako]

Unfortunately, bibliography is not rich enough about this drug for bipolar disorder. It is a pity that we keep using carbamazepine instead of this one.

I've heard it working on anger outbursts too in bipolar and not only.

Do you use it in your clinical practice?

What's your experience with it?

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[Candidate2017]

I used to see it in patients inherited from "prescribers" who try to manage personality issues with medications. They usually end up with hyponatremia, which requires trial reduction, repeat electrolyte labs, other labs and workup, coordination with PCP, as well as trying to figure out if any of the other 6 psychotropics are the true cause of hyponatremia. This takes away valuable appointment time from addressing their actual psychiatric issues.

Nowadays, I remove Trileptal, because patients with maladaptive emotional reactions need therapy not hyponatremia, while patients who actually have bipolar disorder need real bipolar meds.

 

[the5thelement]

I once worked at an inpatient unit where the psychiatrist had EVERYONE on trileptal 300mg bid. I use it rarely - Its not FDA approved for Bipolar and although marketed as a kindler gentler alternative to tegretol, in my experience tegretol works better a mood stabilizer.
Fun fact:"While first synthesized in 1965, oxcarbazepine first appeared on the US market in 2000. In 2010, Novartis pleaded
guilty to marketing oxcarbazepine for non-FDA approved uses, including neuropathic pain and bipolar disorder, in
2000 and 2001"

 

[ObsequiousAplomb]

Unfortunately, bibliography is not rich enough about this drug for bipolar disorder. It is a pity that we keep using carbamazepine instead of this one.

I've heard it working on anger outbursts too in bipolar and not only.

Do you use it in your clinical practice?

What's your experience with it?

Why is it a pity that people use Tegretol, especially given that your prior sentence makes it clear that there's less evidence for Trileptal?

 

[mistafab]

Whats sad is that people scramble to use third, fourth, even fifth line agents when lithium is not given a fair trial.

 

[allantois]

There is research it seems to help with just about any disorder in kids..
I have used it for ODD with some success

 

[shoomer]

Oxcarbazepine is one of the several psych meds we have that doesn't work robustly for any one indication, so we kind of throw it at a bunch of different things and hope it helps. People are often too scared of Lithium, and don't know how to work with carbamazepine's enzyme induction and side effects. So I've seen a lot of bipolar pts get Depakote on their first trial, Trileptal on their second. But the evidence is lacking.

 

[clozareal]

There is research it seems to help with just about any disorder in kids..
I have used it for ODD with some success

As a CAP, this is the first I've heard of this. It failed a large RCT for pediatric bipolar disorder when compared to placebo. I haven't seen robust literature for anything else but it could be due to my own ignorance.

 

[calvnandhobbs68]

As a CAP, this is the first I've heard of this. It failed a large RCT for pediatric bipolar disorder when compared to placebo. I haven't seen robust literature for anything else but it could be due to my own ignorance.

People will use it as part of the "Matthews" protocol for DMDD which is probably where a lot of this acceptance for use for "irritability" and DMDD comes from.

Psychiatric News

psychnews.psychiatryonline.org

 

[J ROD]

It has amazing placebo effects......

 

[allantois]

https://www.tandfonline.com/doi/full/10.1080/08998280.2020.1826259

 

[clozareal]

Thank you! Interesting read

 

[MedMan80]

There is research it seems to help with just about any disorder in kids..
I have used it for ODD with some success

 

[allantois]

Admittedly, I am not great with kids and it's more of a last resort thing. However, it is popular among CAPs in my area

 

[MedMan80]

Admittedly, I am not great with kids and it's more of a last resort thing. However, it is popular among CAPs in my area

I’ve seen it, but why not each for something with more efficacy ie depakote

 

[allantois]

I’ve seen it, but why not each for something with more efficacy ie depakote

eh idk lab monitoring ?

 

[clozareal]

I’ve seen it, but why not each for something with more efficacy ie depakote

Depakote, risperidone, and stimulants have much more evidence for efficacy, but both of them have way more side effects than oxcarbazepine, which is metabolically neutral. But until the safety is first established, then the efficacy, it's a tough sell to use for me except when these other medications have not worked.

 

[MedMan80]

Depakote, risperidone, and stimulants have much more evidence for efficacy, but both of them have way more side effects than oxcarbazepine, which is metabolically neutral. But until the safety is first established, then the efficacy, it's a tough sell to use for me except when these other medications have not worked.

we never really used it in training due to the paucity of evidence. From a clinical perspective I have not seen many patients be successful on it either. Maybe this thread will have me reach for it more often when my bag of tricks run dry?

 

[annoyedpsychiatrist]

the main people i see who prescribe trileptal are older psychiatrists, possibly because they didn't have access to a lot of SGAs back then and the patient couldn't use something like lithium.

 

[ObsequiousAplomb]

the main people i see who prescribe trileptal are older psychiatrists, possibly because they didn't have access to a lot of SGAs back then and the patient couldn't use something like lithium.

Really? Didn't it only come to the US market in 2000? Most of the SGAs predated Trileptal.

 

[annoyedpsychiatrist]

Really? Didn't it only come to the US market in 2000? Most of the SGAs predated Trileptal.

i think trileptal came about before zyprexa had any fda approvals for bipolar and i think seroquel got its fda approval for bipolar in early 2000s. Back then there was no generic abilify either, and of course there wasnt newer stuff like caplyta, vraylar, latuda.

Still, the year 2000 is still quite some time ago if you think about it. If you were a practicing psychiatrist around that time period id imagine youd be 50s-60s now

 

[ObsequiousAplomb]

i think trileptal came about before zyprexa had any fda approvals for bipolar and i think seroquel got its fda approval for bipolar in early 2000s. Back then there was no generic abilify either, and of course there wasnt newer stuff like caplyta, vraylar, latuda.

Still, the year 2000 is still quite some time ago if you think about it. If you were a practicing psychiatrist around that time period id imagine youd be 50s-60s now

By 2000:

Clozaril (1990 for schizophrenia), Zyprexa (1996 for schizophrenia, 2000 for mania), Risperdal (1993 for schizophrenia), and Seroquel (1997 for schizophrenia) had been around a rather long time.

There was also Depakote, approved in 1995 for bipolar disorder but used off-label for a long time before that. Tegretol technically was never FDA approved for bipolar disorder (Equetro was later), but it had been a mainstay of practice for the management of bipolar disorder since the 1970s. Lamictal came to the US in 1994 and used off-label for bipolar disorder until 2003 when the label was expanded.

In 2000 Trileptal didn't have an indication for any psychiatric disorder, and it still doesn't. It didn't have any studies supporting its use, and still doesn't have any great ones. Back in 2000 people were absolutely using all the atypical and many typical antipsychotics off-label for bipolar disorder.

In the years shortly after 2000a lot of options came out:

Geodon (2001 for schizophrenia), Risperdal was approved for mania, Seroquel was approved for bipolar disorder, and Abilify was approved for schizophrenia in 2002.

So for someone trained in 2000, there were many options with more reasonable use prior to Trileptal: every typical antipsychotic, lithium, Depakote, Tegretol, Lamictal, and 4 atypical antipsychotics.

In my room experience, people who trained prior to 2000 either have adamantly refused to prescribe Trileptal or gave in to the illegal marketing and pushing of the drug from their healthcare system to offer Trileptal on a misguided notion that it is lower risk than Tegretol. You probably do see plenty of psychiatrists who have been practicing for 20+ years prescribing it, but I highly doubt that it's because they were trained in 2000 to use Trileptal for bipolar disorder.

 

[clozareal]

we never really used it in training due to the paucity of evidence. From a clinical perspective I have not seen many patients be successful on it either. Maybe this thread will have me reach for it more often when my bag of tricks run dry?

Here the review on stimulants in youth:

The pharmacological management of oppositional behaviour, conduct problems, and aggression in children and adolescents with attention-deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder: a systematic review and meta-an

Evidence indicates that psychostimulants, alpha-2 agonists, and atomoxetine can be beneficial for disruptive and aggressive behaviours in addition to core ADHD symptoms; however, psychostimulants generally provide the most benefit.

pubmed.ncbi.nlm.nih.gov

And the one on mood stabilizers and SGAs in youth:

The pharmacological management of oppositional behaviour, conduct problems, and aggression in children and adolescents with attention-deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder: a systematic review and meta-an

With the exception of risperidone, the evidence to support the use of antipsychotics and mood stabilizers is of low quality.

pubmed.ncbi.nlm.nih.gov

Stimulants seem like they're the best. In terms of mood stabilizers/SGAs, risperidone has the highest quality data for efficacy and the one I've seen work the best followed by Depakote, then lithium (both of which have low quality evidence and wide confidence intervals), and then carbamazepine which has the lowest. This is in youth and not adults.

 

[milesed]

I don't start patients on it, but may continue it if they are doing well. I do check labs q6 mos

 

[hallowmann]

Almost never use it, rarely effective, but will probably continue if stable. Have recently had 2 patients that reported new onset hallucinations and were attending during visits at about the 2-3 week mark of it being started on them while inpatient. Discontinued and hallucinations disappeared within a few days.

I used to see it in patients inherited from "prescribers" who try to manage personality issues with medications. They usually end up with hyponatremia, which requires trial reduction, repeat electrolyte labs, other labs and workup, coordination with PCP, as well as trying to figure out if any of the other 6 psychotropics are the true cause of hyponatremia. This takes away valuable appointment time from addressing their actual psychiatric issues.

Nowadays, I remove Trileptal, because patients with maladaptive emotional reactions need therapy not hyponatremia, while patients who actually have bipolar disorder need real bipolar meds.

I have had very similar experiences as this as well. We used to see it prescribed a ton in training, and now there is this one notorious inpatient unit that puts half their patients on it.

A bit of a rant, but this unit is staffed by psychiatrists that spend <5 min a day per patient and they and their NPs have diagnosed almost every patient with mood lability as having bipolar 1, despite clearly meeting criteria for BPD or PTSD or SUD with no real mania or bipolar disorder to be suspected. They also put people on commitment constantly and have a tendency to discharge all patients on outpatient commitment to our CMHC. Then they send nasty messages to us angry that they are readmitting a patient with chronic SI, and claim that the reason is because we didn't force an LAI or because "we" discontinued (often self-discontinued or just inappropriate) their 2 mg of Abilify or 0.5 mg of Risperdal.

When people ask me what's wrong with seeing tons of patients a day in psych, all I need to think about is the inappropriate care provided at this place.

Whats sad is that people scramble to use third, fourth, even fifth line agents when lithium is not given a fair trial.

Yup.

 

[smalltownpsych]

Almost never use it, rarely effective, but will probably continue if stable. Have recently had 2 patients that reported new onset hallucinations and were attending during visits at about the 2-3 week mark of it being started on them while inpatient. Discontinued and hallucinations disappeared within a few days.


I have had very similar experiences as this as well. We used to see it prescribed a ton in training, and now there is this one notorious inpatient unit that puts half their patients on it.

A bit of a rant, but this unit is staffed by psychiatrists that spend <5 min a day per patient and they and their NPs have diagnosed almost every patient with mood lability as having bipolar 1, despite clearly meeting criteria for BPD or PTSD or SUD with no real mania or bipolar disorder to be suspected. They also put people on commitment constantly and have a tendency to discharge all patients on outpatient commitment to our CMHC. Then they send nasty messages to us angry that they are readmitting a patient with chronic SI, and claim that the reason is because we didn't force an LAI or because "we" discontinued (often self-discontinued or just inappropriate) their 2 mg of Abilify or 0.5 mg of Risperdal.

When people ask me what's wrong with seeing tons of patients a day in psych, all I need to think about is the inappropriate care provided at this place.


Yup.

Ahhh! The old ”LAI would work because the patient keeps discontinuing medication because they get better so we need to do something to keep them on it” logic. These people also believe that medication compliance is the most important aspect of treatment which is why the patients often don’t get better. Misdiagnosed and mistreated and misled patients don’t get better and don’t want to take a medication that doesn’t help them. It is amazing when I ask the patient they usually say that pretty directly unless they have been crushed by the system into compliance/obedience and just repeat the line that was fed to them.

 

[clausewitz2]

Ahhh! The old ”LAI would work because the patient keeps discontinuing medication because they get better so we need to do something to keep them on it” logic. These people also believe that medication compliance is the most important aspect of treatment which is why the patients often don’t get better. Misdiagnosed and mistreated and misled patients don’t get better and don’t want to take a medication that doesn’t help them. It is amazing when I ask the patient they usually say that pretty directly unless they have been crushed by the system into compliance/obedience and just repeat the line that was fed to them.

When you give people a medication that seems like it is actually useful for a problem the patient actually agrees is a priority for them, they often have much less trouble adhering to treatment, shockingly.

 

[Merovinge]

When you give people a medication that seems like it is actually useful for a problem the patient actually agrees is a priority for them, they often have much less trouble adhering to treatment, shockingly.

Exactly why the studies show less discontinuation of Zyprexa in psychosis despite the much higher side effect profile. People like things that work.

 

[aim-agm]

A bit of a rant, but this unit is staffed by psychiatrists that spend <5 min a day per patient and they and their NPs have diagnosed almost every patient with mood lability as having bipolar 1, despite clearly meeting criteria for BPD or PTSD or SUD with no real mania or bipolar disorder to be suspected.

To add to your rant, mood lability (i.e. easily/rapidly altered mood) is the opposite of bipolar disorder. One formulation of the problem of bipolar moods is they are less labile than normal and are determined by an internal process that doesn't respond to external input. Doesn't an untreated bipolar episode often last (i.e. have the same mood) for months?

The only time "X happened and then their mood changed" is consistent with bipolar is if X is "they took a TCA"/"they had a circadian rhythm insult"/etc., not if X was "they heard bad news"/"they got told no"/"they talked with their SO"/etc..

 

[smalltownpsych]

To add to your rant, mood lability (i.e. easily/rapidly altered mood) is the opposite of bipolar disorder. One formulation of the problem of bipolar moods is they are less labile than normal and are determined by an internal process that doesn't respond to external input. Doesn't an untreated bipolar episode often last (i.e. have the same mood) for months?

The only time "X happened and then their mood changed" is consistent with bipolar is if X is "they took a TCA"/"they had a circadian rhythm insult"/etc., not if X was "they heard bad news"/"they got told no"/"they talked with their SO"/etc..

I like that formulation of Bipolar as a mood not being responsive to external stimuli. I can think of quite a few manic patients that were or are in ecstatic moods despite significant negatives going on in their lives. Interestingly, this can become a bit of a defense mechanism very analogous to what is referred to as a manic defense which I think of as a patient with moods that have a normal responsiveness to stimuli but they have learned to use cognitive and behavioral strategies to have an elevated mood and avoid negative affect. Definitely a challenging differential to make between these two groups which might be another reason that the better psychiatrist would have expertise in both the biological and the psychological.

 

[Merovinge]

To add to your rant, mood lability (i.e. easily/rapidly altered mood) is the opposite of bipolar disorder. One formulation of the problem of bipolar moods is they are less labile than normal and are determined by an internal process that doesn't respond to external input. Doesn't an untreated bipolar episode often last (i.e. have the same mood) for months?

The only time "X happened and then their mood changed" is consistent with bipolar is if X is "they took a TCA"/"they had a circadian rhythm insult"/etc., not if X was "they heard bad news"/"they got told no"/"they talked with their SO"/etc..

I would add for nuance that the younger the patient, the shorter the episode and the more likely they are to have rapid cycling. I certainly would not discount someone with a week of manic symptoms followed by a week or two of severe depressive symptoms for example. That said, the typical "my mood changes every 5 minutes for no reason so I must have bipolar" .

 

[Mad Jack]

It's terrible for bipolar disorder, I've never seen it work well. The only patients I've used it in are those that have primary impulsive aggression that fail to respond to or refused to utilize SSRI and do not have evidence of concomitant ADHD or mood disorder (or in whom their ADHD and mood disorder are controlled but their impulsive aggression persists). This is typically a third line after therapy and SSRI, however these are often patients with substantial legal issues that either struggle to attend, cannot afford, or refuse to participate in therapy. These patients have all had significant issues with aggression with numerous legal charges and convictions, and a few improved substantially on oxcarbazepine alone to the point that as far as I know they never ended up with charges in the years I was treating them.

Pharmacotherapy of Primary Impulsive Aggression in Violent Criminal Offenders

Primary impulsive aggression (PIA) can be implicated as a common factor that results in an arrest, disciplinary, and restraint measures during confinement, and criminal recidivism after release. Evidence suggests that anti-impulsive aggression agents ...

www.ncbi.nlm.nih.gov

 

[Mad Jack]

A bit of a rant, but this unit is staffed by psychiatrists that spend <5 min a day per patient and they and their NPs have diagnosed almost every patient with mood lability as having bipolar 1, despite clearly meeting criteria for BPD or PTSD or SUD with no real mania or bipolar disorder to be suspected. They also put people on commitment constantly and have a tendency to discharge all patients on outpatient commitment to our CMHC. Then they send nasty messages to us angry that they are readmitting a patient with chronic SI, and claim that the reason is because we didn't force an LAI or because "we" discontinued (often self-discontinued or just inappropriate) their 2 mg of Abilify or 0.5 mg of Risperdal.

This sort of care is exactly why we're losing ground to NPs. Greedy psychiatrists that want to do the minimum and make as much money as possible by using midlevels to the point that they may as well not be involved in the care at all. That's what happened with anesthesiologists, and I've seen it happen on more than one psychiatric service.

 

[shoomer]

View attachment 360861
This sort of care is exactly why we're losing ground to NPs. Greedy psychiatrists that want to do the minimum and make as much money as possible by using midlevels to the point that they may as well not be involved in the care at all. That's what happened with anesthesiologists, and I've seen it happen on more than one psychiatric service.

Can we blame this entirely on greedy psychiatrists when hospital admin is often just as inclined to fill as many holes with midlevels as possible?

 

[Mad Jack]

Can we blame this entirely on greedy psychiatrists when hospital admin is often just as inclined to fill as many holes with midlevels as possible?

If psychiatrists wouldn't accept the jobs it wouldn't happen. We have control over our job market and options most other physicians don't. That is why it is particularly infuriating when one of us sells out the profession like this. Will it possibly happen regardless? Perhaps. But will enabling it help the profession or patients? Certainly not. Collaborators are no better than the admins they serve, and most people that do this do it for one reason: money.