877-944-6131 Email Us

Clinician’s Corner: Bipolar Treatment

We dispense a fair amount do this well-known seizure medications, divalproex, carbamazepine and lamotrigine.  However, most of the prescriptions filled are prescribed by psychiatrists rather than neurologists.  These three drugs are most commonly used as “mood stabilizers” in the treatment of bipolar disorder.

Valproic acid and Valproate:

  • Divalproex extended release (Depakote-ER®) is a once daily formulation that became available in 2000. Today all forms of valproic acid/valproate are available generically.

Common use: is an anti-seizure drug and can also be considered as first line treatment for mania. Divalproex is also used for panic disorder and migraine prophylaxis. Divalproex is more effective than lithium in mixed episodes.

Adverse effects: hepatotoxicity (Black box warning) increase risk for children under

  • Teratogenicity: pregnancy category-D. Avoid if pregnant
    • third line drug for female patients of childbearing potential
  • Pancreatitis
  • Stomach upset featuring nausea/vomiting and diarrhea
  • Do frequent bloodwork and liver enzymes
  • Lots of drug interactions: consult your Thompson Pharmacist

Patient Education

  • GI upset: Take with food
  • Caution driving
  • Nausea, vomiting and diarrhea may signify pancreatitis.
  • If hair loss occurs, supplement with zinc and selenium
  • Weight gain: Up to 70% of patients taking valproic acid may gain weight. Almost one-half of patients may gain >10% of baseline weight

Carbamazepine (Tegretol®):  was first approved in 1968.

It is commonly available in tablets 100mg (chew) and 200mg

It is also available as extended release Tegretol XR tablets 100,200 and 400mg.

Mechanism: stabilizes cell membranes.  Reduces polysynaptic responses.

Common use:   indicated for treatment of epilepsy, trigeminal neuralgia

Unlabeled use:  Postherpetic neuralgia, PTSD, alcohol withdrawal,

Bipolar disorder: used for mania or mixed episodes

Adverse effects:  contraindicated if history of bone marrow depression

  • Stevens Johnson syndrome—severe dermal reactions.
    • Genetic testing: The HLA*15:02 allele has since been associated with carbamazepine-induced Stevens Johnson Syndrome (Toxic Epidermal Necrolysis) in Taiwanese, Chinese, Indians, Malay, and Chinese- Americans, but not in Caucasians or Japanese individuals
  • Aplastic anemia—black box warning- keep your bloodwork appointments!
  • Get your eyes checked to monitor for eyesight changes
  • Avoid if pregnant, or considering to become pregnant
  • Lots of drug interactions: be sure to consult your Thompson Pharmacist.

Lamotrigine  (Lamictal®) : was FDA approved in December 1994

Lamotrigine use:

  • Lamotrigine has better evidence of efficacy than lithium for monotherapy for bipolar
  • Best choice for prevention of recurrent depressive episodes.
  • The combination of lithium plus lamotrigine can be considered for patient’s refractory to monotherapy.
  • Lamotrigine should not be used for treating mania and has limited efficacy for preventing mania.

Dosage: watch for drug interactions! Consult your Thompson Pharmacist.

Adverse effects: skin rash (discontinue if it appears)-Black box warning. Titrate slowly especially if taking Valproic acid.

Drug interactions: many drug interactions between enzyme blockers and inducers.

  • Although Lamictal does not induce or inhibit other drugs, its metabolism is affected.
  • Folic acid supplementation may be necessary.

Your Thompson Pharmacist is an excellent source when it comes to monitoring for drug interactions with mood stabilizers.  Thompson pharmacists have the experience and the technology with our computer software to help your physician get a handle on the drug:drug interactions.  Go Ahead and ASK… at Thompson Pharmacy, It’s All for YOU!!