Acute psychotic symptoms induced by topiramate

Topiramate-Induced Suicidal Ideation and Olfactory Hallucinations: A Case Report

Antiepileptic drugs prescribed in the context of migraine have been reported to be potentially linked with an increased risk of suicidal ideation and behavior. Meta-analyses support the evidence that amongst antiepileptic drugs, Topiramate has the greatest potential for facilitating the occurrence of suicidal ideation and behavior. Studies indicate that this occurs via the increased incidence of mood disorders amongst the population with migraines using Topiramate as a treatment, with a slow and progressive onset of suicidal ideation (if any). We discuss the unique case of a 43-year-old man known to have chronic migraines, who presented with intense rapid-onset suicidal ideation and olfactory hallucinations, three weeks after the introduction of Topiramate for chronic migraines. After a negative extensive investigation panel to rule out common organic diseases, Topiramate was ceased. The suicidal ideation and olfactory hallucinations resolved in less than 24 h without further interventions. This case report highlights that rapid-onset suicidal ideation and olfactory hallucinations could be linked as an unusual side effect to the introduction of Topiramate. The removal of Topiramate from the patient’s pharmacological treatments prevented further psychological distress linked to ego-dystonic suicidal ideation and a resolution of olfactory hallucinations. He was discharged 48 h later.

Efficacy and safety of topiramate in binge eating disorder: a systematic review and meta-analysis

BACKGROUND

To assess the efficacy and safety of topiramate in treating binge eating disorder (BED), using a systematic review and meta-analysis of the available randomized clinical trials (RCTs).

METHODS

The RCTs assessing topiramate vs placebo with or without adjunctive psychotherapy in BED were reviewed using a systematic search in the PubMed, Web of Science, PsycINFO, Cochrane Database of Systematic Review, and ClinicalTrials.gov search Websites, from inception to November 2019. Main outcomes were the changes in binge frequency, quality of life, and weight, respectively. Effect estimates were pooled using random-effect models and presented as risk ratios (RRs) or mean differences (MDs) and their 95% confidence interval (95% CI). Data extraction was performed by two independent reviewers.

RESULTS

Three studies were eligible for inclusion, involving 528 BED patients. Topiramate was found to be significantly more efficacious than placebo in reducing: (a) the number of binge episodes per week (MD = -1.31; 95% CI = -2.58 to -0.03; I2 = 94%); (b) the number of binge days per week (MD = -0.98; 95% CI = -1.80 to -0.16; I2 = 94%); and (c) weight (MD = -4.91 kg; 95% CI = -6.42 to -3.41; I2 = 10%). However, participants in the topiramate groups withdrew significantly more frequently for safety reasons, relative to placebo participants (RR = 1.90; 95% CI = 1.13-3.18, I2 = 0%).

CONCLUSIONS

Preliminary findings support a possible efficacy of topiramate for the treatment of BED, even if safety concerns could limit the practical use of this treatment in BED subjects.

Use of Topiramate in the Spectrum of Addictive and Eating Disorders: A Systematic Review Comparing Treatment Schemes, Efficacy, and Safety Features

BACKGROUND AND OBJECTIVE

Topiramate has been approved by the US Food and Drug Administration for the treatment of epilepsy since the 1990s, and it has also been used off-label in the treatment of many types of addictive disorders. To date, no systematic review has embraced the entire field of addiction, both substance use and behavioral addictions, including eating disorders, to compare topiramate-based protocols and the related level of evidence in each addictive disorder. Our objective is to fill this gap.

METHODS

A systematic search was conducted using the MEDLINE, PsycINFO, and Cochrane databases without a date or language limit. All trials and meta-analyses assessing the efficacy of topiramate in alcohol use disorder; cocaine use disorder; methamphetamine, nicotine, cannabis, opiate, and benzodiazepine use disorders; binge eating disorder; bulimia; and pathological gambling were analyzed. The quality of the studies was rated using the Cochrane Risk-of-Bias tool for randomized trials (ROB-2), the Risk of Bias In Nonrandomized Studies (ROBINS-I), or the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, depending on the study design. Safety features were assessed based on a wider non-systematic review.

RESULTS

Sixty-two articles were reviewed. Treatment protocols were relatively homogenous across addictive disorders, with slow dose titration schemes and a maximum dose range of 200-400 mg per day. The most supportive evidence for topiramate efficacy was found in alcohol use disorder for drinking reduction parameters only. To a lesser extent, topiramate could be a promising therapeutic option for binge eating disorder and cocaine use disorder. Evidence was weak for other addictive disorders. No major tolerability issues were found, provided that basic safety rules were followed. Adverse drug reactions could lead to early treatment discontinuation.

DISCUSSION

Though off-label, addiction specialists should consider topiramate as a second-line option for drinking reduction in alcohol use disorder, as well as for binge eating disorder or cocaine use disorder.

Psychosis resulting from trimethoprim-sulfamethoxazole treatment for preseptal cellulitis

Trimethoprim-sulfamethoxazole (TMP-SMX) is a commonly used antimicrobial agent because of its low cost, diverse antimicrobial profile, and minimal severe adverse effects. A rare side effect is psychosis, a complication that has not been published in the ophthalmology literature. A 53-year-old female presented to the ophthalmology office with left upper eyelid erythema, focal tenderness, and discharge. She was diagnosed with preseptal cellulitis of the left upper lid and started on TMP-SMX. The next day, the patient's condition improved with reduced swelling and no discharge. However, 2 days later, she experienced visual hallucinations whereby worms were growing out of her left eye accompanied by theme-congruent tactile hallucinations. TMP-SMX was discontinued and substituted for clindamycin, and she reported resolution of her symptoms 8 h later. TMP-SMX has extensive cerebrospinal fluid penetration and causes a folic acid deficiency, which may explain the rare occurrence of neuropsychiatric side effects. This patient had a substance-induced psychosis, in which visual and tactile hallucinations began 3 days after taking TMP-SMX and resolved 8 h after discontinuation, a timeline consistent with the literature. Central nervous system toxicity is rare in nonelderly immunocompetent patients, with only three such cases reported in the literature. While visual and auditory hallucinations have been described previously, this is the first reported case of TMP-SMX-induced tactile hallucinations and unilateral visual hallucinations. Moreover, because TMP-SMX is a first-line agent commonly used to treat orbital and preseptal cellulitis, it is important for ophthalmologists to be aware of this atypical side effect, as it can be life threatening.

Psychiatric side-effects of medications: recent developments

Medications often induce neuropsychiatric side-effects. This article reviews psychiatric side-effects that are well known and describes those induced by recently developed medications. Therapeutic innovations have been prominent in the treatment of HIV infection, Parkinson's disease and epilepsy and therefore psychiatric side-effects caused by these agents are described in more detail.

Psychotropic treatments in Prader-Willi syndrome: a critical review of published literature

Prader-Willi syndrome (PWS) is a rare genetic syndrome. The phenotype includes moderate to intellectual disability, dysmorphia, obesity, and behavioral disturbances (e.g., hetero and self-injurious behaviors, hyperphagia, psychosis). Psychotropic medications are widely prescribed in PWS for symptomatic control. We conducted a systematic review of published literature to examine psychotropic medications used in PWS. MEDLINE was searched to identify articles published between January 1967 and December 2014 using key words related to pharmacological treatments and PWS. Articles with original data were included based on a standardized four-step selection process. The identification of studies led to 241 records. All selected articles were evaluated for case descriptions (PWS and behavioral signs) and treatment (type, titration, efficiency, and side effects). Overall, 102 patients were included in these studies. Treatment involved risperidone (three reports, n = 11 patients), fluoxetine (five/n = 6), naltrexone (two/n = 2), topiramate (two/n = 16), fluvoxamine (one/n = 1), mazindol (one/n = 2), N-acetyl cysteine (one/n = 35), rimonabant (one/n = 15), and fenfluramine (one/n = 15).

CONCLUSION

We identified promising treatment effects with topiramate for self-injury and impulsive/aggressive behaviors, risperidone for psychotic symptoms associated with uniparental disomy (UPD), and N-acetyl cysteine for skin picking. The pharmacological approach of behavioral impairment in PWS has been poorly investigated to date. Further randomized controlled studies are warranted.

WHAT IS KNOWN

Behavioral disturbances in Prader-Willi syndrome including aggressive reactions, skin picking, and hyperphagia might be very difficult to manage. Antipsychotic drugs are widely prescribed, but weight gain and increased appetite are their major side effects.

WHAT IS NEW

Topiramate might be efficient for self-injury and impulsive/aggressive behaviors, N-acetyl cysteine is apromising treatment for skin picking and Antidepressants are indicated for OCD symptoms. Risperidone is indicated in case of psychotic symptoms mainly associated with uniparental disomy.

Report of the WPA section of pharmacopsychiatry on the relationship of antiepileptic drugs with suicidality in epilepsy

INTRODUCTION

This report from the World Psychiatric Association Section on Pharmacopsychiatry examines the possible relationship of antiepileptic drugs with suicide-related clinical features and behaviors in patients with epilepsy.

MATERIALS AND METHODS

A systematic review of the MEDLINE search returned 1039 papers, of which only 8 were considered relevant. A critical analysis of the Food and Drug Administration (FDA) report on the increase risk for patients under antiepileptics to manifest suicidality is also included in this report.

RESULTS

The analysis of these studies revealed that the data are not supportive of the presence of a "class effect" on suicide-related behavior; on the contrary, there are some data suggesting such an effect concerning treatment with topiramate, lamotrigine, and levetiracetam for which further research is needed.

DISCUSSION

For the majority of people with epilepsy, anticonvulsant treatment is necessary and its failure for any reason is expected to have deleterious consequences. Therefore, clinicians should inform patients and their families of this increased risk of suicidal ideation and behavior, but should not overemphasize the issue. Specific subgroups of patients with epilepsy might be at a higher risk, and deserve closer monitoring and follow-up. Future research with antiepileptics should specifically focus on depression and suicidal thoughts.

Psychotic illness in patients with epilepsy

Apart from the rather rare ictal psychotic events, such as non-convulsive status epilepticus, modern epileptic psychoses have been categorized into three main types; chronic and acute interictal psychoses (IIPs) and postictal psychosis (PIP). Together, they comprise 95% of psychoses in patients with epilepsy (PWE). Four major questions, that is, "Is psychosis in PWE a direct consequence of epilepsy or schizophrenia induced by epilepsy?", "Is psychosis in PWE homogeneous or heterogeneous?", "Does psychosis in PWE have symptomatological differences from schizophrenia and related disorders?", "Is psychosis in PWE uniquely associated with temporal lobe epilepsy (TLE)?" are tried to be answered in this review with relevant case presentations. In the final section, we propose a tentative classification of psychotic illness in PWE, with special attention to those who have undergone epilepsy surgery. Psychotic disorders in PWE are often overlooked, mistreated, and consequently lingering on needlessly. While early diagnosis is unanimously supported as a first step to avoid this delay, necessity of switching from antiepileptic drugs with supposedly adverse psychotopic effects. to others is more controversial. To elucidate the riddle of alternative psychosis, we need badly further reliable data.

Antiepileptic drugs and suicidality

The current study is a systematic review of the literature concerning the possible relationship of antiepileptics and suicide-related clinical features and behaviours. A MEDLINE search returned 863 papers but only five were chosen as relevant. A critical analysis of the Food and Drug Administration report is also included. Overall, the current review suggests there are no convincing data concerning a 'class effect' of antiepileptics in inducing any type of suicide-related behaviours. Further research is needed concerning topiramate, lamotrigine and maybe leviracetam. Clinicians are expected to inform patients and their families on the possible increased risk but it is important not to overemphasise the issue, since stopping or refusing to start antiepileptics may result in serious harm, including death of the patient. Future randomised controlled trials should specifically focus on issues concerning depression and suicidal thoughts in patients with epilepsy.

Beneficial and adverse psychotropic effects of antiepileptic drugs in patients with epilepsy: a summary of prevalence, underlying mechanisms and data limitations

Antiepileptic drugs (AEDs) can have both beneficial and adverse psychotropic effects. They act on neurotransmitter systems, neuronal ion permeability and other targets, although the exact mechanisms are not generally fully elucidated. A systematic review of the literature reveals evidence for both positive and negative effects on depression, anxiety, aggression, psychosis and sleep in patients with epilepsy. Topiramate, vigabatrin, levetiracetam, tiagabine and zonisamide have been associated primarily with adverse psychotropic effects, whilst gabapentin, pregabalin, lacosamide and lamotrigine, in particular, have demonstrated a more beneficial psychotropic profile, especially with regard to affective symptoms. This review, however, identifies specific methodological issues with studies that have reported on the psychotropic effects of AEDs, suggesting that some of the findings might be inconclusive or unreliable because of confounding factors, particularly the presence of psychiatric history. More rigorous double-blind, randomized, placebo-controlled trials on larger numbers of patients with epilepsy, with clear inclusion/exclusion criteria, that are specifically designed to investigate psychotropic changes are more likely to produce results that inform clinical practice and direct future research.

The Impact of Topiramate (Topamax®) Therapy on the Development of Aggressive and/or Agitated Behavior

The use of topiramate therapy to control the neuropsychiatric and behavioral disturbances in individuals with mental and/or developmental disabilities with co-occurring psychiatric disturbances has become a standard of practice in many long-term care assisted living facilities. With increased utilization of this anticonvulsant, there has been a rise in the number documented cases of agitation and/or aggressive behavior associated with topiramate therapy. It is the purpose of this article to explore the current literature documenting the connection between topiramate utilization and the development of aggressive and/or agitated behavior.

The safety and tolerability of newer antiepileptic drugs in children and adolescents

The newer antiepileptic drugs (AEDs) provide more therapeutic options and overall improved safety and tolerability for patients. To provide the best care, physicians must be familiar with the latest tolerability and safety data. This is particularly true in children, given there are relatively fewer studies examining the effects of AEDs in children compared with adults. Since we now have significant paediatric literature on each of these agents, we provide a comprehensive and current literature review of the newer AEDs, focusing on safety and tolerability data in children and adolescents. Because the safety profiles in children differ from those in adults, familiarity with this literature is important for child neurologists and other paediatric caregivers. We have organized the data by organ system for each AED for easier reference.

Acute topiramate overdose--clinical manifestations

INTRODUCTION

The clinical manifestations of acute topiramate toxicity are described.

METHODS

Seven cases of acute and acute-on-chronic topiramate toxicity observed in two clinical units of Polish Poison Control Centers in 2004-2005 were analyzed.

RESULTS

The patients were 4 women and 2 men aged between 16 and 38 (mean 21.0 +/- 8.4) years. The doses of topiramate ranged from 10.7 to 218 mg/kg. The most frequent symptom was somnolence (66.7%) and, vertigo, agitation, and mydriasis were less common (33.4%). One patient who was not previously treated with topiramate experienced three secondarily generalized tonic-clonic seizures. Metabolic acidosis, lasting for 3-7 days, was observed in four cases, and did not influence the outcome.

CONCLUSIONS

The clinical manifestations of acute poisonings with topiramate ranged from asymptomatic to severe, but no distant sequelae or fatalities were observed. The course of acute poisoning seems to be more severe in patients who were not previously treated with topiramate.

Pediatric Case Report of Topiramate Toxicity

BACKGROUND

Topiramate is an FDA-approved second generation antiepileptic drug with actions on voltage-dependent sodium and calcium channels and GABA and excitatory amino acid receptors. There has only been one prior pediatric case report of topiramate toxicity. We report a 33-month-old girl with persisting neurologic symptoms after acute ingestion of topiramate.

CASE REPORT

A 33-month-old girl was found at her sitter'shouse with a bottle of topiramate (100-mg tablets). She presented to the emergency department 3 days post-ingestion. The child appeared confused and was only able to crawl. At one point, she looked directly at mother and asked, "Where is my mommy?" She had visual hallucinations and screamed while pointing to objects on the wall. Neurologic exam was notable for the slurred speech and severe ataxia. All laboratory testing, urine chemical dependency screen, CSF, chest X-ray, head CT, and EEG showed no abnormalities. Topiramate level on the third day post-ingestion was 9.4 mcg/mL, and 4.2 mcg/mL on the fourth day. Patient became oriented to family and regained normal gait on the fourth day. Her slurred speech persisted until the sixth day after ingestion.

CONCLUSION

Topiramate is an anti-epileptic drug with multifactorial mechanisms of action not entirely understood. We report here a 33-month-old girl with prolonged neurologic symptoms including hallucination, slurred speech, and severe ataxia after acute topiramate ingestion. This is the first pediatric case report of hallucination and prolonged neurologic symptoms with acute topiramate ingestion.

Topiramate-induced psychosis in two members of the one family: a case report

Introduction

The use of topiramate has increased in recent years. It is now used by various specialties to treat a wide range of medical conditions. A small number of case reports describe psychosis as an adverse event of topiramate but most are in patients being treated for epilepsy and none describe a family history of this side effect.

Case presentation

We present a case report of topiramate-induced psychosis in a patient with familial essential tremor, whose sister also developed this same adverse effect.

Conclusion

Physicians need to be aware of psychosis as a rare but debilitating side effect of this drug. Several predictors have been identified and a careful history, including family history, needs to be obtained prior to initiation of therapy to stratify the risk.

Topiramate in the treatment of partial and generalized epilepsy

Topiramate (TPM) is a widely-used drug for the treatment of epilepsy. It is useful for several types of partial-onset and generalized-onset seizures, and is therefore considered a broad-spectrum agent. It is also effective as a prophylactic against migraine headaches. TPM was first approved for prescription use in 1996. In various countries it is now approved for adjunctive and monotherapy of partial-onset seizures and for therapy of generalized tonic-clonic seizures of nonfocal origin, for children and adults. For initial monotherapy of new-onset seizures, a target dose of 100 mg/day for adults is recommended. Adjunctive use with enzyme-inducing drugs and use for refractory seizures requires higher dosages, though the optimum dose for most patients does not exceed 400 mg/day. Excretion is primarily renal and TPM is not a significant hepatic enzyme inducer. Although it is usually safe and well-tolerated, adverse effects limit use in about 25% of patients. The most salient of these is cognitive dysfunction, especially problems with expressive speech and verbal memory. Weight loss, renal stones, paresthesias and other central nervous system side effects may occur. Tolerability is improved by low initial doses and slow titration to effect.

Safety and efficacy of anticonvulsants in elderly patients with psychiatric disorders: oxcarbazepine, topiramate and gabapentin

Few controlled studies are available to guide the clinician in treating potentially assaultive elderly individuals with psychiatric disorders. Safety concerns limit the use of benzodiazepines and antipsychotic medications in the elderly individual, making anticonvulsants an attractive alternative. This paper reviews three specific anticonvulsants for this purpose: gabapentin, oxcarbazepine and topiramate, describing safety and efficacy in elderly patients with severe agitation from psychosis or dementia. Gabapentin, renally excreted, with a half-life of 6.5-10.5 h, may cause ataxia. Oxcarbazapine, hepatically reduced, may cause hyponatremia, and topiramate may cause significant cognitive impairment. Nonetheless, these are important medications to consider in the treatment of agitation.

Effects of topiramate on the prepulse inhibition of the acoustic startle in rats

The anticonvulsant topiramate (TPM) has been recently proposed as a novel adjuvant therapy for bipolar disorder and schizophrenia, yet its efficacy remains controversial. As both disorders are characterized by gating deficits, we tested the effects of TPM on the behavioral paradigm of prepulse inhibition (PPI) of the acoustic startle response, a validated animal model of sensorimotor gating. TPM (10, 18, 32, 58, 100 mg/kg, intraperitoneal, i.p.) enhanced PPI in rats in a dose-dependent fashion, prevented the PPI reduction mediated by the dopaminergic agonist apomorphine (0.25 mg/kg, subcutaneous, s.c.) and potentiated the effects of the antipsychotic drugs haloperidol (0.05, 0.1 mg/kg, i.p.) and clozapine (2.5, 5 mg/kg, i.p.). Conversely, TPM elicited no significant effect on the PPI disruption mediated by the NMDA receptor antagonist dizocilpine (0.05, 0.1 mg/kg, s.c.) and surprisingly antagonized the attenuation of dizocilpine-induced PPI disruption mediated by clozapine (5 mg/kg, i.p.). Our results suggest that TPM may exert diverse actions on the neural substrates of sensorimotor gating. While the pharmacological mechanisms of such effects are still elusive, our findings might contribute to shed light on some controversies on the therapeutic action of TPM, and point to this drug as a putative novel adjuvant therapy for some clusters of gating disturbances.

Topiramate-induced psychotic exacerbation: case report and review of literature

Background. Topiramate (TPM) is a new antiepileptic drug that is used mainly in the treatment of refractory partial epileptic seizures. There are some studies reporting TPM's effectiveness in the treatment and maintenance of some psychiatric illnesses such as acute mania, some other affective disorders, post-traumatic stress disorder and binge-eating disorder. On the other hand, it has been shown that TPM may cause mild to moderate cognitive impairment and is thought to be responsible for a series of neuro-psychiatric signs and symptoms. Some of the available articles that have mentioned the relationship of psychotic symptoms and topiramate usage are discussed. Objective. The present paper aims to discuss a case of psychotic exacerbation purported to occur after TPM administration and to review specifically the literature on TPM's potential for inducing psychotic symptoms. The patient presented here is thought to be an undiagnosed schizophrenia patient until his admission to our clinic (Department of Psychiatry, Gazi University Medical School) with TPM-exacerbated psychotic symptoms. Conclusions. The current findings are still subject to controversy because of the presence of both individual case reports and case series on the association between appearance of psychotic symptoms and TPM usage.

Topiramate-induced psychosis in patients with essential tremor: report of 2 cases

Two patients with essential tremor who had no psychiatric history developed symptoms of psychosis (visual hallucinations, paranoia, and vivid dreams) 3 days after starting topiramate (25 mg BID) for tremor control. All adverse symptoms resolved several days after topiramate was discontinued.

Adverse psychiatric effects of antiepileptic drugs

Psychiatric symptoms provide potential insights into the pathophysiology of psychiatric conditions in epilepsy patients. Evaluating the psychiatric effects of newer AEDs is complicated by several important factors including (a) the relatively high rate of mood and anxiety disorders in persons with pharmacoresistant epilepsy, and (b) the variety of methods used to assess the occurrence and severity of psychiatric symptoms. Clinical trials to assess adverse psychiatric effects of AEDs need a control group to adjust for the spontaneous occurrence of symptoms, as well as to demonstrate potential positive psychotropic effects. The follow-up should be long enough to differentiate between drug-related effects and the natural course of the comorbid disorder. Psychiatric problems should be defined using appropriate instruments as well as self-report.

Topiramate augments the antipsychotic-like effect and cortical dopamine output of raclopride

Recent clinical studies have shown that the anticonvulsant drug topiramate may improve negative symptoms in schizophrenia when added to a stable regimen of neuroleptic medication. It has also been shown that addition of topiramate to neuroleptics might be beneficial in treatment-resistant schizophrenia. Clinically effective doses of antipsychotic drugs (APDs) have been found to suppress conditioned avoidance response behavior (CAR), a preclinical test of antipsychotic activity with high predictive validity, in rats. Therefore, we investigated the putative antipsychotic-like activity of topiramate when added to the selective dopamine (DA) D2 receptor antagonist raclopride, using the CAR model in the rat. Extrapyramidal side effect liability of the drug combination was evaluated in parallel by means of the catalepsy test. We also examined the effect of this drug treatment on DA release in the medial prefrontal cortex (mPFC) and the nucleus accumbens (NAC), using in vivo microdialysis in freely moving animals. Topiramate (40 mg/kg), while ineffective when given alone, significantly augmented the antipsychotic-like effect of raclopride (0.075 mg/kg) on CAR without any concomitant catalepsy. Addition of topiramate to rats treated with raclopride generated a large increase in DA output in the mPFC, whereas no additional effect on the raclopride-induced DA release in the NAC was obtained. These data support the adjunctive use of topiramate in schizophrenia to ameliorate negative symptoms and suggest that this treatment may increase the efficacy, but not the extrapyramidal side effect liability, of the APDs used.

Topiramate as an Adjuvant Treatment With Atypical Antipsychotics in Schizophrenic Patients Experiencing Weight Gain

Schizophrenic patients commonly suffer weight gain, which is often associated with widely prescribed antipsychotic medicines. It is distressing to most patients who experience it and may affect their response to treatment of schizophrenia. Weight gain is also associated with treatment noncompliance and several medical conditions. This study explored the efficacy and tolerability of topiramate as an adjuvant treatment of patients with schizophrenia who were carrying excess weight. In this 12-week, randomized, placebo-controlled prospective study, 66 hospitalized patients with schizophrenia who were carrying excess weight were given topiramate at doses of 100 mg/day or 200 mg/day, or a placebo. The primary measures made were body weight, body mass index, waist measurement, hip measurement, and waist-to-hip ratio. Safety measures included physical examinations and the monitoring of adverse effects, clinical laboratory data, and vital signs. The Clinical Global Impression-Severity of Illness scale (CGI-S) and the Brief Psychiatric Rating Scale (BPRS) were used to quantify changes in schizophrenic symptoms and signs. In the 200-mg/day topiramate group, body weight, body mass index, waist measurement, and hip measurement decreased significantly compared with the 100-mg/day topiramate and placebo groups over 12 weeks. However, the waist-to-hip ratio did not change in any group. Scores on the CGI-S and BPRS decreased significantly over the 12-week period in both topiramate groups, but the decrease was not clinically meaningful. These results suggest that a higher dose of topiramate is efficacious as an adjuvant treatment of patients with schizophrenia experiencing excess weight gain. Further clinical research is required to establish guidelines for the use of topiramate as an antiobesity agent in schizophrenic patients.

Behavioural effects of the newer antiepileptic drugs: an update

The negative and positive effects of the nine newer antiepileptic drugs that have received a product licence in the UK or in the US are reviewed. The importance of avoiding misinterpretation of the data because of confounding factors such as alternative psychosis, the release phenomenon or drug interactions is emphasised. Vigabatrin has been associated with both psychosis and depression. Due to the concentric visual field defects that may occur with vigabatrin, its use is now limited, although it remains the drug of choice for infantile spasms. Lamotrigine seems to be largely associated with improvement rather than deterioration of mood and behaviour. It may have a role in treating affective disorder. Gabapentin probably has relatively little effect on behaviour but may exacerbate behavioural problems in some children with pre-existing difficulties. Topiramate may precipitate both psychosis and depression, but these are less likely to occur if the currently recommended lower starting doses, escalation rates and target doses are used. The data for tiagabine are limited, but there is no clear evidence for psychosis or depression being caused by this drug. Oxcarbazepine may be of value in treating mood disorder, but the information is very limited. There are few reports of behavioural disturbances with levetiracetam, but the data suggest that there is no significant increase in psychosis or depression. There are some reports of psychosis and other behavioural disturbances with felbamate, but the use of this drug is limited by the serious adverse effects of hepatotoxicity and aplastic anaemia. There is some evidence for psychosis with zonisamide, but there is also a suggestion that this drug may be of benefit in treating psychiatric disorders. Careful individual assessment of each patient should enable the clinician to determine whether the medication or some other factor is responsible for any behavioural disturbance.

Amantadine for weight gain associated with olanzapine treatment

Patients with schizophrenia (Sch), schizoaffective, schizophreniform, or bipolar (BP) I disorders [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)]; not manic or acutely psychotic [Brief Psychiatric Rating Scale (BPRS) total score < or =45]; treated with olanzapine for 1-24 months; and who had gained > or =5% of their initial body weight were examined to determine whether amantadine could attenuate weight gain or promote weight loss. Olanzapine (Olz; 5-20 mg/day) was co-administered with double-blind treatment of 100-300 mg/day amantadine (Olz+Amt, n=60) or placebo (Olz+Plc, n=65). Visit-wise analysis of weight showed that weight change from baseline [last-observation-carried-forward (LOCF)] in the Olz+Amt group was significantly different from the Olz+Plc group at weeks 8 (P=0.042), 12 (P=0.029), and 16 (primary endpoint, mean+/-S.D.: -0.19+/-4.58 versus 1.28+/-4.26 kg, P=0.045). Mean BPRS total score, positive subscale, and anxiety-depression scores improved comparably in both groups, and Montgomery-Asberg Depression Rating Scale (MADRS) total score improved in the Olz+Amt group. Overall, amantadine was safe, was well tolerated, and attenuated weight gain or promoted weight loss in some patients who had gained weight during olanzapine therapy.

Acute topiramate toxicity

Topiramate (Topamax) is an anti-epileptic medication for which acute toxicity is infrequently reported. A 5-yr-old girl, not previously taking topiramate, developed neurological symptoms after acute ingestion of this medication. She was intermittently agitated, complained of "not being able to feel anything," demonstrated arching movements of the back, and perseverated upon questioning. Computerized tomography of the head and electroencephalography were both normal, and urine toxicology testing for drugs of abuse was negative. A serum topiramate level was 10.5 mcg/mL, confirming the ingestion. The patient was observed for 24 h, over which time her symptoms completely resolved.

A past psychiatric history may be a risk factor for topiramate-related psychiatric and cognitive adverse events

OBJECTIVES

Topiramate (TPM) is a new antiepileptic drug (AED) that has been found to be associated with a high prevalence of cognitive adverse events (CAEs). The prevalence of psychiatric adverse events (PAEs) has yet to be established. The purpose of this study was to determine the prevalence of PAEs related to TPM when used in polytherapy regimens in a large cohort of adult patients with epilepsy, to identify any association between the occurrences of CAEs and PAEs and to identify predictors of PAEs and CAEs.

METHODS

Investigators from 16 epilepsy centers (PADS group) prospectively obtained postmarketing safety and efficacy data on 596 patients aged 16 years and older. All data were recorded on standardized data retrieval forms, completed at the initial visit, while follow-up data were obtained every 6 months or at the time of discontinuation.

RESULTS

PAEs were identified in 75 (12.6%) patients: 30 (5%) experienced symptoms of depression and 34 (5.7%) of aggressive behavior and irritability, while 9 patients experienced symptoms of psychosis (1.5%). CAEs were reported by 247 (41.5%) patients. There was a significant association between the occurrences of CAEs and PAEs. A past psychiatric history was a predictor of CAEs, while older age and past psychiatric history were predictors of PAEs.

CONCLUSIONS

The use of TPM in polytherapy regimens can cause PAEs and CAEs and their occurrence is significantly correlated. Patients with a past psychiatric history may be at a higher risk for experiencing PAEs and CAEs.

Effects of topiramate in patients with cerebellar tremor

PURPOSE

To evaluate the safety and potential beneficial effect of topiramate (TPM) as monotherapy or adjunctive therapy to carbamazepine (CBZ) in patients with cerebellar tremor.

METHODS

Nine patients with cerebellar tremor participated a 4-week, open-label, prospective-controlled trial. TPM was given as monotherapy (n=7 cases), or in combination with CBZ (n=2 cases), at dosages ranging from 25 mg twice daily to 100 mg twice daily. The severity of tremor was assessed clinically on a 0-4 scale, by tremograms, by the Patients Global Impressions Scale, and by a "free writing" task at baseline and after 4 weeks.

RESULTS

TPM was discontinued in four patients due to adverse effects (sedation=2; cognitive impairment=2; increased aggressiveness=2; asthenia=1). During TPM, all patients improved. The mean tremor amplitude, compared with the baseline period, was reduced from 20% to 75%. After TPM, mean clinical scores of postural tremor and kinetic tremor decreased from 2.1+/-0.8 to 0.9+/-0.9 and from 2.1+/-1 to 1.4+/-1 (P<.05), respectively. All patients with head tremor improved. Writing, eating, and drawing were improved with TPM. Four patients chose to keep taking the drug.

CONCLUSIONS

Our study indicates that TPM may be useful for the management of cerebellar tremors. A prospective placebo-controlled trial of TPM in this kind of tremor is warranted. TPM dosages should be titrated slowly to avoid the potential side effects of the drug. The range and the frequency of adverse events might limit the clinical usefulness of TPM.

The effects of adjunctive topiramate on cognitive function in patients with epilepsy

PURPOSE

We investigated possible cognitive effects of topiramate (TPM) in polypharmacy on patients with intractable epilepsy.

METHODS

Study 1 evaluated 22 consecutively admitted patients whose antiepileptic drugs (AEDs) on admission to the Montreal Neurological Hospital included TPM. Performance on neuropsychological tests administered on and subsequently off TPM was analyzed. Four patients also were tested before taking TPM, allowing comparisons off, then on, and then off the drug again. Measures included intellectual function, verbal and nonverbal memory, language, word and design fluency, somatosensory sensitivity, and motor skills. In Study 2, 16 patients at the Minnesota Epilepsy Group were tested first off, then on TPM with nine cognitive tasks that measured concentration, verbal fluency, language, and psychomotor speed.

RESULTS

In Study 1, significant (p < or = 0.01) improvements were observed off TPM on 13 measures including verbal and nonverbal fluency and certain verbal and perceptual tasks. Notably, verbal learning and memory were unaffected; a limited effect was observed on nonverbal memory. Patients tested 3 times scored better in both tests off TPM compared with on this drug. In Study 2, declines on TPM were observed on all measures, significantly (p < or = 0.05) for tests of fluency, sustained concentration, and visual motor processing speed.

CONCLUSIONS

TPM was associated with declines in fluency, attention/concentration, processing speed, language skills, and perception; working memory but not retention was affected. As the two studies used an opposite order of testing on versus off TPM, our results clearly show a performance decrement while patients are taking TPM, without respect to which condition is tested first.

Characteristics of patients initiated on the new antiepileptic drugs: a PADS study

Whereas randomized controlled trials remain a standard for evaluating and comparing efficacy and safety of the new antiepileptic drugs (AEDs), postmarketing drug research offers a useful means of comparing efficacy and safety of new AEDs. However, differences in baseline characteristics of patients in different drug groups create the potential for bias in drug comparison studies. In this study, baseline demographic characteristics of 1,386 patients initiating lamotrigine (LTG), tiagabine (TGB), or topiramate (TPM) were compared to identify patient characteristics that may influence AED use in epilepsy patients. Data were collected at 14 epilepsy centers and included medications, seizure types and syndromes, and prior adverse events. There were 402 patients in the LTG group, 725 TPM, and 259 TGB. The groups differed both in their number of concurrent AEDs (p<0.001) and in their number of prior AEDs (p<0.01). There was no difference in proportion with partial versus generalized epilepsy syndromes. The groups differed in the proportions of patients with complex partial seizures (p=0.049), primary generalized tonic-clonic seizures (p=0.01), and myoclonic seizures (p=0.03). Baseline behavioral adverse event rate was lowest in patients initiating TPM (p<0.01); LTG patients had the lowest rate of prior AED-related rash (p=0.02). There was no relationship between AED assignment and patient age, age of epilepsy onset, epilepsy duration, institutionalization status, gender, or psychiatric history. Numerous epidemiological differences were identified among patients placed on the new AEDs, including current and prior AED profiles, seizure types, and prior adverse event history. Accounting for these differences is of crucial importance because they may bias conclusions of nonrandomized post-marketing trials comparing the drugs.

The use of newer anticonvulsants in neuropsychiatric disorders

Anticonvulsants are becoming increasingly popular for the management of psychiatric and neuropsychiatric syndromes. This may be related to antikindling properties of these agents in addition to modulation of gamma-aminobutyric acid, serotonin, and other neurotransmitters. Treatment selection is complicated by the inconsistent availability of randomized controlled data among the growing range of choices. Moreover, generalization of psychiatric to neuropsychiatric applications of anticonvulsant treatments is not universally applicable. This paper reviews the use of newer anticonvulsants in the management of neuropsychiatric disorders, particularly aggression and agitation. The largest body of treatment data is available for valproic acid, which appears to be efficacious and well-tolerated in a wide range of neuropsychiatric disorders. Less consistent data are available for other medications. Further prospective studies are warranted to examine the use of these medications in neuropsychiatric populations.

Treatment of psychosis, aggression, and irritability in patients with epilepsy

Psychosis, irritability, and aggression in persons with epilepsy are frequently the focus of clinical intervention. These neuropsychiatric symptoms may occur due to the bidirectional relationship between psychosis and epilepsy, in which the potential etiopathogenic mechanisms are believed to be closely related to the seizure disorder itself and also may result from underlying brain injury or behavioral intolerance of antiepileptic or other medication. Epileptic patients are at heightened risk for mood disorders, psychotic disorders, and delerium. The possible lowering of seizure threshold by psychotropic drugs should not contraindicate appropriate use of psychotropic agents, and risk may be minimized by the selection of agents not associated with a relatively high likelihood of altering seizure threshold. Behavioral toxicity of antiepileptic drugs (AEDs) is addressed by selection of alternative agents, and some AEDs appear to possess positive psychotropic effects. The use of antipsychotic, antidepressant, and other psychotropic agents in psychosis, irritability, and aggression in epilepsy is discussed, including dosage ranges, major side effects, and potential interactions between antieplieptic and psychotropic medication.

Antiepileptic drugs in posttraumatic stress disorder

Antiepileptic drugs might be effective in the treatment of patients with Posttraumatic Stress Disorder, a condition with unmet pharmacologic needs. We review the literature on the efficacy and tolerability of antiepileptic drugs in Posttraumatic Stress Disorder, both case reports and open studies, as well as controlled studies if available. The results of the studies will be presented together with their methodological limitations (e.g., open trials, use of additional medications, and lack of use of standardized scales for Posttraumatic Stress Disorder). The effects of antiepileptic drugs on kindling, a suggested pathogenesis for Posttraumatic Stress Disorder are overviewed, and suggestions for further research are raised.

Acute psychotic disorders induced by topiramate: report of two cases

We report on two epileptic patients who developed acute psychosis after the use of topiramate (TPM). One patient exhibited severe psychomotor agitation, heteroaggressiveness, auditory and visual hallucinations as well as severe paranoid and mystic delusions. The other patient had psychomotor agitation, depersonalization, derealization, severe anxiety and deluded that he was losing his memory. Both patients had to be taken to the casualty room. After interruption of TPM in one patient and reduction of dose in the other, a full remission of the psychotic symptoms was obtained without the need of antipsychotic drugs. Clinicians should be aware of the possibility of development of acute psychotic symptoms in patients undergoing TPM treatment.

Emerging options in the treatment of bipolar disorders

Bipolar disorder is a common and severe condition, and has a clinical outcome that is frequently sub-optimal. Only a small number of therapeutic options are currently available for the disorder. A growing range of novel therapeutic options for the treatment of bipolar disorder are under investigation. These include the anticonvulsants, atypical antipsychotics and options such as the omega-3 fatty acids and transcranial magnetic stimulation. Of the anticonvulsants, lamotrigine is currently the agent for which the greatest amount of controlled clinical data is accumulating, particularly in the depressed and rapid cycling phases of the illness. Olanzapine is currently the atypical antipsychotic with the largest body of evidence in mania, although data is emerging on other atypical antipsychotics including risperidone and ziprasidone. Data regarding the atypical agents in other phases of the illness are awaited. The options available for this difficult to treat condition is increasing with the new range of agents.

Behavioural effects of the new anticonvulsants

Of the 9 new anticonvulsants that have been marketed recently in the UK or US, a number appear to have either adverse or beneficial effects on behaviour. There is now a considerable database of information, in terms of the number of patients treated and/or the number of published reports, on vigabatrin, lamotrigine, gabapentin and topiramate. Oxcarbazepine has been available in some centres for several years and there is extensive experience with the drug in Scandinavia. It appears that the profile of adverse and beneficial effects is similar to that of carbamazepine. Behavioural effects have probably been greatest with vigabatrin, with psychosis, depression and other behavioural problems recorded, but the use of this drug has been limited because of the concern about visual field constriction. The cognitive and behavioural effects of topiramate have caused concern, but these may be much less of a problem if lower starting dosages and escalation rates are used. Psychosis and depression have been associated with topiramate, as they have with another carbonic anhydrase inhibiting drug, zonisamide. Although zonisamide has been used for many years in Japan and Korea, experience elsewhere with this drug is currently very limited. Gabapentin seems to be less associated with adverse behavioural effects than some of the other new anticonvulsant drugs. The reports of behavioural disturbance with gabapentin in children may be related to dose escalation. Behavioural disturbance as a direct result of lamotrigine seems to be uncommon, although indirect effects on behaviour, through the so-called 'release phenomenon' from improved seizure control and consequent ability to misbehave, can occur. Positive behavioural effects have been described with several of the new anticonvulsants, particularly gabapentin, lamotrigine and oxcarbazepine; all of these drugs may have mood-levelling effects that could be of value in treating affective disorders. The information on tiagabine and levetiracetam is too limited to allow any firm conclusions to be drawn with regard to positive or negative behavioural effects. When interpreting reports of behavioural changes with anticonvulsants, it is important to avoid attributing the effect to the drug when one or more of the other multiple causes of behavioural disturbance in people with epilepsy may be responsible or when an indirect effect such as 'forced normalisation' may be the cause. Many of the published studies are retrospective and unblinded rather than double-blind, placebo-controlled, prospective trials, implying that much of the data must be interpreted with caution at this stage.

Topiramate in refractory partial-onset seizures in children, adolescents and young adults: a multicentric open trial

PURPOSE

This study was to evaluate the efficacy and safety of topiramate (TPM) in refractory partial epilepsy in children, adolescents and young adults.

METHODS

We performed a prospective open label add-on study in 55 patients (age 2-30 years, mean 15 years) with refractory partial seizures. Topiramate was added to one or two other baseline drugs and the efficacy was rated according to seizure type and frequency.

RESULTS

TPM was initiated at a daily dose of 0.5-1 mg/kg, followed by a 2-week titration at increments of 1-3 mg/kg/24h, up to a maximum daily dose of 12 mg/kg. After 9 months of treatment, 11 patients (20%) had 100% fewer seizures and 25 patients (45%) had a more than 50% seizure reduction. TPM appeared to be effective both in cryptogenic (76.2%) and symptomatic (58.8%) partial epilepsies. Mild to moderate adverse events were present in 25 patients (45.4%), mostly represented by drowsiness, nervousness and hyporexia with or without weight loss.

CONCLUSION

TPM was an overall effective and safe add-on drug both in cryptogenic and symptomatic childhood refractory partial seizures, the adverse reactions being generally mild or moderate.

Neuropsychological effects of epilepsy and antiepileptic drugs

Epilepsy and its treatment can have deleterious cognitive and behavioural consequences. Affected individuals have a higher prevalence of neuropsychological dysfunction than the general population because of complex interactions among several multifaceted and overlapping influences--for example, underlying neuropathologies, ictal and interictal neuronal discharges, a plethora of antiepileptic drugs, and numerous psychosocial issues. Research into the clinical relevance of these factors has been dogged by a range of methodological pitfalls including lack of standardisation of neuropsychological tests, small numbers and multiple testing, and statistical failure to appreciate differential effects of interactive elements in individual patients. Although antiepileptic drugs can impair neuropsychological functioning, their positive effect on seizure control might improve cognition and behaviour. Each person should be assessed individually with respect to factors unique to his or her seizure disorder and its treatment.

Topiramate in refractory epilepsy: a prospective observational study

PURPOSE

This prospective observational study explored the efficacy and tolerability of topiramate (TPM) in patients with refractory epilepsy attending a single outpatient clinic.

METHODS

One hundred seventy patients (82 men, 88 women, aged 18-75 years) with refractory localization-related (n = 134) or idiopathic generalized epilepsy (n = 36) were started on adjunctive TPM using a standard titration schedule. TPM was introduced after a 3-month prospective baseline, and doses were adjusted according to clinical response. End points were seizure freedom for 6 months, > or =50% seizure reduction for 6 months compared with baseline at the highest tolerated TPM dose (responder), or discontinuation of TPM because of side effects, lack of efficacy, or both.

RESULTS

Thirty-nine (23%) patients were seizure-free, and 80 (47%) more patients had a useful therapeutic response. Thirteen seizure-free patients and 16 responders took 100 mg of TPM daily or less. TPM was discontinued in 51 (30%) patients. The most common side effects resulting in withdrawal were fatigue, weight loss, irritability, paresthesia, depression, and headache. Concomitant antiepileptic drugs (AEDs) were stopped in 30 patients. Twelve were established on TPM monotherapy, eight of whom remained seizure-free. Final TPM doses and concentrations varied widely among the three outcome groups.

CONCLUSIONS

TPM was efficacious as add-on and monotherapy in patients with refractory partial and generalized seizures in everyday clinical use. A good response was obtained in many patients with TPM doses substantially lower than those studied in regulatory clinical trials. The wide variation in dose-response and dose-toxicity relationships may reflect different neurobiologies causing refractory epilepsy and differential efficacy of AED combinations.

Efficacy and tolerability of topiramate in childhood and adolescent epilepsy: a clinical experience

A 3-year retrospective review was undertaken of the use of topiramate in 51 children aged 3-16 years with partial and generalized epilepsies who attended a tertiary referral epilepsy centre in a large children's hospital. The mean follow-up period was 19 months (range 6-33 months). Twenty-six children (51%) were still receiving topiramate at the time of their last review. Fifteen children (29%) showed a greater than 50% reduction in their seizure frequency and four children (8%) became seizure free, three on topiramate monotherapy. The drug appeared to be most effective in children with moderate learning difficulties with 75% showing an improvement in seizure control compared with 25% of children with normal educational functioning. Topiramate was withdrawn in 25 patients. The reasons for withdrawal included adverse effects in 20, lack of effect in three and worsening of seizures in two patients. Adverse side effects were reported in 57% of the 51 patients. The majority of the side effects were related to behavioural and cognitive difficulties, with less-common side effects including anorexia, weight loss and headaches.