Expert: Ivan Goldberg, M.D. - 7/5/2010

Question
QUESTION: Dear Dr. Goldberg:

You have discussed the option of a low dose combination of Lithium, Depakote and Tegretol in several of your posts.

I would like to discuss this option with my pdoc. I have been diagnosed with BP II and have not responded well to either antidepressants (rapid cycling) and antipsychotics (sedation). How do you start this therapy? Do you start with one medications and titrate up until there is a response or do you start patients on all three? What do you consider an 'optimal' dose? How do you assess whether the combination is successful?

I am taking 200 mg of Lamotrigine.

Thanks

ANSWER: Hi, Tom . . .

If a patient of mine has uncontrolled bipolar disorder and a history of having done poorly with individual trials of lithium, Depakote, and Tegretol, I will frequently treat them with the triple combination. If they are on one of those drugs I will add small doses of the other two. If they are on none of them, I will start therm on small doses of all three.

For great info on the treatment of people with bipolar disorder please purchase:

http://www.amazon.com/Treatment-Bipolar-Illness-Casebook-Clinicians/dp/039370537

Best regards . . .

Ivan
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---------- FOLLOW-UP ----------

QUESTION: What do you suggest in terms of initial doses? How fast would you titrate up considering that it may take 6 - 12 month to see a response. Thanks.

Answer
Tom . . .

I usually start with:
lithium 300 mg/day + Tegretol 200 mg/day + Depakote 500 mg/day
and usually increase the doses by those amounts every 10-14 days. I monitor blood levels of all drugs as I go along.

Most recently I have been using a quadruple combination and have added Lamictal to the mix and on a few occasions Benzal.

Best regards . . .

Ivan
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