Eye Don’t Know Why Eye Prescribe This Stuff . . . Additional Worries About Topamax (topirimate)

I got another bulletin of alarm in the mail the other day . . . I get these periodically.  They come in a white envelope with a BIG red warning on the front that yet another major side effect was found with one of the many medications that are available for my use.  This one spoke to the risk of visual field changes that can occur as a result of a blockage of fluid in the eye.  The blockage of fluid results in increased pressure in the eye (much like glaucoma) and can result in permanent damage to the eye and permanent loss of vision.  This may occur in the presence of redness and pain . . . but can occur in the absence of redness and pain as well.

Now, as a prescriber of many medicines . . . it is what I do all day . . . I am well versed in the horrible, terrible side effects that most of the medicines I prescribe can potentially cause.  And I spend a good portion of my day warning my patients about how bad medicines can be.  When I recommend a medication to someone, it is with the full understanding of these potential difficulties, but the clinical estimation that the potential benefits of the medicine outweigh the potential risks and side effects.  For example, in prescribing an antidepressant for a patient who is depressed, I do talk about the slight increased risk of suicidal thoughts with the medicine but that is balanced out by the risk of suicidal thoughts that come from untreated depression.  The potential benefits outweigh the potential negatives.

But what about Topamax.  It is one of the many anti-seizure medicines that have been on the market forever looking for a psychiatric purpose.  Unlike the commonly prescribed Depakote (valproic acid), Topamax has not been found to have reliable mood stabilizing or mood enhancing properties as a solo agent. It can, in some patients, be useful as an “add-on” to an existing regimen that is not working, but often at the expense of clarity of thought.  Dosing of Topamax must be very slow and careful, because it often causes cognitive dulling.  This can be from too much too fast . . . or too high a dose . . . or it can just happen no matter what.

Topamax’s biggest claim to fame is that it helps you lose weight.  Most of the studies reporting this are from the neurology literature, looking at the effect on patients with seizure disorders.  In studies done in the psychiatric community, there are clearly some patients who loose weight on it.  This tends to occur early in treatment (within the first 8 weeks or so).  Weight loss in that period can be 5-15 lbs.

So . . . what’s the good doctor complaining about????

One of the thorns in my paw is patients coming in saying  “my therapist said you should put me on Topamax cause it will help me lose weight”.

Oh . . . if life were only that easy!

I am, by nature, a collaborative kind of doc.  I am totally open to suggestions from either patients or from other professionals involved in someone’s care.  My concern is that the hope that gets generated by a suggestion given to a patient must then be tempered by my discussion of the potential risks . . . and by a realistic discussion of the potential benefits.  Yes . . . I become Doctor Danny Downer . . . but that is my role in this (and I am ok with it).

In my “In The Trenches Real Life Experience” with Topamax I do not get the kind of reliable weight loss results that can (repeat CAN) be reported in some (repeat SOME) studies looking at Topamax.  More often than not, the patient experiences side effects (most often cognitive dulling) and no significant loss of weight.  That is why I do not use it very often.  And with the additional concern about vision issues and eye health . . . there is yet one more issue to discuss with the patient.

I think that . . . instead of talking about throwing one more medicine at a patient . . . I think I will have a conversation about what kind of diet the patient has.  What are the current eating patterns that support health and weight loss.  What are the current exercise patterns that support health and weight loss.  THAT is the discussion that needs to take place.  THAT is where the true path to health is.  Many people need medicine to function at their best.  Many people will NOT be able to get off medicine without the return of significant mental health symptoms . . . BUT . . . if they eat right and exercise sensibly how much better would they feel? How much LESS medicine could they be on?  If they began a regimen of gentle stretching and yoga . . . meditation and purposeful breathing exercises . . . how much better would they feel?

That is the discussion that needs to be held.  It is not the “easy” way to achieve weight loss and contentment, but is the way to achieve them, and keep them, and hold them as their own.

–Dan Hartman, MD



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