Managing Bipolar During HepC Treatment Without Losing Your Liver

I have been on Interferon/Ribovarin (HepC TX) and also have Chronic Fatigue Sydrome separate from HepC. I have been on TX for 6 mos now and the depression is TRULY starting to come through. MY CONCERN is that I am 10 months drug/alcohol free, menopausal & bipolar. I have NOT taken anti-depressants since 2006 because at that time I was put on 6 diff meds in a 9 month period and ended up relapsing after the seroquil knocked me out for 2 days. (Yes, I was taking ALL as prescribed)

I am a recovering cocaine addict and have never been much for pills! BUT, the Depakote worked till my HepC flared up, then came, lamictyl , abilify, seroquil, and some other product that caused HUGE sores & holes in my tongue and mouth! CMC Mental health here in Charlotte, NC is LIKE a joke and I ALWAYS feel like a guinea pig with them!

BUT I NEED HELP! WHAT MEDS DO YOU SUGGEST? I walk 1-2 miles daily still & workout at least 4-5 times a week! I have no other medical conditions. I was TRYING to get by WITHOUT any more drugs then the HepC Tx….HELP!

What MEDS would you suggest??? Is Cymbalta OK to use with HepC TX? I have researched it some, I jsut want something that is NOT going to make me eat all day and lay in bed any more than I already do

As difficult as this situation sounds, it is easy to get some clarity if we just get back to basics.  Lets start with the information that we have.  You have Bipolar Disorder (I will assume this is correct).  You have a major liver-busting illness (the Hep C) so we must be gentle on your liver.  You have a history of substance abuse that you are trying (valiantly) to move away from.  

Let’s address the mood disorder first.  As you may know, it is imperative that we don’t aggravate the underlying Bipolar Disorder with the meds we choose. You have already failed a trial of Lamictal, my first choice for Bipolar Depression.   The next step in the algorithm would be to place you on a mood stabilizer (to prevent manic swings/irritability) and then an antidepressant.  You have been on Abilify (would have been my first choice) and not done well enough.  If that trial was not complete, it might still be an option.  A great option for you might be Lithium.  Lithium was the gold-standard for years and fell out of favor with the wide range of other options available.  It is still a GREAT medicine and, for people with liver illness, has the added advantage of being excreted solely by the kidneys with no metabolism by the liver.  Once the mood stabilizer is in place, you can then consider your antidepressant options.  

We typically avoid Cymbalta in patients with significant liver disease.  There has been cases of significant worsening of liver disease with it.  You mention being on other antidepressants, but don’t specify.  You can certainly use any of the SSRI’s alone or in combination with Wellbutrin.  Both Wellbutrin and Lithium can make an SSRI more effective, so prior failure of SSRI’s in the absence of these two “boosters” does not preclude another trial.  

Keep yourself connected with others.  Keep attending AA/NA meetings.  Keep in therapy.  Keep walking and exercising (kudos for doing this already).  Meditate.  Tend to your spirituality.  Take fish oil.  Whenever possible, take someone with you to your meetings with the doctors.  They can support you and advocate for you when you might not be feeling your best.  It is also more difficult for a doc or a medical system to blow you off when you have a vocal advocate with you.  This is a very difficult time for you both medically and psychologically.  Be patient with yourself and try to pamper yourself and treat yourself well.  Once the treatment for the Hep C is over, you will gradually have less of the emotional disturbance that comes with that treatment.  But even that can take months to settle out.  The correct medication regimen is vitally important here. 

–Dan Hartman, MD

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