Topiramate and Aripiprazole Cribsheet

First off, for years BPD was seen as a disorder that doesn't improve with meds, per se, you prescribe when there's other stuff going on. For example, I am already on meds for PCOS, low oestrogen levels and Insulin Resistance, and I suffer from depression so I have antidepressants. All of that should, in theory, aid management of my BPD too (less triggers, less susceptible to triggers). Out of all my BPD symptoms, two of them: namely insomnia and anxiety, along with the paranoia, anger and flashbacks etc that comes along with them can be treated and is treated by my Drs with a tiny bit of antipsychotic at night. I can add a bit more into my day of said drug too if I am too jittery for words. 

Downside? Majorly the weight gain the Quetiapine brings with it, to a person who is already fighting a losing battle with weight and bingeing on food because of my insulin issues. So the IR gets worse; gut gets worse; hormones get worse - oh look, more triggers - BPD gets worse and boom! full circle. Extra Quetiapine and so on and so on. 

The best write up I have seen on how most BPDers need to be treated is here on BPD Demistifyed. Initially, in a crisis, emergency medication to keep her alive followed by psychotherapy/DBT and modified meds as things change. Frankly I do not believe I can do very well without both elements. In reality, my PTSD symptoms and depression, anxiety and anger issues have been CBTed (mainly on the down-low .... clever doctors) and the community support from the SureStart centre and Health Visitor plus the main work of the local crazy-team has been to get me up and running, not to deal with the BPD at all.

This is getting to be a problem, particularly as I BPD a lot and there is no DBT. I don't even know how I would feel about DBT - a therapy designed specially for people like me - because I have never had access to it. 

sigh

Makes me think I need more pharmacological help, or more focused perhaps - replace my current antipsychotic with a mood stabiliser perhaps? Try Aripiprazole instead? 

Firstly I checked to see if it is safe-ish for me personally to try these drugs. The latest study for drugs given to BPDs says contrary to earlier beliefs drugs do help, and out of the ones that do Topiramate and Aripiprazole seem to me to be least damaging to my IR and weight gain.

For example, reported in 2009 we have 

A safety and tolerability laboratory study of the combination of aripiprazole and topiramate in volunteers who drink alcohol (Kenna, Leggio, Swift).

This was done at Department of Psychiatry and the Center for Alcohol and Addiction Studies, Brown University, the patients were not alcoholics, and they drank a bit less on the drugs, the drugs together caused no extra addiction issues, did not work badly together. So we have safety sorted. Ok. 

Back in 2006 we had the big one, Aripiprazole in the treatment of BPDs - they noted a a significant reduction of global psychological stress, the findings corroborated previous findings of antidepressant and anxiolytic effects from aripiprazole. The most interesting thing they said was, I think: 

 aripiprazole was more effective in treating the aggression component of borderline psychopathology. Among our patients, aripiprazole appeared to influence the intensity of the subjective state of anger (state anger) as well as their readiness to react with anger (trait anger). Furthermore, the tendency to direct anger outward (anger out) and inward (anger in) decreased significantly. This is important because the socially desirable tendency to control anger was strengthened (anger control).

and 

Aripiprazole appears to be a safe and effective agent for improving not only the symptoms of borderline personality disorder but also the associated health-related quality of life and interpersonal problems.

Bingo

All the Quetiapine can do is numb me a teeny bit more - not enough - and make managing my IR hard.

Moving on, studies have been done or are still ongoing on, basically Metformin and Second Generation Antipsychotics-induced Obesity (Reynolds/Kirk and Baptista/Kin/Beaulieu/du Baptista)

and as they rightly summarise, the problem I am facing is this:

Obesity and metabolic syndrome, with increased risk of eventual cardiovascular disease and type II diabetes, are significant problems for patients receiving antipsychotic drugs and are likely contribute to their decreased life expectancy. Several drug-related mechanisms may contribute to these problems, including effects both influencing food intake and on glucose and lipid metabolism. The metabolic consequences of different antipsychotic drugs vary substantially; these variations reflect differences in receptor pharmacology and provide clues as to the underlying pharmacological mechanisms.

Just a reminder - I'm only 34. I really don't want any of this. I mean, no one does - but I've been on crazymeds all my adult life, it wears one down. 

Reynolds & Kirk saw that 

The minimal weight gain seen with ziprasidone and aripiprazole may reflect their having further pharmacological effects that protect against changes in food intake and related metabolic factors. Understanding the pharmacology of metabolic consequences of current antipsychotic drug treatment is clearly the key to developing improved pharmacotherapies that avoid these problematic and limiting adverse effects.

There was a study using Topiramate too (Ellinger/Ipema/Stachnic), which rather fuzzily led to this:

Data for the use of metformin and topiramate in the treatment and prevention of second-generation antipsychotic-induced weight gain are limited. Both may be effective in helping patients lose weight via mechanisms that have yet to be clearly defined. The use of metformin results in greater weight loss than topiramate, and topiramate is associated with more risks and may compromise the treatment of schizophrenia. Treatment of antipsychotic-induced weight gain with metformin may be an option after lifestyle and dietary changes have failed.

And the study in Taiwan, no results yet - all going along the same basic principle that these two drugs do something interesting to BPDs, specially the angry ones filing the gaping maw with booze, food, starvation or something equally yuk; speciallt the IR/Type 2 diabetic patients and those who are obese anyway or will be with their dopey-meds very soon: 

 Topiramate for Treatment of Patients With Borderline Personality Disorder and Alcohol Dependence, A Study of the Safety and Effectiveness of Topiramate on Insulin Sensitivity in Overweight or Obese Patients With Type 2 Diabetes and would you believe it, in the journal of Obesity, Efficacy and safety of topiramate in combination with metformin in the treatment of obese subjects with type 2 diabetes: a randomized, double-blind, placebo-controlled study (Toplak/Hamman/Moore/Masson et al).

I'll be interested to know what my doctors reckon.