Equetro

[browri]

I'm sure many here take carbamazepine, but I'm more specifically interested in the Equetro brand.

Has anyone here tried Equetro before and had any luck?

Anyone here who has taken both generic carbamazepine and Equetro and felt there may have been any differences?

Before taking Depakote ER, I was taking Oxtellar XR, which is the extended release brand of oxcarbazepine. I needed something more calming than that because we needed the anti-convulsant to pull the mood-stabilizing weight. Reason being is that appropriate mood-stabilizing doses of AAPs pretty much invariably cause akathisia for me. So the AAPs need to take a back seat and act as a booster. We decided to switch to Depakote, but I have gained quite a bit of weight. I'm not totally convinced that I even want to switch, but oxcarbazepine did do a good job, and I understand that carbamazepine can be even more calming.

As always, thanks in advance!

[browri]

I suppose another good question to add to this is whether anyone has taken both carbamazepine and oxcarbazepine at some point in time and can describe to me their experience with each and their differences if any.

[centaurus]

When I first took carbamazepine (Tegretol XR) it worked. I was on 800mg.  Second time it didn't do anything to stabilize my mood. 

Oxcarbazepine never worked, it's too weak for me. 

But I think Depakote ER is far stronger and better for my mixed states than carbamazepine. 

 

No Equetro in Europe though.

 

Also as it is strong CYP450 (CYP3A4) inducer it lowered quetiapine levels and it became inneffective.

Edited January 22 by centaurus
grammar

[browri]

1 hour ago, centaurus said:

When I first took carbamazepine (Tegretol XR) it worked. I was on 800mg.  Second time it didn't do anything to stabilize my mood. 

Oxcarbazepine never worked, it's too weak for me. 

But I think Depakote ER is far stronger and better for my mixed states than carbamazepine. 

No Equetro in Europe though. 

Also as it is strong CYP450 (CYP3A4) inducer it lowered quetiapine levels and it became inneffective.

Yeah when I took generic immediate release oxcarbazepine, my dose was 300mg tid (900mg daily). When we converted to the Oxtellar XR (extended release oxcarbazepine) I went to 1200mg because the bioavailability of oxcarbazepine in the extended release form is lower.

Based on that, I would say my target dose would be somewhere between 600mg and 800mg like many, although I understand you can go as high as 1600mg on it, which is not something I'm interested in.

I did consider the enzyme induction, but my other two medications, Trintellix and Rexulti, both have very long half-lives, and I'm hoping that dose increases would be sufficient to compensate for the enzyme induction assuming I don't go too high on carbamazepine.

@centaurus aside from the fact that you felt oxcarbazepine was weaker, how would you say oxcarbazepine and carbamazepine compared from a tolerability perspective? I do have some concerns that carbamazepine may not be able to control mixed states as well as valproate as I do have a tendency to rapidly cycle and experience minor mixed states, which valproate of course is the king of. However, oxcarbazepine actually worked pretty well for me and we really only needed just a little bit more, so I'm wondering if carbamazepine may have worked.

[jt07]

20 hours ago, browri said:

Anyone here who has taken both generic carbamazepine and Equetro and felt there may have been any differences?

I took them both when Equatro was substituted for generic carbamazepine at my pharmacy (why I have no idea). I did not notice any difference at all.

[centaurus]

Yea, I was also on 1200mg oxcarbazepine. 

I think  800mg dose of carbamazepine should be enought. Usually maximum dose is 1200mg, when the blood levels of drug are at the therapeutic end range. (4-12mg/L)

https://www.drugs.com/interactions-check.php?drug_list=3639-0,497-1767,3490-0&types[]=major&types[]=minor&types[]=moderate&types[]=food&types[]=therapeutic_duplication&professional=1

There is interaction data between carbamazepine and vortioxetine/brexpiprazole. 

 In general  oxcarbazepine had a better tolerability profile, no risk of blood dyscrasias ( WBC drop)  and lesser  liver cytochrome enzyme induction, no migraine headaches,water retention.

Do you want switch to carbamazepine only because of weight gain from Depakote?

Somewhere I read that carbamazepine could  lose it's effectiviness over time, if i found a study I'll post. 

 

Edited January 22 by centaurus
grammar; add text

[browri]

1 hour ago, jt07 said:

I took them both when Equatro was substituted for generic carbamazepine at my pharmacy (why I have no idea). I did not notice any difference at all.

do you usually take the immediate release or controlled release tablets?

1 hour ago, centaurus said:

https://www.drugs.com/interactions-check.php?drug_list=3639-0,497-1767,3490-0&types[]=major&types[]=minor&types[]=moderate&types[]=food&types[]=therapeutic_duplication&professional=1

There is interaction data between carbamazepine and vortioxetine/brexpiprazole. 

Yes I figured there would be, but like I said, they have long half-lives and accumulate quite a bit. I could adjust the doses accordingly. I'm still on a fairly low dose of Rexulti and I could still bump the Trintellix to 20mg in the winters.

1 hour ago, centaurus said:

Do you want switch to carbamazepine only because of weight gain from Depakote?

That is a major part of it. However, one difference is that I felt like oxcarbazepine was actually soothing. Like when I took the immediate release tablets, I remember feeling very calm and "feel-good-y" after I took it. It helped with my anxiety better than Depakote does I think, and where Depakote has pretty much no positive impact on my depression, oxcarbazepine was actually more helpful as an anxiolytic (and antidepressant when combined with an actual AD).

1 hour ago, centaurus said:

Somewhere I read that carbamazepine could  lose it's effectiviness over time, if i found a study I'll post. 

Well that may be because it induces its own metabolism, requiring constantly higher doses to maintain plasma levels.

[centaurus]

23 minutes ago, browri said:

That is a major part of it. However, one difference is that I felt like oxcarbazepine was actually soothing. Like when I took the immediate release tablets, I remember feeling very calm and "feel-good-y" after I took it. It helped with my anxiety better than Depakote does I think, and where Depakote has pretty much no positive impact on my depression, oxcarbazepine was actually more helpful as an anxiolytic (and antidepressant when combined with an actual AD).

Yes, Depakote does nothing to stabilize from below. Well if you responded well on oxcarbazepine ,then you should respond to carbamazepine as well. Try it. For some it could be really effective medication.

 

23 minutes ago, browri said:

Well that may be because it induces its own metabolism, requiring constantly higher doses to maintain plasma levels.

Yes,thats a point.

Edited January 22 by centaurus

[jt07]

6 hours ago, browri said:

do you usually take the immediate release or controlled release tablets?

7 hours ago, centaurus said:

I've only ever taken the immediate release tablets.

[browri]

17 hours ago, centaurus said:

Yes, Depakote does nothing to stabilize from below. Well if you responded well on oxcarbazepine ,then you should respond to carbamazepine as well. Try it. For some it could be really effective medication.

Yeah this much I know. My thinking is that I needed something more calming than oxcarbazepine but not as calming as valproate. Carbamazepine should theoretically fall somewhere right in the middle

11 hours ago, jt07 said:

I've only ever taken the immediate release tablets.

Any nausea or vomiting? I understand these are side effects that are less prominent with oxcarbazepine but can be more common with carbamazepine. But I also understand that they can go away over time if you do experience them.

[jt07]

I did not experience any nausea or vomiting. The thing is that every time my dose was increased, I experienced a drunk-like sensation and double vision which went away in a day or two once I got used to the higher dose. No real nausea though. The double vision thing is how I know I've taken too much even today. The only side effect I might have had in the beginning (which I can't remember, just going on others' experiences) is some tiredness. I really haven't had many side effects at all. It is weight neutral.

About sedation ... it's not really sedating, at least not for me. Perhaps it's a little sedating in the beginning, but once that goes away it is not sedating. I take four 200 mg pills throughout the day, and never once do I feel sedated or sleepy. It also does nothing for my anxiety and has certainly not helped my insomnia. I have never taken oxcarbazepine, but I can't imagine that carbamazepine is more sedating. That is my experience. Perhaps, YMMV.

[browri]

9 hours ago, jt07 said:

I did not experience any nausea or vomiting. The thing is that every time my dose was increased, I experienced a drunk-like sensation and double vision which went away in a day or two once I got used to the higher dose. No real nausea though. The double vision thing is how I know I've taken too much even today. The only side effect I might have had in the beginning (which I can't remember, just going on others' experiences) is some tiredness. I really haven't had many side effects at all. It is weight neutral.

About sedation ... it's not really sedating, at least not for me. Perhaps it's a little sedating in the beginning, but once that goes away it is not sedating. I take four 200 mg pills throughout the day, and never once do I feel sedated or sleepy. It also does nothing for my anxiety and has certainly not helped my insomnia. I have never taken oxcarbazepine, but I can't imagine that carbamazepine is more sedating. That is my experience. Perhaps, YMMV.

My pdoc seems to think that carbamazepine would be more sedating/settling than oxcarbazepine. I do recall that oxcarbazepine was similar in that the side effects really were relegated to initiation of treatment. Things like blurred/double vision, sedation, confusion, were all things I experienced starting up on oxcarbazepine but they went away over time. I would expect the same for carbamazepine but I'm hoping it's slightly more sedating.

[jt07]

Well, I wish you lots of luck. I may have a quite different reaction to carbamazepine than most. My brain really loves carbamazepine. At first, I was given 100 mg chewables, and one of those was enough to pull me out of a suicidal state within 20 minutes. Later, in the hospital, they did the proper blood level initiation of therapy, but even below therapeutic levels, it worked for me at least somewhat. I am absolutely sure that it was not the placebo effect. I am not susceptible to the placebo effect after having been through so many drug failures. If anything, I suffer from the nocebo effect.

The reason I take carbamazepine is that it eliminates suicidal ideation for me and keeps me from falling into those desparate gut-wrenching depressive states. I consider it to be the med that literally saved my life.

[browri]

I would describe oxcarbazepine as "soothing". When I was taking 300mg tid of it, I could feel it an hour after taking it. Everything just calmed down and I felt "cozy". I don't know how else to describe it. We just needed a bit MORE when I was taking oxcarbazepine and I'm thinking going directly to valproate and not at least giving carbamazepine a try was a mistake. Here's to hoping my pdoc is on-board with the change at my appt on Monday.

Likely the pharmacy will have to order the Equetro brand for me so I won't start until Tuesday. However, I worked out that it's actually cheaper for me to do the brand. Equetro on my prescription formulary has no prior auth or step therapy requirements. It also has no quantity limits. It's a non-preferred brand. So my copay would be $55/30-day or $165/90-day (90-day mail order isn't any cheaper). Then the savings card will pay for most of it. I pay the first $20, then they'll pay $100 for a 30-day, $150 for a 60-day, or $200 for a 90-day. This means whether it's a 30 or a 90-day, it'll be $20. Whereas if I went for the generic Carbatrol capsules, it would be $10/30-day or $30/90-day. So it actually makes more sense to take a bit of savings and go for the Equetro directly if my insurance isn't going to stop me. And it'll help rack up my out-of-pocket maximum on my insurance so I get "free" healthcare for the second half of the year.

[jt07]

I found valproate to be a heavy medication with lots of side effects. It gave me an insane appetite and worsened my depression. I understand it's a good go-to med for mixed states and possibly even mania, but I would advise not taking it if you don't need it. It is much rougher than carbamazepine.

[browri]

30 minutes ago, jt07 said:

I found valproate to be a heavy medication with lots of side effects. It gave me an insane appetite and worsened my depression. I understand it's a good go-to med for mixed states and possibly even mania, but I would advise not taking it if you don't need it. It is much rougher than carbamazepine.

Yeah I'm starting to realize this. I have had some accelerated hair loss (I was already losing it anyway). weight gain. Depressive side effects. I know that I can't go to 1500mg on it because that's where I really started to notice the depressive effects.

[argh]

1 hour ago, browri said:

Yeah I'm starting to realize this. I have had some accelerated hair loss (I was already losing it anyway). weight gain. Depressive side effects. I know that I can't go to 1500mg on it because that's where I really started to notice the depressive effects. 

Have you tried biotin supplementation? Zinc/Selenium?

https://psycheducation.org/treatment/mood-stabilizers/valproatedivalproex-divalproex/depakote-induced-hair-loss/

[browri]

I do use a shampoo with supplemental selenium. I don't take zinc or biotin though. To be honest, I was going to go bald whether I took Depakote or not, and I'm really not making a concerted effort to keep my hair. If anything I'm trying to get on board with the Mr. Clean look that I'll be sporting sometime in the next 5-10 years lol. Mind you I'm only 27.

[browri]

So I ended up calling my pdoc and talking with him about some of my symptoms. He said he wanted me to go from 1250mg on the Depakote to 1000mg until our appt on Monday to see how I feel. I have no doubt I'll be less depressed, but I'm still kind of concerned about being appropriately "settled". I don't want to precipitate any sort of full hypomanic or mixed episode. Nevertheless, this is what the pdoc said to do. So do it I shall.

[browri]

It's official. I'm switching from the Depakote to Equetro. Here's the titration my pdoc requested I follow:

Days 1-2: Equetro 100mg bid, Depakote ER 750mg qhs

Day 3: Equetro 100mg bid, Depakote ER 500mg qhs

Day 4: Equetro 200mg bid, Depakote ER 500mg qhs

Days 5-6: Equetro 200mg bid, Depakote ER 250mg qhs

Day 7: Equetro 200mg bid, discontinue Depakote, get labs (CBZ level, CMP, and CBC)

I see him again on 2/11. We'll likely decide then whether we need to increase the Equetro to 600mg and whether we need to adjust the Trintellix, Vyvanse, and Rexulti.