Dear Editor:
We read with interest the recent Clinical Update in the March issue of Psychiatry 2006 addressing the use of the anticonvulsant medication, topiramate, in the treatment of post-traumatic stress disorder.1 As noted in this article and elsewhere, topiramate is routinely being utilized in the offlabel treatment of a wide range of psychiatric disorders that include mood, anxiety, and even psychotic illnesses.2 There is also growing evidence this anticonvulsant agent exerts a demonstrated efficacy in the treatment of binge eating disorder and bulimia nervosa.3 Because of the increased use of topiramate in the clinical setting, we report a case of new-onset panic attacks that developed in a young woman who had been prescribed topiramate for treatment of her chronic bulimia nervosa. Although there are two other case reports in the medical literature that draw a relationship between topiramate and the development of panic attacks in persons with bipolar affective disorder,4,5 this appears to be the first report of new-onset panic symptoms occurring in a person treated only with topiramate for a chronic eating disorder.
Case report. Ms. D., a 34-year-old woman, had been treated in our clinic over the course of the past two years for bulimia nervosa, purging type. For nearly 17 years, she had engaged in one or two daily binging episodes followed by self-induced emesis. She consistently denied symptoms of a mood or anxiety disorder. A variety of serotonin reuptake inhibitors had been tried in the past, the most recent being fluoxetine at 40mg/day, without achieving a significant reduction in her eating disordered behaviors. She was also receiving weekly psychotherapy with a therapist specializing in eating disorders. The only other medication she was taking at the time of the initiation of topiramate was esomeprazole for chronic esophagitis. The dosage of this medication had remained unchanged for many months.
Ms. D. discontinued fluoxetine while traveling in Europe and, when seen again in the clinic, had not taken this medication for nearly three months. She agreed to a trial of topiramate starting at 25mg/day for two weeks and subsequently increased to 50mg/day. Approximately one week after reaching the dose of 50mg/day, she developed new-onset symptoms of racing heart, shortness of breath, chest tightness, lightheadedness, and overwhelming fear. When the first attack occurred she received a full cardiac evaluation in the emergency department including serum chemistries and a physical exam. The results of these studies were unremarkable. Upon returning home she continued to take the topiramate, but had several more panic attacks over a 48-hour period. The topiramate was stopped and within 10 days the panic attacks gradually diminished in frequency, then ceased. Two weeks later (at the patient's request since she believed the topiramate had been effective in reducing her binge/purging episodes) the topiramate was re-initiated at 25mg/day for two weeks and then increased to 50mg/day. Once again, within 7 to 10 days of reaching this higher dosage, the panic attacks resumed. Although Ms. D had never experienced panic attacks prior to starting the topiramate, she has grown less distressed by their intermittent occurrence and employs behavioral strategies (i.e., deep breathing, self-talk) that allow her to manage the symptoms. She continues to take the topiramate at an increased dosage of 75mg/day and has reduced her binge/purging episodes to several times per week rather than on a daily basis.
This naturalistic “on-off-on” trial suggests a strong association between the use of topiramate and the development of new-onset panic attacks in this patient. The exact mechanism behind this development is unclear. However, it has been hypothesized that topiramate’s carbonic anhydrase properties may elevate central CO2 levels, which create a panicogenic effect.4,5 Hence, in vulnerable persons this pharmacologic action could trigger panic attacks or worsen a pre-existing disorder. Although further research is warranted in the area of topiramate-induced panic attacks, clinicians who prescribe this agent should be mindful of this potential occurrence.
With regards,
Richard C. Christensen, MD, MA
Associate Professor Director, Community Psychiatry Program
Lorrie K. Garces, MD
Fellow in Community Psychiatry
Contributor Information
Richard C. Christensen, Associate Professor, Director, Community Psychiatry Program.
Lorrie K. Garces, Fellow in Community Psychiatry.
References
- 1.Berlant J. Topiramate as a therapy for chronic posttraumatic stress disorder. Psychiatry 2006. 2006;3:40–5. [PMC free article] [PubMed] [Google Scholar]
- 2.Arnone D. Review of the use of topiramate for treatment of psychiatric disorders. Ann Gen Pyschiatry. 2005;4:5–19. doi: 10.1186/1744-859X-4-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Nickel C, Tritt K, Muelbacher M, et al. Topiramate treatment in bulimia nervosa patients: A randomized, double-blind study. Int J Eat Disorders. 2005;4:295–300. doi: 10.1002/eat.20202. [DOI] [PubMed] [Google Scholar]
- 4.Goldberg JF. Panic attacks associated with the use of topiramate. J Clin Psychopharmacol. 2001;4:461–2. doi: 10.1097/00004714-200108000-00019. [DOI] [PubMed] [Google Scholar]
- 5.Damsa C, Warczyk S, Cailhol L, et al. Panic attacks associated with topiramate. J Clin Psychiatry. 2006;2:326–7. doi: 10.4088/jcp.v67n0222d. [DOI] [PubMed] [Google Scholar]