Q:  Is Topomax Dose Too High

Dr. Phelps,

I am taking 250mg Topomax in the morning and 250mg at  night with 25mg Seroquel for sleep. My doctor believes that I probably will have to go up to around 300 to 350mg morning/night to kick the Seroquel completely to be on only on the Topomax to sleep normally. Is this extremely too high? I am functioning fine: vocabulary, memory, etc. But, physical fitness is still a problem--I feel the Topomax is wearing me out. Please advise.

Thank you,
Dan
 

Dear Dan -- 
The "top end" of Topomax dosing has not really been defined for psychiatry.  I used 600 mg in one patient with terrible symptoms who seemed to get better the farther we went, but she eventually backed it down and in fact eventually went off -- so what looked pretty good at first, and "more is better", didn't seem to be so great after a while.  The point being: we don't really know the territory past about 400 mg as that's where the neurologists had already led the way.  You're "functioning fine" is indeed one crucial indicator to follow and I would have to defer to your doctor entirely (the "wearing me out" on the other hand sounds concerning).  Risks and eventual outcome on these doses is just basically unknown, as far as I know (I'll bet there are some neurologists out there who have had plenty of patients up in this range, but we have poor "cross talk" with them in our psychiatric literature).  

Dr. Phelps