Trileptal is not really a "new" medication. It's just an old one, carbamazepine (Tegretol) with an oxygen stuck on on it. But fortunately this oxygen solves the biggest problem that kept carbamazepine a very distant third choice compared to lithium and Depakote -- the tendency to decrease white blood cells, which are your infection-fighting cells. Since people don't "feel" their white blood cells, these could get dangerously low and leave a person vulnerable to infection. Tegretol is still a reasonable choice. It's still around as a choice because as generic carbamazepine it's quite a bit cheaper than Trileptal.

The difference with Trileptal is that it does not cause the blood cell problem. The medication has been in use in Europe for 10 years, and that's how the manufacturer has learned this. How do you know if they are right? Here's why: if the manufacturer says it's not a problem, and they're wrong, they could get sued and would very likely lose millions of dollars. So they do not make these claims lightly. Compare Tegretol: there are warnings all over the paperwork that comes with that medication, from the manufacturer, to make sure no one forgets to caution patients about this problem.

Trileptal also seems to cause side effects less often than Tegretol. I only rarely have to stop the medication due to sedation, nausea, or dizziness -- the big problems with Tegretol. People have gotten those side effects at higher doses on Trileptal, but not severely and lower doses were tolerated okay.

A few of my patients so far have had to stop Trileptal for ankle swelling. That's related to the known problem with hyponatremia -- a lowering of blood sodium that occurs in about 3 people per 100 treated.
For most people this feels like getting the 'flu: generally a little ill, slowed down, weak, maybe a headache. This would be regarded as a "side effect". Since I tell my patients to lower the dose for any side effect, this has not become a problem. The very worst thing I could find in the published literature on hyponatremia and Trileptal (the manufacturer sent the existing data on this at my request) was a coma in a 70 year old who was also taking Depakote. When Trileptal was stopped she came out of it with no lasting problems. For more, see a nice review of this hyponatremia issue from 1994.

What about weight gain, since many similar medications seem to cause this problem? "Weight gain" is listed for Tegretol, and Trileptal seems to act like that medication in almost all respects. But I've not seen people gain weight on Tegretol, and I've used a lot of it. If it does cause weight gain at all, it's not even close to the league of Depakote, or less so, lithium. So far Trileptal seems, like Tegretol, to be neutral as far as weight gain risk goes.

Finally, does it work?! Yes; it seems to be basically identical to Tegretol in that respect. It does not work for everyone, which is of course the same story as for any of these mood stabilizers -- for any given person, sometimes one will work and another not at all. Tegretol has not been as well studied as Depakote, and particularly lithium, for which we have the best research. But most studies show Tegretol in the same general league as Depakote in terms of effectiveness, which has certainly been my experience with it as well. And so far, Trileptal has been at least as good as Tegretol -- I think perhaps a bit more so. I've had more patients say "now this one, this really works", I think, than did so for Tegretol (but that could be just my initial excitement about having a "new" option with less risk than Tegretol).

Thus it appears that at this point, with 10 years of European experience and now some here in the U.S., Trileptal has many advantages over other mood stabilizers:

Low potential for risky side effects; few side effects at all, in most people (though that is true of lithium and Depakote at low doses); does not require blood tests before or during its use; can be started quicker than lamotrigine; does not appear to be associated with weight gain like Depakote (or less so lithium); less likely than lithium to produce bothersome side effects; and seems to be as effective as Tegretol was or even more so. Conclusion: Trileptal is ready to join the ranks of "first-line" treatments for bipolar disorder and has already done so in my practice. Particularly if weight gain is a highly feared risk, I start with Trileptal. [Update 6/20/02: here's another bipolar specialist writing with enthusiasm for this medication approach; the first I've heard to say he or she uses it first, as I have come to do frequently. The most recent bipolar expert consensus (April 2002) also has moved Trileptal into a close second choice amongst the mood stabilizers.] If you're going to talk to your doctor about it, you might be interested in the standard handout I use with my patients before starting the medication, which is available also for doctors through the Providers' Resource Center.