Abstracts

Rationale: Antiepileptic drugs are effective psychotropics, especially for bipolar disorder, which leads to their use off-label in treatment refractory cases. A recent publication suggests that rufinamide may be beneficial adjunctively for bipolar disorder with comorbid psychopathology. This report addresses two negative cases with significant psychiatric adverse effects. Methods: Case analysis with literature reviewResults: Case 1: 38yo female with treatment resistant rapid cycling bipolar disorder had failed rational polypharmacy. Rufinamide (200mg qhs titrated to 400mg total daily dose) was initiated as an adjunctive agent to her regimen of quietapine, olanzapine, verapamil, and lamotrigine. Within one week, the patient reported increased depression with change from passive to active suicidal ideation, and increased irritability. With discontinuation of rufinamide, depressive severity decreased with only passive suicidal ideation, and decreased irritability. Case 2: 33yo female with treatment resistant psychotic bipolar depression, posttraumatic stress disorder, intermittent explosive disorder and generalized anxiety disorder had failed rational polypharmacy and electroconvulsive therapy. Rufinamide 200mg bid was initiated as an adjunctive agent to her regimen of escitalopram, ziprasidone, haloperidol, clonazepam and zolpidem. Within two days, increased agitation was noted; over the ensuing five days, the patient reported both further worsening of agitation and increased suicidal ideation with command auditory hallucinations. Following discontinuation of rufinamide, agitation diminished and suicidal ideation retuned to baseline. Conclusions: Rufinamide may lead to increased suicidal ideation in treatment refractory bipolar patients. Secondary to the course of severe bipolar disorder, rufinamide cannot be specifically implicated; however, clinicians should be aware of this potential significant adverse effect.