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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 16 of 16. This is the beginning of the thread.
Posted by Wallabee on July 7, 2000, at 0:22:17
I'm new to this site, neat tho. Diagnosed Bipolar at 19, now 33. Until last year had been on Lithium (900 - 1800mg daily, depending . . .) in combo with other meds (benzos, tricylics, wellbutrin and after the worst, the major tranqs). With treatment successfully avoided repeat psychotic episodes, but I was never satisfied with the stability of my mood or its range and period (usually depressive on Li - may post diff thread). For these reasons, and concerns about my thyroid, switched to lamictal six months ago. Made the switch very gradually, while monitoring my mood closely using markers such as sleep, libido, appetite and "disposition to life". I am now completely off of lithium (desirable from a side effect standpoint), but noticed along the way that my mood was actually most stable (and more stable than it is now) when I was on a Lithium Lamictal combo, in my case 300mg lithium daily plus 150 - 200mg Lamictal. If, over the next year, I am not satisfied with results on lamictal alone, I may accept the (presumably reduced, with a lower dose of Li) risk of thyroid probs and go back on the combo. Has anyone else observed optimal benefit from a combo of Lithium and Lamictal?
Posted by Craig on July 7, 2000, at 2:21:56
In reply to Lamictal and Lithium combo, posted by Wallabee on July 7, 2000, at 0:22:17
I'm on Lamictal 350mg/day and just added lithium 450mg/day last week. I'm having bloodwork later today and most likely will increase lithium to 900 mg/day. As to concerns about thyroid, I was told that when taking taking Synthroid, your lithium dosage can be as high as necessary because Synthroid can be adjusted and balance the effect of lithium. I'll have to keep you posted about the Lamictal and lithium combo - it's too soon to tell. I also take Wellbutrin, Paxil, Zyprexa, Klonopin, Synthroid and Cytomel. (I joke with my pharmacist and say it's amazing that I'm able to walk upright!)
> I'm new to this site, neat tho. Diagnosed Bipolar at 19, now 33. Until last year had been on Lithium (900 - 1800mg daily, depending . . .) in combo with other meds (benzos, tricylics, wellbutrin and after the worst, the major tranqs). With treatment successfully avoided repeat psychotic episodes, but I was never satisfied with the stability of my mood or its range and period (usually depressive on Li - may post diff thread). For these reasons, and concerns about my thyroid, switched to lamictal six months ago. Made the switch very gradually, while monitoring my mood closely using markers such as sleep, libido, appetite and "disposition to life". I am now completely off of lithium (desirable from a side effect standpoint), but noticed along the way that my mood was actually most stable (and more stable than it is now) when I was on a Lithium Lamictal combo, in my case 300mg lithium daily plus 150 - 200mg Lamictal. If, over the next year, I am not satisfied with results on lamictal alone, I may accept the (presumably reduced, with a lower dose of Li) risk of thyroid probs and go back on the combo. Has anyone else observed optimal benefit from a combo of Lithium and Lamictal?
Posted by Wallabee on July 7, 2000, at 6:47:14
In reply to Re: Lamictal and Lithium combo, posted by Craig on July 7, 2000, at 2:21:56
The great thing about the combo is that when taking lithium and lamictal togther, there appeared to be no need for anything else - no other antidepressant, tranquilizers etc. Granted it was for a short period (3 months). On Lamictal alone I still need at least benzo's from time to time, and maybe will need more (though probably no more antidepressants). I'm trying to make my meds as simple as possible, and avoid the thyroid drugs altogether (the switch from Li was pre-emptive of thyroid and kidney problems). Has anyone taken the Li/Lamictal combo for more than a year?
Posted by noa on July 7, 2000, at 9:34:43
In reply to the good thing about the combo, posted by Wallabee on July 7, 2000, at 6:47:14
I have no experience with this combo, but my pdoc has told me he uses the combo a lot, because he does not like to have patients on too high a lithium dose, even tho lithium is what he considers the gold standard. He doesn't want them to go higher than blood level of 1.0. So, he usually pairs it with either lamictal or depakote, so less lithium is needed.
While I was on lithium, my thyroid went further hypo than it was and that made me more depressed. I ended up deciding to discontinue the lithium because it hadn't done that much for me anyway (I am not bipolar--no mania or hypomania). I have since consulted with an endocrinologist who told me essentially what you said above, ie, that I could have stayed on the lithium, but just adjust the thyroid hormone dose to keep up.
Good luck.
Posted by SLS on July 7, 2000, at 12:06:56
In reply to Re: Lamictal and Lithium combo, posted by Craig on July 7, 2000, at 2:21:56
> I'm on Lamictal 350mg/day and just added lithium 450mg/day last week. I'm having bloodwork later today and most likely will increase lithium to 900 mg/day. As to concerns about thyroid, I was told that when taking taking Synthroid, your lithium dosage can be as high as necessary because Synthroid can be adjusted and balance the effect of lithium.
Lithium use can also produce thyroid tumors, goiter, and occasionally, hyperthyroidism.
- Scott
Posted by Wallabee on July 7, 2000, at 17:35:51
In reply to Re: Lamictal and Lithium combo, posted by SLS on July 7, 2000, at 12:06:56
Just wondering if u are out there and can let me know how u've fared on the combo and what else you may have needed.
Posted by Wallabee on July 7, 2000, at 17:51:38
In reply to Re: Lamictal and Lithium combo, posted by SLS on July 7, 2000, at 12:06:56
And how was the lamictal on its own scott (or were u on other stuff)?
I found it got me out of the general lethargy that characterized my twelve years on lithium, and my rapid cycles are gone, even on this low dose (150mg/day). Nevertheless I feel a bit more vulnerable to and nervous about an upswing (what the lithium seemed to take the edge off of) which is why I'm nervous to take anymore of the lamictal. I also had, just last night, some really nasty anxiety laden "dreams" as I was falling asleep (meeting a strange creature attacking me in the bushes, feeling trapped under a large unidentified heavy object that was falling on me) only ever had that happen to me before years ago on Melleril, and I came off of it right away.
Was wondering if those had to do with the clonazepam I had taken (for fear of not sleeping at all) but resisted for a bit too long because I was here going through postings = )
I did find I could get by on a much much lower dose of lithium - 300mg (yes, the blood levels were low - .4 - but it still felt like it made big a diff, and aren't our feelings what its all about = ) when I was taking both.
The only side effect I've noticed with the lamictal was coordination - or to be more specific, a dulling of my proprioception and ability to orient myself spatially - I have a much harder time tying a tie now, and not because my fingers are clumsy; and I find it a bit harder to park a car straight.
> > I'm on Lamictal 350mg/day and just added lithium 450mg/day last week. I'm having bloodwork later today and most likely will increase lithium to 900 mg/day. As to concerns about thyroid, I was told that when taking taking Synthroid, your lithium dosage can be as high as necessary because Synthroid can be adjusted and balance the effect of lithium.
>
>
> Lithium use can also produce thyroid tumors, goiter, and occasionally, hyperthyroidism.
>
>
> - Scott
Posted by SLS on July 8, 2000, at 10:24:00
In reply to And how was the lamictal alone scott, posted by Wallabee on July 7, 2000, at 17:51:38
Dear Wallabee,
> And how was the lamictal on its own scott (or were u on other stuff)?Lamictal alone provides me with a small antidepressant effect. It has allowed me to function well enough to participate on Psycho-Babble.
> I found it got me out of the general lethargy that characterized my twelve years on lithium, and my rapid cycles are gone, even on this low dose (150mg/day). Nevertheless I feel a bit more vulnerable to and nervous about an upswing (what the lithium seemed to take the edge off of) which is why I'm nervous to take anymore of the lamictal. I also had, just last night, some really nasty anxiety laden "dreams" as I was falling asleep (meeting a strange creature attacking me in the bushes, feeling trapped under a large unidentified heavy object that was falling on me) only ever had that happen to me before years ago on Melleril, and I came off of it right away.
I saw for the first time on this board that a few people (two) have had Lamictal induce both mania and a worsening of rapid-cyclicity. I feel pretty sure now that Lamictal is capable of doing this. If you are sure that this is the case with you, and Lamictal is the only drug you have found that provides relief from depression, I think it makes sense to remain on it and add lithium.
> Was wondering if those had to do with the clonazepam I had taken (for fear of not sleeping at all) but resisted for a bit too long because I was here going through postings = )
For me, Lamictal has produced more vivid dreams.
> I did find I could get by on a much much lower dose of lithium - 300mg (yes, the blood levels were low - .4 - but it still felt like it made big a diff, and aren't our feelings what its all about = ) when I was taking both.
This is not surprising. I recently read an abstract that indicated that 0.4 - 0.6 was sometimes enough. I guess you can figure out what works for you clinically.
At 0.4, do you have any hand tremors at all?
> The only side effect I've noticed with the lamictal was coordination - or to be more specific, a dulling of my proprioception and ability to orient myself spatially - I have a much harder time tying a tie now, and not because my fingers are clumsy; and I find it a bit harder to park a car straight.
These things are definitely side effects of Lamictal and are known as ataxia. At dosages higher than 300mg, I experience these same things, along with a significant impairment of memory. When I first raised the dosage to 300mg, these things appeared, but were small in magnitude. Within a few months, they disappeared completely. I didn't stay at the higher dosages to see if the side effects would disappear, as it wasn't helping anyway.
- Scott
Posted by Angela5 on July 8, 2000, at 11:48:23
In reply to Re: And how was the lamictal alone scott » Wallabee, posted by SLS on July 8, 2000, at 10:24:00
I was just put on Lamictal to augment Wellbutrin. I am currently on 100 mg/day of Wellbutrin (I got a rash at 200 mg/day, so trying to see if it will go away at 100). They started me on 25 mg/day of Lamictal for a week, which didn't have any effect, then increased it to 50 mg/day. My pdoc said that if I don't notice an effect within 2 days on 50 mg to discontinue it, but I was reading in Dr. Bob's Tips that the minimum theraputic dose tends to be 100 mg/day. Does anyone have any experience with this?
Also, yesterday evening (my 2nd day on 50 mg), I got dizzy upon standing, felt very nauseous, and my vision was weird. I had pain in my right eye and felt like it was seeing higher than my left eye (?) - I guess, basically, it just all seemed out of whack, and very far-away things while driving were blurry. Are these common side effects of Lamictal, and do they go away?
Thanks,
Angela
Posted by AndrewB on July 8, 2000, at 13:12:48
In reply to Re: And how was the lamictal alone scott » Wallabee, posted by SLS on July 8, 2000, at 10:24:00
Scott,
Dr. Ivan Goldberg says that lamotrigine does cause mania or anxiety in a small number of people.
Have you received any mood improvement from lamotigine?
So the sulpiride is just making you sleepy. If it doesn't work, whats next? Mirapex?
Lamotrigine inhibits glutamate release. Glutamate and NMDA receptors (which respond to glutamate) have been implicated in depression. Some drugs that I have been gathering info. on lately are memantine, nimodipine and ketamine (low dose nasal spray or eye drops). These are either direct or indirect NMDA receptor antagonists. Recent studies have shown antidepressant efficacy for ketamine and nimodipine. It is reported that memantine and nimodipine work synergistically together. Ketamine's AD effect is increased when combined with lamotrigine. Just something for you to look into. I know you have been looking farther afield for treatment options lately.
AndrewB
Posted by SLS on July 8, 2000, at 14:30:48
In reply to Re: And how was the lamictal alone scott, posted by AndrewB on July 8, 2000, at 13:12:48
Dear Andrew,
THANKS !!!
I guess it is time for me to look into NMDA and sigma receptors. I'm not really sure where to begin. Any suggestions?
> Have you received any mood improvement from lamotrigine?
Yes, but it is minimal. However, since it is steady, I remain on it and hope it will help augment antidepressants. The first time I tried Lamictal, I had just discontinued a combination of Nardil and desipramine. Within 2 weeks at 25mg, I thought my quest had ended and my life begun. I felt about 50% well. Enough for me to go back to work and chase girls. Unfortunately, the antidepressant effect plateaued and then fell-off. In retrospect, I realize that the Lamictal had actually worked synergistically with the improvement rebound I often experience when I discontinue either Nardil or a tricyclic. Man, I thought that was it.
I don't know to what degree Lamictal works as an antidepressant in unipolar or dysthymic presentations, but it is often sufficient monotherapeutically for treating bipolar depression. Are you thinking of trying it? I think it might have some indirect pro-dopaminergic effects. My guess. One of the facts that has me thinking this way is that it is so apt to produce nausea, which is why I also think Effexor may produce greater pro-dopaminergic activity than is recognized. I have a few other reasons as well.
> So the sulpiride is just making you sleepy. If it doesn't work, whats next? Mirapex?
Well, I decided to raise the dosage to 150mg a day as of yesterday. The "cruddiness" seems to have disappeared for the moment. I don't feel anything positive at this point, but I will give it a bit more time. I have no reason to be optimistic. I'll let you know about all of the details as they occur.
As to what to do next, I really don't know. I will probably play with Provigil to see what it does, either with or without sulpiride. I think I will leave DA agonists and naltrexone for combining with an MAO inhibitor.
I am facing a decision as to whether or not to see a new doctor before continuing. Parnate is the next proposed step, but it might make sense to get another opinion before proceeding.
> Glutamate and NMDA receptors (which respond to glutamate) have been implicated in depression. Some drugs that I have been gathering info. on lately are memantine, nimodipine and ketamine (low dose nasal spray or eye drops). These are either direct or indirect NMDA receptor antagonists. Recent studies have shown antidepressant efficacy for ketamine and nimodipine. It is reported that memantine and nimodipine work synergistically together. Ketamine's AD effect is increased when combined with lamotrigine. Just something for you to look into.
Where do you find this stuff? I could use some additional resources. I am not familiar with ketamine or memantine. What do they do? Are they available in the U.S.? What research has been done specifically regarding depression?
Does nimodipine do things other than block L-type calcium channels? I saw one person report success with it on the board before it turned over. I don't recall what his/her diagnosis was. Expensive stuff. I think its only indication is for post-stroke application to help prevent necrosis.
> I know you have been looking farther afield for treatment options lately.
Yes, although I am still a bit hesitant to think beyond mainstream. Do you think that either hypericum or sAME are effective in cases of *severe* depression? I pray that I will be patient enough to try different things before reaching backwards for Parnate et al.
Thanks again.
Sincerely,
Scott
Posted by Wallabee on July 8, 2000, at 22:50:35
In reply to Re: And how was the lamictal alone scott » Wallabee, posted by SLS on July 8, 2000, at 10:24:00
Thanks very much for the info Scott. I think that I will keep my lamictal dose low (I thought that by increasing it I might better stabilize my mood, but I think that this is as good as I will get, and really, it's very good). If manic tendencies like persistent sleeplessness or alertness show, I will add lithium again.
(this is long, by the way, sorry, so I should answer your question . . .
So, tremors on lithium at .4 meq/l, almost none really, in fact even at higher doses, they were barely noticeable. Perhaps, having spent a year dealing with the horrors of high doses of stelazine, lithium's tremors seemed quite bearable.
The joy of lamictal is that it has left me feeling very much myself, while so far (6 months) providing a stability of mood that was lacking on any of my Lithium / antidepressant combos. In that respect, my dreams on lamictal don't really seem vivid compared to those on the other antidepressants I have taken. What was peculiar about my feelings of the other night (dreams is inappropriate, really, because it happened right as I was falling to sleep) was the acute anxiety which is atypical for me.
thanks again!
Posted by Wallabee on July 8, 2000, at 23:47:05
In reply to Lamictal side effects and doseage Qs, posted by Angela5 on July 8, 2000, at 11:48:23
Angela,
Have a look under the tips section. I seem to recall seeing both dizziness and changes in vision as being reported. Nausea definitely (I'm realizing I have had that, tho I thought it was some kind of stomach bug), and also, possibly my atypical anxiety, tho that seems rare and thankfully has been an isolated problem for me.
> Also, yesterday evening (my 2nd day on 50 mg), I got dizzy upon standing, felt very nauseous, and my vision was weird. I had pain in my right eye and felt like it was seeing higher than my left eye (?) - I guess, basically, it just all seemed out of whack, and very far-away things while driving were blurry. Are these common side effects of Lamictal, and do they go away?
>
> Thanks,
>
> Angela
Posted by SLS on July 9, 2000, at 7:51:07
In reply to Lamictal side effects and doseage Qs, posted by Angela5 on July 8, 2000, at 11:48:23
Hi Angela.
I don't know why my post didn't show up yesterday. I probably forgot to "Confirm" it.
> I was just put on Lamictal to augment Wellbutrin. I am currently on 100 mg/day of Wellbutrin (I got a rash at 200 mg/day, so trying to see if it will go away at 100). They started me on 25 mg/day of Lamictal for a week, which didn't have any effect, then increased it to 50 mg/day. My pdoc said that if I don't notice an effect within 2 days on 50 mg to discontinue it, but I was reading in Dr. Bob's Tips that the minimum theraputic dose tends to be 100 mg/day. Does anyone have any experience with this?
The average dosage of Lamictal used to treat depression is 200mg. However, the range of effectiveness varies between 50-300mg. My opinion is that two days at an increased dosage will not allow you to determine whether or not it will help you. I would consider the absolute minimum to be one week, and would recommend at least two. You must remain at 50mg for two weeks anyway to avoid the rash that Lamictal can sometimes cause if the dosage is raised too quickly.
> Also, yesterday evening (my 2nd day on 50 mg), I got dizzy upon standing, felt very nauseous, and my vision was weird. I had pain in my right eye and felt like it was seeing higher than my left eye (?) - I guess, basically, it just all seemed out of whack, and very far-away things while driving were blurry. Are these common side effects of Lamictal, and do they go away?
Yes, all of the things you are experiencing are possible side effects of Lamictal. Nausea is common. I don't know if side effects can be used as a guage of what an individual's therapeutic dosage will be, but I think it makes sense to wait until they subside before you increase the dosage to 100mg. Most of the side effects of Lamictal are temporary, and usually resolve quickly. I would hope to see them disappear within a week.
-----------------------------------------------------------
From Internet MentalHealth:
Adverse experiences in patients receiving lamotrigine were generally mild, occurred within the first 2 weeks of therapy, and resolved without discontinuation of the drug.Commonly Observed:
The most commonly observed adverse experiences associated with the use of adjunctive therapy with lamotrigine (incidence of at least 10%) were dizziness, headache, diplopia, somnolence, ataxia, nausea and asthenia.
-----------------------------------------------------------diplopia = double vision double vision
somnolence = sleepiness
ataxia = incoordination
asthenia = muscle weakness
headache = headachePlease post of your progress.
- Scott
Posted by AndrewB on July 9, 2000, at 11:13:49
In reply to Re: And how was the lamictal alone scott » AndrewB, posted by SLS on July 8, 2000, at 14:30:48
> Where do you find this stuff? I could use some additional resources. I am not familiar with ketamine or memantine. What do they do? Are they available in the U.S.? What research has been done specifically regarding depression?The info. on NMDA receptors and drugs is scattered. Usual sources- medscape, search engines. You should look at Dr Goldstein's site: http://www.drjgoldstein.com/frames/05artbook.html. He uses NMDA antagonists and occasionally agonists (either direct or indirect) to treat CFIDs pain and cognitive dysfunction (and energy?) in the main but also has noted mood improvements.
Ketamine was recently made a schedule three drug in the US due to its abuse on the streets. Note that street abuse of the drug creates disassociative states not unlike schizophrenia, which are quite distinct from the effect of ketamine at low doses. Used mainly as an anethsthetic.
Memantine available only in Germany. I ordered some recently but have yet to do a trial with it. Main uses are for dementia, glucauma, neuropathic pain, and hearing loss(?). The common thread in its effectiveness for these diverse conditions is its ability to prevent neuronal die off due to excess glutamate (via the NMDA receptors) activity.
A simple medscape search will reveal the research done on nimodipine and ketamine concerning mood and depression. Little research is out there. It has yet to be established in what way the NMDA receptors may be involved with mood.
>
> Does nimodipine do things other than block L-type calcium channels? I saw one person report success with it on the board before it turned over. I don't recall what his/her diagnosis was. Expensive stuff. I think its only indication is for post-stroke application to help prevent necrosis.
>
Nimodipine, at least according to Goldstein, is indirectly involved with NMDAand dopamine receptors. Nimodipine is expensive here but can be purchased inexpensively from overseas. Though nimodipine's only indicated usage may be for post-stroke prevention of neuronal death, its off label uses are, I believe, significant.AndrewB
Posted by Angela5 on July 9, 2000, at 12:07:27
In reply to Re: Lamictal side effects and doseage Qs » Angela5, posted by SLS on July 9, 2000, at 7:51:07
Thanks for your help, Wallabee and SLS. I'll keep you posted.
By the way, Scott, I liked the "double vision double vision." :)
This is the end of the thread.
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