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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 Briana on May 31, 2001, at 9:42:24
Hi all. Sorry to beat a dead horse, as I am sure that you have discussed Lamictal before, but I haven't been on line in awhile. I'm considering a switch to Lamictal so that I can get off lithium. I currently take 1200 mg lith, 2400 mg Neurontin, celexa and klonopin as needed. I've gained 25 lbs on the lithium and neurontin, and I need to get my weight under control. I have bipolar disorder AND TLE, so my neurologist suggested Lamictal. I would be discontinuing the Neurontin as well. I am wondering
a) how it works as a sole mood stablizer
b) HOW GREAT A RISK IS THE RASH? I am a hypochondriac, and seeing a warning about a fatal rash on the drug insert has me very scared
c) what are the side effects?Any input would be totally appreciated.
Thanks,
Briana
Posted by loosmrbls on May 31, 2001, at 12:13:01
In reply to Lamictal -- PLEASE PLEASE advise, posted by Briana on May 31, 2001, at 9:42:24
Initial case reports show Lamictal has great promise as a sole mood stabilizer, or in combinateion with others. However, there are no large studies to confirm this "scientifically." It is certainly worth a shot.
As for the rash, simply stopping the drug at the first sign of a rash is sufficient. Not all drug rashes on Lamictal are potentially fatal, but to prevent potentially bad outcomes, one needs to stop the drug if a rash starts to develop. I would not let this stop you from giving it a try
Posted by SalArmy4me on May 31, 2001, at 17:18:13
In reply to Lamictal -- PLEASE PLEASE advise, posted by Briana on May 31, 2001, at 9:42:24
Hi Brianna,
The fear of a Lamictal rash has caused many to avoid the drug, and they now suffer with a drug that has more side-effects.
The fears over Lamictal (lamotrigine) rashes are unfounded. The chance of having a mild to moderate rash are 3%--according to clinical trials. But clinical trials done years ago do not necessarily predict the incidence of side-effects now. Besides, most of these rashes were due to taking a combination of Valproate and Lamictal, and they resolve without hospital stays. I believe that the chance of a seizure from Wellbutrin is much higher, and the chance of a hypertensive crisis with phenelzine is a little higher.
The chance of having a severe rash leading to hospitalization is reported as 0.3%. With those odds, it is easier to get hit by
lightening than it is to have a Lamictal rash. Point in case: You never hear in the paper about someone severely harmed
by Lamictal.
I have taken Lamictal for one year with a moderate benefit and absolutely no side-effects. I believe that Lamictal will replace Lithium as the drug of choice in bipolar disorder in 10 years, due to its prominent antidepressant effect and benign side-effect profile.
Posted by SLS on June 2, 2001, at 11:07:56
In reply to Re: Lamictal -- PLEASE PLEASE advise » Briana, posted by SalArmy4me on May 31, 2001, at 17:18:13
Dear Sal,
> The fears over Lamictal (lamotrigine) rashes are unfounded.
I think using the word "unfounded" is deceptive and perhaps dangerous. I have known several people who have had the rash evolve early using a titration schedule more rapid than that suggested by the drug manufacturer. They were forced to discontinue Lamictal and restart it. Using the more gradual titration schedule, they were successful in establishing a therapeutic dosage. I don't know if this is related to the rash phenomenon, but I would experience an itch in the inner corner of both eyes upon dosage increases. This includes a dosage increase from 200mg to 300mg. This itch would last from a few hours to a day or so. It just so happens that this itch is similar to what I experience as a result of an allergy to oak tree pollen.
> The chance of having a mild to moderate rash are 3%--according to clinical trials.
In my opinion, 3% is large enough a number to warrant adherence to the prescribed titration schedule. Line up 33 people. 1 of them might die. Unacceptable.
Better to be safe...
- Scott
Posted by SalArmy4me on June 2, 2001, at 11:24:30
In reply to Re: Lamictal -- PLEASE PLEASE advise » SalArmy4me, posted by SLS on June 2, 2001, at 11:07:56
The danger of a SEVERE rash leading to hospitalization is 0.03%--three hundredths of a percentage point. Rash is a common problem with many medications, but since Lamictal is newer, patients can't get over the idea that something harmful_could_ occur no-- matter how many hundreths of a percent this "danger" represents.
Did you know that, "At doses of up to 300 mg/day, Wellbutrin's incidence of seizures is approximately 0.1% (1/1000) but increases to approximately 0.4% (4/1000) at the recommended dose (for treatment of depression) of 400 mg/day of the sustained-release formulation or 450 mg/day of the immediate-release formulation."
Why is there more concern about Lamictal rashes than there is about Wellbutrin? People are taking Wellbutrin like it was candy around the world. One day, Lamictal will become candy in the world and we're going to kick ourselves because we thought it was going to kill us.
> Dear Sal,
>
> > The fears over Lamictal (lamotrigine) rashes are unfounded.
>
> I think using the word "unfounded" is deceptive and perhaps dangerous. I have known several people who have had the rash evolve early using a titration schedule more rapid than that suggested by the drug manufacturer. They were forced to discontinue Lamictal and restart it. Using the more gradual titration schedule, they were successful in establishing a therapeutic dosage. I don't know if this is related to the rash phenomenon, but I would experience an itch in the inner corner of both eyes upon dosage increases. This includes a dosage increase from 200mg to 300mg. This itch would last from a few hours to a day or so. It just so happens that this itch is similar to what I experience as a result of an allergy to oak tree pollen.
>
> > The chance of having a mild to moderate rash are 3%--according to clinical trials.
>
> In my opinion, 3% is large enough a number to warrant adherence to the prescribed titration schedule. Line up 33 people. 1 of them might die. Unacceptable.
>
> Better to be safe...
>
>
> - Scott
Posted by SLS on June 2, 2001, at 13:12:20
In reply to Re: Lamictal -- PLEASE PLEASE advise » SLS, posted by SalArmy4me on June 2, 2001, at 11:24:30
> > > The chance of having a mild to moderate rash are 3%--according to clinical trials.> > In my opinion, 3% is large enough a number to warrant adherence to the prescribed titration schedule. Line up 33 people. 1 of them might die. Unacceptable.
> >
> > Better to be safe...> The danger of a SEVERE rash leading to hospitalization is 0.03%--three hundredths of a percentage point. Rash is a common problem with many medications, but since Lamictal is newer, patients can't get over the idea that something harmful_could_ occur no-- matter how many hundreths of a percent this "danger" represents.
Whatever, Sal.What percentage of those 3% of subjects you cited who developed mild to moderate rash-reactions were discontinued so that the reaction not reach the point of severity and fatality? Something to think about, eh?
> Did you know that, "At doses of up to 300 mg/day, Wellbutrin's incidence of seizures is approximately 0.1% (1/1000) but increases to approximately 0.4% (4/1000) at the recommended dose (for treatment of depression) of 400 mg/day of the sustained-release formulation or 450 mg/day of the immediate-release formulation."
Yes, I did. I believe I posted such within the last week or so. So, what's your point?
Sal, you can do whatever you want the next time you start taking Lamictal. However, I would suggest to you and anyone else reading this that the potential danger and statistical probability of experiencing a serious rash-reaction using a rapid titration schedule of Lamictal is such as to warrant following the instructions of the manufacturer. What percentage of your patients have you titrated Lamictal rapidly without the appearance of the rash-reaction?
You do a lot of good work here. You wouldn't want to spoil it with an unnecessary tragedy.
> In my opinion, 3% is large enough a number to warrant adherence to the prescribed titration schedule. Line up 33 people. 1 of them might die. Unacceptable.
>
> Better to be safe...
>
> - Scott
- Scott
Posted by petter on June 3, 2001, at 1:04:14
In reply to Re: Lamictal -- PLEASE PLEASE advise, posted by SLS on June 2, 2001, at 13:12:20
>
> > > > The chance of having a mild to moderate rash are 3%--according to clinical trials.
>
> > > In my opinion, 3% is large enough a number to warrant adherence to the prescribed titration schedule. Line up 33 people. 1 of them might die. Unacceptable.
> > >
> > > Better to be safe...
>
> > The danger of a SEVERE rash leading to hospitalization is 0.03%--three hundredths of a percentage point. Rash is a common problem with many medications, but since Lamictal is newer, patients can't get over the idea that something harmful_could_ occur no-- matter how many hundreths of a percent this "danger" represents.
>
>
> Whatever, Sal.
>
> What percentage of those 3% of subjects you cited who developed mild to moderate rash-reactions were discontinued so that the reaction not reach the point of severity and fatality? Something to think about, eh?
>
> > Did you know that, "At doses of up to 300 mg/day, Wellbutrin's incidence of seizures is approximately 0.1% (1/1000) but increases to approximately 0.4% (4/1000) at the recommended dose (for treatment of depression) of 400 mg/day of the sustained-release formulation or 450 mg/day of the immediate-release formulation."
>
> Yes, I did. I believe I posted such within the last week or so. So, what's your point?
>
> Sal, you can do whatever you want the next time you start taking Lamictal. However, I would suggest to you and anyone else reading this that the potential danger and statistical probability of experiencing a serious rash-reaction using a rapid titration schedule of Lamictal is such as to warrant following the instructions of the manufacturer. What percentage of your patients have you titrated Lamictal rapidly without the appearance of the rash-reaction?
>
> You do a lot of good work here. You wouldn't want to spoil it with an unnecessary tragedy.
>
> > In my opinion, 3% is large enough a number to warrant adherence to the prescribed titration schedule. Line up 33 people. 1 of them might die. Unacceptable.
> >
> > Better to be safe...
> >
> > - Scott
>
>
> - ScottHi Scott!!
Im on Lamictal 100mg for cronic depression. my current coctail are Effexor+Remeron+Litium+Lamictal. This combo works great, after suffering many years, and trying many different combo.
One problem with Lamictal for me is a serve lightsensetive, photofobi. I also burn my skin after only a couple of minuts in the sun.
Do you know any other med to replace Lamital with, and that have the same antidepressiv properties as Lamital have??
I live in Sweden, and I am a mental healt proffesional. We are not so familiar here in Sweden with the newer med like Lamictal etc.
Any advise? Please.
Sincerely.
Petter
Posted by SLS on June 3, 2001, at 11:35:23
In reply to Re: Lamictal -- PLEASE PLEASE advise » SLS, posted by petter on June 3, 2001, at 1:04:14
Hi Petter.
> Im on Lamictal 100mg for cronic depression. my current coctail are Effexor+Remeron+Litium+Lamictal. This combo works great, after suffering many years, and trying many different combo.You are taking a great combination of drugs! Very good.
> One problem with Lamictal for me is a serve lightsensetive, photofobi. I also burn my skin after only a couple of minuts in the sun.
Important: I am not a doctor.
Thank you for the flattery to ask me questions.
Since 4 drugs are involved, I want to have a pharmacist or someone who knows more than me answer. I do not know what is the probability Lamictal is responsible for photosensitivity. Remeron and Effexor also cause photosensitivity.
Why do you think Lamictal is the drug causing photosensitivity?
Is the photosensitivity too severe that you MUST change drugs?
> Do you know any other med to replace Lamital with, and that have the same antidepressiv properties as Lamital have??
No.
Lamictal is unique.
How long have you been taking this combination of all 3 drugs?
Are you sure Lamictal is necessary?
If you do not know, maybe test if Lamictal is necessary. You can try reducing the dosage of Lamictal to see if you relapse and the depression returns again.
If you need all 4 drugs AND you know that Lamictal is causing photosensitivity, maybe you can use instead:
- Anticonvulsants: Topomax (topiramate) or Neurontin (gabapentin)
- Atypical neuroleptic antipsychotics: Zyprexa (olanzapine) or Risperdal (risperidone) or Zeldox (ziprasidone) or Solian (amisulpride)
- Dopamine agonists: pramipexole (Mirapex) or ropinerole (Requip) or pergolide (Permax) or piribedil (Trivastal) or bromocriptine (Parlodel)
- Stimulants: dl-amphetamine (Adderall) or Cylert (pemoline) or Ritalin (methylphenadate)
> I live in Sweden, and I am a mental healt proffesional. We are not so familiar here in Sweden with the newer med like Lamictal etc.
>
> Any advise? Please.
>
> Sincerely.
>
> Petter
Again, I am not a doctor. But maybe my ideas are good to research.I wish I could help you better. Maybe others can help you also.
Good luck.
:-)
Sincerely,
Scott
Posted by Cam W. on June 3, 2001, at 13:57:57
In reply to Re: Lamictal -- PLEASE PLEASE advise » SLS, posted by petter on June 3, 2001, at 1:04:14
Petter - If this combination of drugs is working, I'd consider using a sunblock (SPF > 30) rather than trying to change meds. Hell, you live in Sweden; how often does the sun shine ;^). I really can't add anything else to Scott's post. - Cam (a Canadian)
Posted by SLS on June 3, 2001, at 14:41:39
In reply to Re: Lamictal -- PLEASE PLEASE advise » petter, posted by Cam W. on June 3, 2001, at 13:57:57
> Petter - If this combination of drugs is working, I'd consider using a sunblock (SPF > 30) rather than trying to change meds. Hell, you live in Sweden; how often does the sun shine ;^). I really can't add anything else to Scott's post. - Cam (a Canadian)
That's just like you, Cam. Take the easy, obvious, safe, effective, economical, and logical way out.Have you no shame?
:-)
- Scott
Posted by petter on June 3, 2001, at 16:03:52
In reply to Re: Lamictal -- PLEASE PLEASE advise » petter, posted by SLS on June 3, 2001, at 11:35:23
> Hi Petter.
>
>
> > Im on Lamictal 100mg for cronic depression. my current coctail are Effexor+Remeron+Litium+Lamictal. This combo works great, after suffering many years, and trying many different combo.
>
> You are taking a great combination of drugs! Very good.
>
> > One problem with Lamictal for me is a serve lightsensetive, photofobi. I also burn my skin after only a couple of minuts in the sun.
>
> Important: I am not a doctor.
>
> Thank you for the flattery to ask me questions.
>
> Since 4 drugs are involved, I want to have a pharmacist or someone who knows more than me answer. I do not know what is the probability Lamictal is responsible for photosensitivity. Remeron and Effexor also cause photosensitivity.
>
> Why do you think Lamictal is the drug causing photosensitivity?
>
> Is the photosensitivity too severe that you MUST change drugs?
>
> > Do you know any other med to replace Lamital with, and that have the same antidepressiv properties as Lamital have??
>
> No.
>
> Lamictal is unique.
>
> How long have you been taking this combination of all 3 drugs?
>
> Are you sure Lamictal is necessary?
>
> If you do not know, maybe test if Lamictal is necessary. You can try reducing the dosage of Lamictal to see if you relapse and the depression returns again.
>
> If you need all 4 drugs AND you know that Lamictal is causing photosensitivity, maybe you can use instead:
>
> - Anticonvulsants: Topomax (topiramate) or Neurontin (gabapentin)
>
> - Atypical neuroleptic antipsychotics: Zyprexa (olanzapine) or Risperdal (risperidone) or Zeldox (ziprasidone) or Solian (amisulpride)
>
> - Dopamine agonists: pramipexole (Mirapex) or ropinerole (Requip) or pergolide (Permax) or piribedil (Trivastal) or bromocriptine (Parlodel)
>
> - Stimulants: dl-amphetamine (Adderall) or Cylert (pemoline) or Ritalin (methylphenadate)
>
> > I live in Sweden, and I am a mental healt proffesional. We are not so familiar here in Sweden with the newer med like Lamictal etc.
> >
> > Any advise? Please.
> >
> > Sincerely.
> >
> > Petter
>
>
> Again, I am not a doctor. But maybe my ideas are good to research.
>
> I wish I could help you better. Maybe others can help you also.
>
> Good luck.
>
> :-)
>
>
> Sincerely,
> ScottHi Scott, Cam!!!
Im really flattered and impressed that you answer me so fast and gave me so many alternative, and options. Thank you very much. This would not likely occur in Sweden. I think you in US have a more open attitude in subjects like this.
I know that Lamictal cause this photofobia and lightsensetiv, because before I started it I had the tree other med mix without any problem. This make my situation very difficult and precarious, because Lamictal is great for depression. I also tried reduced it to 50 mg, but relapsed, and sign of depression returned.
I also tried atypical neuroleptics such as Risperdone and Zeldox, but without any succes. I also tried Mirapex, with the same result.
I know Cam, Sweden is not associated with summer. But we now have summertime, and sunshine does often shine. Sun block don´t help against the lightsensetive(eyes)
So, what about Neurontin?? I have heard that it does not recomend in bipolar depression. But I read someplace that it can act as a antidepressant. what are you experience?
Sincerely
Petter
Posted by Cam W. on June 3, 2001, at 16:25:45
In reply to Re: Lamictal -- PLEASE PLEASE advise, posted by petter on June 3, 2001, at 16:03:52
Petter - Neurontin™ (gabapentin) may be worth a try, but from what I have seen, it does not work as well as Lamictal™ (lamotrigine) in bipolar depression. Topamax™ (topiramate) may be a better option, as it does seem to have better antidepressant action than Neurontin.
As with the Lamictal, the Topamax dose needs to be titrated slowly to minimize the cognitive side effects (simple math, name finding problems) associated with it.
Hope this is of some help. - Cam
Posted by chloe on June 3, 2001, at 18:24:42
In reply to Re: Lamictal -- PLEASE PLEASE advise » petter, posted by Cam W. on June 3, 2001, at 16:25:45
Cam,
I started Lamictal 12.5 last Saturday for uncontrolled rapid cycling. I felt ok the first day, but the second day I was totally slugged out with a terrible headache that nothing helped.I know starting this drug slowly is extremely important, and I am very drug sensitive, hence a half a pill every 3-4 days. But I have read on this board that a headache can indicate too large an increase of medication. I have been trying to ask my pdoc if I could take half of a half (if that possible, the pill is already so tiny!), about 6 mgs every other day. My question is will I build up a better blood level this way? It seems like every fourth day, would cause levels to rise and fall alot.
Any insight into how long the half life of this drug is, and how it is absorbed or metabilized would really help.
Your knowledge, and willingness to share is a real asset to this board! I always look forward to reading your posts.Many thanks in advance
Posted by briana on June 3, 2001, at 18:32:00
In reply to Re: Lamictal -another question! » Cam W., posted by chloe on June 3, 2001, at 18:24:42
I am also interested in reading your response to Chloe's post. I am about to take Lamictal for the first time (I started this thread) and what I want to know is whether it is too fast to take 25 every other day for 2 weeks, then 25 every day for 2 weeks, then titrate upward.
Also, is the rash fatal if caught early?
I am confused about the incidence of the rash and the seriousness of the threat. I've read conflicting things about that here.
What are other side effects?
How many people have died from this rash? Do we ever hear about them? I haven't.
Does it interact with Klonopin at all? How about Celexa?
I'm taking Neurontin and Lithium and I am going on the Lamictal to hopefully replace both.
I feel really stupid, but I am scared of this rash!!
> Cam,
> I started Lamictal 12.5 last Saturday for uncontrolled rapid cycling. I felt ok the first day, but the second day I was totally slugged out with a terrible headache that nothing helped.
>
> I know starting this drug slowly is extremely important, and I am very drug sensitive, hence a half a pill every 3-4 days. But I have read on this board that a headache can indicate too large an increase of medication. I have been trying to ask my pdoc if I could take half of a half (if that possible, the pill is already so tiny!), about 6 mgs every other day. My question is will I build up a better blood level this way? It seems like every fourth day, would cause levels to rise and fall alot.
>
> Any insight into how long the half life of this drug is, and how it is absorbed or metabilized would really help.
> Your knowledge, and willingness to share is a real asset to this board! I always look forward to reading your posts.
>
> Many thanks in advance
Posted by Cam W. on June 3, 2001, at 19:37:33
In reply to Re: Lamictal -another question! » Cam W., posted by chloe on June 3, 2001, at 18:24:42
• Chloe - The half-life of Lamictal is approximately 33 hours when you first start taking it. The half-life does decrease by about 26% once a steady state (when the amount taken just offsets the amount excreted by the body) after about 14 days, to approximately 26 hours Its rate of absorption is slowed by food, but the extent to which it is absorbed is not, with peak levels occurring 1.4 to 4.8 hours. Lamictal's absolute bioavailability (the amount of drug absorbed and available for mood stabilizing/anticonvulsant activity) is about 98%, which is high compared to other drugs. It is metabolized (hydrolyzed) by the liver.
At the 12.5mg and 6.25mg dosage every 3 to 4 days you probably won't get much of a therapeutic effect, but your body should start adjusting to the side effects. It may take longer to reach a therapeutic effect (ie two months, instead of one), but the lessening of side effects, especially if you are sensitive to them, may make the wait worth it. This slower titration would probably not be adviseable if you were using the Lamictal as an anticonvulsant, but may be appropriate for people who are using it for mood stabilization (and bipolar depression) and are sensitive to its side effects. Do follow your doctor's advice, though. You both need to stay on the same page for treatment therapy, and he/she knows your condition much better than I could.
• Briana - The Lamictal monograph states that a normal starting regimen is 25mg to 50mg daily for two weeks and increasing by 25mg or 50mg every two weeks. Clinically, I find that when used as an adjunct for mood stabilization that taking 25mg for a week or two, then raising it by 25 mg every week or two, seems to work the best and avoids rashes. I should add that, if taken with valproic acid (Depakene™) or divalproex (Epival™ or Depakote™), the dose of Lamictal should be halved because these drugs interfere with Lamictal's metabolism.
As for the rash, yes it is a concern, but not as big a concern as once thought. The Stevens-Johnson life-threatening rash is "usually" seen in children under 12 years, who are titrated too fast. It is the inclusion of children in the statistics that gives a value of 1 in 100 (children have a risk of S-J rash of about 1 in 50). Still, in adults, 1 in 10 get some sort of rash, especially if the dose is increased too fast. This would freak me out if I was taking the drug and one should contact their doctor immediately if they do notice a rash. Chances are it is not S-J, but I wouldn't risk it. We have had a few people who have developed a rash with quick titration, but when rechallenged at a lower dose and increased that dose slower, these people were able to remain on Lamictal, with no return of rash.
So, yes the rash is important to watch for during the initial titration phase of the drug, but if a person does develop a rash, I would say follow the doctor's orders. A doctor must be comfortable with trying a rechallenge with Lamictal, at least until some more scientific study into this area is done.
I hope these answers are of some use to both of you. - Cam
Posted by SLS on June 3, 2001, at 21:41:04
In reply to Re: Lamictal -another question! Briana and » chloe, posted by Cam W. on June 3, 2001, at 19:37:33
This was a nice post, Cam. I'm glad you jumped in to give such a well- balanced presentation.
> • Briana - The Lamictal monograph states that a normal starting regimen is 25mg to 50mg daily for two weeks and increasing by 25mg or 50mg every two weeks. Clinically, I find that when used as an adjunct for mood stabilization that taking 25mg for a week or two, then raising it by 25 mg every week or two, seems to work the best and avoids rashes. I should add that, if taken with valproic acid (Depakene™) or divalproex (Epival™ or Depakote™), the dose of Lamictal should be halved because these drugs interfere with Lamictal's metabolism.
The titration schedule I am familiar with when Lamictal is to be used to treat affective disorders and without the concommitant administration of valproate or enzyme-inducing drugs is as follows:
25mg x 2 weeks (12.5mg b.i.d.)
50mg x 2 weeks (25mg b.i.d.)
100mg x 1 week (50mg b.i.d.)
+50mg every 1 week
For bipolar disorder (depression):
- Average effective dosage = 200mg
- Range = 50mg - 300mgI don't know what dosages have been found to effectively treat rapid-cycling presentations or unipolar depression.
It's a great drug.
My impression is that the risk of precipitating a severe reaction to Lamictal is almost zero if it is administered properly.
- Scott
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
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