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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 6 of 6. This is the beginning of the thread.
Posted by JahL on April 1, 2002, at 22:23:23
Dear Dr Kramer.
Another very treatment resistant individual with BP NOS, social phobia, derealisation. Tried in excess of 40 meds.
Another noted pdoc who sometimes frequents these pages suggested I exploit the synergy I enjoy from Lamictal & Klonopin (neither works alone; together they help moderately) and explore complex AED cocktails. ADs are a no-no; tried 15 or so & all worsened my depression (when they weren't briefly inducing euthymia).
Anecdotally, are there any AEDs (I've already added Keppra & Neurontin to no effect) that might be good candidates to add to Lamictal? Oxycarbamazepine? Tiagabine? Topiramate? Zonisamide???
I have read encouraging reports about Lamictal + VPA (which reduced SI when I took it alone) but I am concerned about the obvious interaction.
Do you have any thoughts?
Thanks for your time.
J.
Posted by Dr. Kramer on April 2, 2002, at 11:28:12
In reply to Dr Kramer: AED cocktails for BPII/NOS., posted by JahL on April 1, 2002, at 22:23:23
> Dear Dr Kramer.
>
> Another very treatment resistant individual with BP NOS, social phobia, derealisation. Tried in excess of 40 meds.
>
> Another noted pdoc who sometimes frequents these pages suggested I exploit the synergy I enjoy from Lamictal & Klonopin (neither works alone; together they help moderately) and explore complex AED cocktails. ADs are a no-no; tried 15 or so & all worsened my depression (when they weren't briefly inducing euthymia).
>
> Anecdotally, are there any AEDs (I've already added Keppra & Neurontin to no effect) that might be good candidates to add to Lamictal? Oxycarbamazepine? Tiagabine? Topiramate? Zonisamide???
>
> I have read encouraging reports about Lamictal + VPA (which reduced SI when I took it alone) but I am concerned about the obvious interaction.
>
> Do you have any thoughts?
>
> Thanks for your time.
>
> J.Sure. They're all possiblities. I've had good luck giving Depakote and Lamictal together; it's by no means prohibitive, you just have to pay attention, keep the doses low, and watch blood levels. It works.
Posted by SLS on April 2, 2002, at 16:21:48
In reply to Dr Kramer: AED cocktails for BPII/NOS., posted by JahL on April 1, 2002, at 22:23:23
> I have read encouraging reports about Lamictal + VPA (which reduced SI when I took it alone) but I am concerned about the obvious interaction.Just a thought, JahL...
If you are a little squirrely about adding Depakote to Lamictal, you may want to try filling that role by adding Neurontin first. In a superficial way, Neurontin and Depakote are similar in that they are both pro-GABAergic. Lamictal is not. This combination has been used quite a bit at the NIMH by Post's group. They claim some good results with BP II. Otherwise, just cut in half the dosage of Lamictal when you add Depakote. 1/2 is usually right on target.
Lamictal: Na+ channel blockade + NMDA antagonism (no increase in GABA activity)Depakote: Na+ channel blockade + increased GABA activity
Neurontin: Increased GABA activity (no Na+ channel blockade)
- Scott
Posted by JahL on April 2, 2002, at 18:43:42
In reply to Re: Dr Kramer: AED cocktails for BPII/NOS. » JahL, posted by SLS on April 2, 2002, at 16:21:48
>
> > I have read encouraging reports about Lamictal + VPA (which reduced SI when I took it alone) but I am concerned about the obvious interaction.
>
>
>
> Just a thought, JahL...
>
>
> If you are a little squirrely about adding Depakote to Lamictal, you may want to try filling that role by adding Neurontin first. In a superficial way, Neurontin and Depakote are similar in that they are both pro-GABAergic. Lamictal is not. This combination has been used quite a bit at the NIMH by Post's group. They claim some good results with BP II. Otherwise, just cut in half the dosage of Lamictal when you add Depakote. 1/2 is usually right on target.
>
>
> Lamictal: Na+ channel blockade + NMDA antagonism (no increase in GABA activity)
>
> Depakote: Na+ channel blockade + increased GABA activity
>
> Neurontin: Increased GABA activity (no Na+ channel blockade)+++++++++++++
Hi Scott.
Tried Neurontin but it didn't add anything to the Lamictal. Keppra, another AED I was happy to add because of lack of drug-drug interaction potential, actually worsened my depression.
I'd be a lot happier mixing Depakote with Lamictal if under the supervision of a pdoc. However I doubt any UK pdoc would go near such a combo. Most won't go near Lamictal monotherapy IME. Drug 'rationalisation' is the order of the day here.
I'm worried about provoking a reaction which could force me off Lamictal, which isn't an option. I've had a couple of reactions before... Any self-induced 'injury' would make me a 'liability' and would give pdocs all the justification they need not to continue treating me. Bit of a lose-lose situation.
Still, life's too short to wait for the UK medical establishment to wake up so I'll probably give it a go. I think the Lamictal PDF gives pretty comprehensive guidelines re: adding Depakote. I should read more but I have the same sort of cognition problems I've seen you describe before.
Anyway, thanks.
Any other ideas re: AED cocktials from anyone are welcome.Ta,
J.
Posted by Ritch on April 2, 2002, at 22:08:38
In reply to Re: Dr Kramer: AED cocktails for BPII/NOS. » SLS, posted by JahL on April 2, 2002, at 18:43:42
> Any other ideas re: AED cocktials from anyone are welcome.
>
> Ta,
> J.
Hi JahL,We can't get this here in the states (yet), but have you tried clobazam? It is supposed to be similar to clonazepam (for anx. disorders) but it is more effective for complex partial seizures whereas clonazepam is most effective for absence seizures. Also, clorazepate.. tried that one? Might make for a good add-on. Tiagabine caused pronounced derealization episodes for me and MB. Not sure you might want to chance that one.
Just trying to grasp some straws here,
Mitch
Posted by SLS on April 3, 2002, at 10:43:54
In reply to Re: Dr Kramer: AED cocktails for BPII/NOS. » SLS, posted by JahL on April 2, 2002, at 18:43:42
> I'm worried about provoking a reaction which could force me off Lamictal, which isn't an option. I've had a couple of reactions before... Any self-induced 'injury' would make me a 'liability' and would give pdocs all the justification they need not to continue treating me. Bit of a lose-lose situation.
What reaction are you talking about?If you are worried about the rash / Steven Johnson Syndrome, I don't think you are any longer at risk now that you are at therapeutic dosages, as long as you maintain a similar blood-level. The only drug-drug interaction I am aware of is that Depakote increases the elimination half-life of Lamictal by a factor of 2. When I added Depakote to an ongoing trial of Lamictal 300mg, I simply reduced the dosage of Lamictal to 150mg. I had no trouble with it. There are blood-tests available to help you monitor Lamictal blood-levels if you feel more comfortable doing that.
I hope you can convince your doctor that it is worth a try. The PDR and the manufacturer's package-insert label describe very clearly how to dose both medications when they are used in combination. Clearly, Lamictal was developed as an add-on to traditional anticonvulsants in the treatment of partial-seizure epilepsy. Please post your progress with this.
Good luck.
- Scott
This is the end of the thread.
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