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Re: Lamictal Restart - Attn SLS, Cam, JohnL Sulpicia

Posted by Ron Hill on January 29, 2001, at 11:08:05

In reply to Lamictal restart dosage help, posted by Sulpicia on January 28, 2001, at 15:42:36

Hi Sulpicia,

Boy you have been doing your homework, huh? Your daughter is fortunate to have such a caring and intelligent mom. I'm not going to be able to tell you anything you don't already know, but I'll add my two cents worth since your daughters situation hits close to home.

I am BP II currently taking Lithobid (600 mg/day), Prozac (20 mg/day), and Wellbutrin (100 mg/day). My meds are currently working extremely well (PTL). However, I was initially misdiagnosed as ADHD and prescribed Ritalin. The Ritalin pushed me into mania big time. But the mania felt so good that I could not be convinced by the people around me that something was wrong. And my ex-pdoc did not recognize my mania but instead kept writing scripts for Ritalin (can you say malpractice?).

I mention this only to say that I have a BIG CONCERN about putting a BP patient on a stimulant (Adderall in this case) without first having a mood stabilizer fully in place. Yes, I know you have this concern also.

At the same time, as a parent you want to "fix" the depression ASAP. However, as you know, a switch into mania could (maybe) result in a more treatment resistant BP disorder. So I can see how its been hard for you to decide in this case.

Here is what I would do (beware, however, I am no expert, so take my advice with that in mind):

1) Ditch the Adderall, keep the Wellbutrin, and slowly titrate the Lamictal up to a therapeutic level. Carry the kid through the short-term depression by taking special care of her until the Lamictal kicks in. In particular, talk with the kid a lot and help her fully understand what is happening in her brain and that the depression will be short lived. This too shall pass. Repeatedly fill her with hope and positive thoughts.

Encourage her to spend some time outside during sunlight hours and, if at all possible, have her exercise daily. Encourage her to have visitors and invite her friends over, provided your daughter is willing to be vulnerable enough to let her friends know that she is going through a short-term depression. I wouldn't spoil the kid, but I would be very understanding and cut the kid more slack than would otherwise be allowed.

After the full dose of lamictal is in place, if the kid is coming out of the depression but is still lethargic, unmotivated, with lack of energy and enthusiasm, then add an SSRI to the mix keeping the Wellbutrin and mood stabilizer in place. However, do not add an SSRI without a mood stabilizer fully in place.

2) Talk to the pdoc about the efficacy of adding Neurontin, Tegretol, or another AED (but not Depokote) as an adjunct mood stabilizer until the Lamictal can be fully ramped up.

Well that's my two cents. Solicit responses from SLS, Cam W, and JohnL.

I took Lamictal at one time and I liked it. However, I developed a rash and decided to quit. Fortunately, Lithobid works well for me. At some time in the future I may try adding a small amount of Lamictal to my Lithobid because I really liked Lamictal. As I later learned, I ramped up the lamictal way too fast in my first trial.

Best Wishes!

-- Ron


> Sorry in advance to anyone who's read this b4; I posted this earlier on the kiddie forum.
> Hi Folks --
> I have one horribly depressed 15 y/o with bipolar II dx. She was doing really well on wellbutrin and lamictal. Alas:
> a week or so after we moved to 150mgs during a nice slow and by the books increase, she developed an actinic
> rash and mouth ulcers. We took her off for nine frantic days while I tracked down and read *everything* written
> about lamictal, lamictal and wellbutrin, SJS, TENS, actinic rashes, restarts, you name it. Rash went away w/in 24
> hrs of starting prednisone. No biopsy [I read the derm stuff last like an idiot] so no confirmation other than
> hypersensitivity. In view of the facts that: she didn't respond to depakote at all [8 wks therapeutic level] and was
> rendered unconscious after 36 hrs by starting dose of lithium, had 4 p-hospitalizations and nearly died, we
> decided to restart the lamictal. There is virtually no data here for us to work with. I know the rule: start low and go
> slow. So far so good and up to 25mgs w/out problems. Am checking temp, lymph nodes, and skin. *Frequently*
> Her severe depression returned w/in 24 hrs of stopping lamictal and has not shown any signs of letting up. Terrible
> hypersomnia, 22 hrs per day, sadness, apathy, hunger, unable to eat, bathe or do anything. Once last week she
> was able to stay awake for 24 hrs straight and made it to school. For one day out of the last 2 wks. Not a bad
> strategy to use sleep deprivation to combat depression. Anyway, at the safe rate of increase she will be at the
> level were she got relief in about 6 wks. She'll never make it. Pdoc tried provigil to no effect. This morning we
> were down to 2 choices: try adding adderall [tricky at best w/ BP II and recent substance abuse remission] , or
> exceed the traditional increase rate and pray. Started adderall 20mgs this AM; couldn't get up until severely
> harrassed and threatened, and only managed 4 hrs awake. No mania tho or drug cravings. Thank god for AA.
> So, here's the question: I need experiential, or best guess, or even ethical calculus input here -- how fast can we
> increase the lamictal?
> And yes, just in case you're wondering, I *do* realize that we're playing with fire but the situation is dire. Pdoc is
> fabulous, highly experienced but there is simply no available data on which to make a decision. We're reluctant to
> do a faster increase but also horrified of relapse. Between a rock and hard place indeed.
> Any and all input appreciated.




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