Posted by AnneL on January 4, 2004, at 9:56:01
In reply to Lithium or Lamictal rash?? » Ron Hill, posted by katia on January 4, 2004, at 1:56:56
Katia,
Lamictal has been associated in rare cases of causing SJS. I would like to add that many, many other medications, such as common antibiotics have also been associated with SJS.
A benign rash will occur in approximately 10 to 11 percent of those taking it. The problem that you are currently facing is whether or not a seemingly benign rash is actually a precursor to SJS. This is the reason why most pdocs will request that the patient stop Lamictal at the onset of any rash. However, that being said, some pdocs who are becoming very experienced with Lamictal in the Bipolar patient (Calabrese, J.
Huang, et al., Lauren Marangell, M.D.) and are referring patients to a dermatologist experienced with SJS to assist with making determinations as to whether it is SJS or a benign rash. The concept is that if a proper diagnosis is made before 3 days, the patient can resume Lamictal at their last dose without having to restart at the slow titration level. How up-to-date your Pdoc is with recent research into the SJS/Lamictal debate and current management trends will determine how your Pdoc addresses your rash. Obviously, a Pdoc cannot diagnose SJS, only a dermatologist who has actually seen and treated cases of SJS is qualified to make this diagnosis.
The problem is that many Pdocs may not be up-to-date on the emergence of other treatment options available in the decision-making tree when a rash appears. Step 1: Get a referral to a dermatologist who is experienced in SJS. Step #2:
Research the professionals who are named in the following text. I hope that you will be able to continue Lamictal after your rash has been diagnosed as benign or that you receive steriod treatment immediately if it is suspect. :) AnneLDr. Joseph Calabrese appears to have the most experience with Lamictal. Here are some articles and links that I think may be helpful to you:
J Clin Psychiatry. 2002 Nov;63(11):1012-9.
Rash in multicenter trials of lamotrigine in mood disorders: clinical relevance and management.
PsychEducation.org
PsychEducation.org (Dr. Jim Phelps)
Details on the Lamotrigine Rash"First, do we know how this medication compares with others which are also recognized to cause "Stevens-Johnson Syndrome", and other severe skin reactions (e.g. TEN)? Is is more likely to cause this than Tegretol, for example? There are only two studies I've found so far that speak to this "relative frequency" question, and both are limited by the very small numbers of patients taking lamotrigine, so at this point I'm not sure anyone can really answer that question.
In one study, the rash rate for anticonvulsants generally was given as 2.5%,Sharma whereas the rate usually given for lamotrigine is 10% when the medication is started according to the manufacturer's recommended rates (25 mg to start). However, in one of those studies the rash rate on placebo was 5%, probably because of all the attention given to "the rash" when explaining to patients the risk of the pills they were about to take. So, for now we can say that it appears the risk of lamotrigine is somewhat higher than carbamazepine, but it's not clear how much higher.
Just for comparison, here are rates for kids getting rashes on antibiotics:Ibia
Penicillin 7.4%
Sulpha-based 8.5%
Cephalosporins 2.6%
One cephalosporin
called Ceclor 12.3%If rash, then what?
There are ways to identify the rashes that carry great risk (e.g. Stevens-Johnson syndrome; TEN; . The problem is that simple rashes, lacking the known danger signs, can also be risky, so it's not easy to say "oh, this rash is safe". And since there is a very low rate of severe skin reactions that can (rarely) even be fatal, any rash that appears while a person is taking lamotrigine should raise concern.What are the signs of great risk? Here are the versions I've heard so far: s
"Anything above the neck"
"Around or in the mouth"
"Soft tissues (like mucous membranes of mouth, nose, eyes -- including the membrane over the eye (conjunctiva), so a red, sore eye counts) (or the anus, also a mucous membrane, also counts)
"Anything on the face"
Obviously these all describe nearly the same area, but the "soft tissues" version is the most specific.Three strategies for rash
Stop for any rash anywhere.
Have a dermatologist you can get patients in to see within 24-48 hours; hold the doses until seen.
Stop for any rash above the neck; for anything else, reduce the dose to the previous level, and hold it there until you can tell whether the rash is going away (if so, continue upward again but more slowly and/or by smaller steps; use Benadryl or topical Caladryl to control itching while you're waiting).
Why the hurry to see the dermatologist? Well, the obvious reason is because if there is a risk, you want to stop right away. Secondly, if the medication is stopped for more than 3 days (for any reason), the patient must start again from the very beginning of the dose steps. Therefore if the patient can be evaluated very quickly, she can stop the medication, get a "green light" from the dermatologist, and resume the medication at the same dose.If you don't have a dermatologist handy, then strategy #2 may not be practical. That leaves #1 and #3. Number 3 has been recommended in several meetings I've attended, e.g. by Dr. Lauren Marangell at the Menninger Utah meeting, Winter 2002. She spoke confidently of that approach there. There is at least one article which notes having used this approach successfully.e.g.Huang But at a more recent meeting, the manufacturer's representatives were more cautious: by their account, if you can't do #2, you should do #1."
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poster:AnneL
thread:98867
URL: http://www.dr-bob.org/babble/20031231/msgs/296307.html