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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 40. This is the beginning of the thread.
Posted by Zo on March 25, 2002, at 16:51:07
I see a lot of Lamictal problems on the board, and I don't think it's commonly known that increasing your dose by 25mg a week, or whenever you're ready to, can be the key to remarkable success--and backing up if you overshoot the dose that works for you.I've been on Effexor for years, Dex for a few years. . .and still, TDR remained. Got up to 250mg Lamictal and--poof!
No more depression!
Zo
Posted by Janelle on March 25, 2002, at 17:17:37
In reply to Increase Lamictal very SLOWLY, posted by Zo on March 25, 2002, at 16:51:07
Posted by Bekka H. on March 25, 2002, at 17:29:30
In reply to Increase Lamictal very SLOWLY, posted by Zo on March 25, 2002, at 16:51:07
Hi Zo,
Thanks for your inspiring message! Can you tell me what doses of Dexedrine and Effexor you are on?
Have you had any problems with Lamictal-induced insomnia? I've read a number of posts here from people who have this problem (including me!). Several people suggested Neurontin and/ Klonopin.
Do you take your Lamictal early or late in the day?
Thank you for any advice.
Bekka
Posted by Bekka H. on March 25, 2002, at 17:31:13
In reply to What is TDR? (nm) » Zo, posted by Janelle on March 25, 2002, at 17:17:37
Hi Janelle,
I shouldn't speak for Zo, but I think they might have meant TRD, which is Treatment Resistant Depression.
Bekka
Posted by Bob on March 25, 2002, at 23:05:57
In reply to Increase Lamictal very SLOWLY, posted by Zo on March 25, 2002, at 16:51:07
Zo:
I think you're right, a lot of people do have trouble with Lamictal. I think a lot of it has to do with the medical community having no idea about the need for an extremely slow titration in some cases. No doctor I've come across suggests 25mg/week or slower. When I tried Lamictal, the "starter pack" recommended 25mg x 2 /day. Within days I was itchy, burning, and had a rash on areas of my body. I've actually hear of people who titrate with 12.5mg increments.
It almost reminds me of the situation with withdrawl from psychiatric drugs. Years ago, almost no doctor understood or acknowleded the difficulty of getting of certain SSRIs. Now it is more widely known, but I still don't think the full depth of it is realized. Sometimes people have to titrate down very, very slowly. The only thing slower is the medical community's awareness of it.
Posted by JohnX2 on March 26, 2002, at 3:38:19
In reply to Increase Lamictal very SLOWLY, posted by Zo on March 25, 2002, at 16:51:07
I had a false start on this medication (Lamictal).
My 1st doctor wanted me to titrate the dose to 600 mg in a few weeks.Aout a year later I restarted the medicine with the right dosing strategy and it lifted my major depression with no bad rash. Could have saved myself a lot of depression if my 1st pdoc knew what he was doing. :(
John
>
> I see a lot of Lamictal problems on the board, and I don't think it's commonly known that increasing your dose by 25mg a week, or whenever you're ready to, can be the key to remarkable success--and backing up if you overshoot the dose that works for you.
>
> I've been on Effexor for years, Dex for a few years. . .and still, TDR remained. Got up to 250mg Lamictal and--poof!
>
> No more depression!
>
> Zo
Posted by Zo on March 26, 2002, at 4:03:16
In reply to Re: What is TDR? - Janelle, posted by Bekka H. on March 25, 2002, at 17:31:13
Posted by Zo on March 26, 2002, at 4:05:03
In reply to Re: Increase Lamictal very SLOWLY, posted by JohnX2 on March 26, 2002, at 3:38:19
Posted by Zo on March 26, 2002, at 4:14:21
In reply to Re: Increase Lamictal very SLOWLY-Zo, posted by Bekka H. on March 25, 2002, at 17:29:30
I think I just posted to you on another thread. . .
My Effexor dose decreased over the past fear years, from 400 to 225mg. Maybe because I was on Neurontin too, at the time. It helped with sleep, but I wouldn't recommend strictly for that, it knocked me out---but also seems to have permanently knocked out my fibromyalgia pain. Haven't been on it for maybe a year--still pain-free.
So. . .Effexor 225mg & Dex 10mg in a.m.--and recently added 100mg Provigil, for a little frosting on the cognitive cake.. . .but geez, I am close to anorectic on it. What happens when all the Zyprexa weight is gone? Hope I can eat.
And all my Lamictal at bed, 250mg is where I maxxed out. Plus 10mg Ativan. I feel *human* when I get out of bed in the morning. What a novel idea.
Klonopin is an *excellent* drug, really more effective than Ativan, but it aggravates my ADD, I'm stumbling all the next day. I highly recommend it for sleep. . .but the benzos are like the pstims, they hit everyone differently. Take your pick!
Zo
Posted by Emme on March 26, 2002, at 9:19:55
In reply to Increase Lamictal very SLOWLY, posted by Zo on March 25, 2002, at 16:51:07
Hi folks,
For those who don't know, Lamictal can be gotten in 5 mg tablets. I did an agonizingly slow titration of 5 mg/week to start and then 7.5 mg/week. It meant suffering longer with the depression, but Lamictal had helped me on my first trial. My two mild rashes on the first trial spooked my doctor and me. Then we tried some other unhelpful options and with the advice of a neurologist and with the oversight of a dermatologist, went for a rechallenge with a super slow tiration. It worked - only one flushing reaction which lasted a few hours and was gone. So for those who are very sensitive or are otherwise worried about this drug, going even slower than the recommended 12.5mg/week is an option if you can hang in there while waiting to reach a therapeutic dose.
cheers,
Emme
Posted by jazzdog on March 26, 2002, at 12:53:54
In reply to Re: Increase Lamictal very SLOWLY, posted by Emme on March 26, 2002, at 9:19:55
I titrated by 12.5 mg increments, and still had burning flushing reactions for about half and hour each time. At 100 mg, I switched to 25 mg increases - proportionately, it was only 25% at that level. I'm now at 225, and still rising, though it's taken me four months to get here. This drug requires patience, but it's worth it.
- Jane
Posted by jazzdog on March 26, 2002, at 12:56:25
In reply to Re: Increase Lamictal very SLOWLY-Zo » Bekka H., posted by Zo on March 26, 2002, at 4:14:21
Hi Zo -
Has the Provigil helped your cognition? I need all the help I can get, and I was considering Provigil, because I think 10 years of Zoloft has depleted my dopamine and made me stupid. Also, I could use a little anorexia :).
- Jane
Posted by Zo on March 26, 2002, at 17:18:44
In reply to Provigil for cognition? (sidebar) » Zo, posted by jazzdog on March 26, 2002, at 12:56:25
My god, I could hardly stand three months of Xoloft, it was kinda "sweet" but I stumbled around in a haze and called it my Stupid drug.
Yes , yes , and yes! See my post about same dated today somewhere on this board! A whole new area of clarity on top of what Dex opened up.
Zo . .. (and it's getting really hard to eat, and not eating is awfully stimulating for me)
Posted by SLS on March 27, 2002, at 19:13:04
In reply to Re: Unbelievable. 600mg? Malpractice. (nm) » JohnX2, posted by Zo on March 26, 2002, at 4:05:03
I don't know if that would qualify as malpractice.
When used as an adjunct to traditional anticonvulsants in treating partial siezures, I believe the therapeutic range lies between 300mg and 500mg. However, I don't think 600mg is appropriate for treating mood-disorders. I don't think I have read of anyone needing more than 300mg, but I'm sure some people do. I lose the mild antidepressant effect it affords me whenever I try to reduce my dosage of Lamictal below 300mg.
- Scott
Posted by jazzdog on March 27, 2002, at 20:01:51
In reply to Re: Provigil for cognition? Yesss!, posted by Zo on March 26, 2002, at 17:18:44
Hi Zo - thanks for responding. I've been through all your threads (I think) and I'm encouraged by your response. How long have you been taking it? You probably said somewhere, but I can't find it. In another thread, there's some speculation that lamictal and provigil might eventually counteract one another because one stimulates glutamate and the other reduces it - though it seems to my novice mind that this might mean that they ameliorate the side effects from one another. Since you're taking both, I'd appreciate knowing about any changes in the good response you're having. Like you I'm on 250 lamictal, though I've just gotten rid of my ssri.
- Jane
Posted by SLS on March 28, 2002, at 7:18:17
In reply to Re: Provigil for cognition? Yesss!, posted by jazzdog on March 27, 2002, at 20:01:51
> In another thread, there's some speculation that lamictal and provigil might eventually counteract one another because one stimulates glutamate and the other reduces it...
> - Jane
Hi.This was my initial concern as well when I tried the combination almost two years ago. Sometimes it pays handsomely to be dumb. Sometimes not. In this case, I would also like simply to know how someone else responded to the combination. My ability to best evaluate my trial of Provigil was confounded by my having started taking sulpiride the week prior. (A neuroleptic antipsychotic with antidepressant properties at low dosages). I was taking Lamictal 300mg at the time. Within an hour of my first 100mg dosage of Provigil, I felt a significant improvement. It lasted for one or two hours, but this is sometimes exactly what becomes a positive prognosticator of future long-term response. Unfortunately, I abandoned the trial after only three days when I began to feel like a zombie and experienced a great deal of anxiety, which is uncharacteristic of me. I discontinued both sulpiride and Provigil on the same day. For the next two weeks, I felt much worse than I could account for by my baseline depression. I blamed Provigil and its possibly antagonistic effects to Lamictal. Of course, I can't be sure because I changed two things at once. It could just as easily have been sulpiride. Not smart.
The "smart" part of me still leans in favor of blaming Provigil, but my reactions to some drugs are atypical. Sometimes, one drug will kick another out of bed (an untenable metaphor that I'm too lazy to replace). The offending drug somehow changes the dynamics of the system and renders a previously helpful drug regime useless. This is not a common occurrence, though.
- Scott
Posted by Elizabeth on April 4, 2002, at 5:52:12
In reply to Re: Unbelievable. 600mg? Malpractice., posted by SLS on March 27, 2002, at 19:13:04
Hardly. I've certainly heard of people taking that much. When I tried Lamictal (for a completely off-label use), I went up to 500 mg. (It didn't do me any good at any dose in that range.)
It's not clear how much people need for mood disorders -- it seems to be quite variable, though, and I would certainly allow for the possibility that some need high-end doses. Pharmacokinetic factors may play a role in some cases. Also, remember that the therapeutic serum level range for Depakote goes higher in bipolar d/o than epilepsy -- this could easily be the case for Lamictal as well. Therapeutic levels of Lamictal haven't been established, AFAIK, but it's worth considering the possibility that using higher doses would improve the response rate and the degree of response in mood disorders. I certainly don't think it's been studied enough that we can definitely say that it's no good increasing the dose past a certain amount. Lamictal's general safety and tolerability make it reasonable to consider that higher doses might be beneficial. Just because it's not the primary indication, that doesn't mean that the effective dose is likely to be lower -- it could just as easily be higher.
-elizabeth
Posted by JohnX2 on April 4, 2002, at 10:05:35
In reply to high-dose Lamictal: why not?, posted by Elizabeth on April 4, 2002, at 5:52:12
I think you 2 are missing the point of Zo's post.
The doctor tried to titrate the dose to 600 mg in just a *few weeks*.John
> Hardly. I've certainly heard of people taking that much. When I tried Lamictal (for a completely off-label use), I went up to 500 mg. (It didn't do me any good at any dose in that range.)
>
> It's not clear how much people need for mood disorders -- it seems to be quite variable, though, and I would certainly allow for the possibility that some need high-end doses. Pharmacokinetic factors may play a role in some cases. Also, remember that the therapeutic serum level range for Depakote goes higher in bipolar d/o than epilepsy -- this could easily be the case for Lamictal as well. Therapeutic levels of Lamictal haven't been established, AFAIK, but it's worth considering the possibility that using higher doses would improve the response rate and the degree of response in mood disorders. I certainly don't think it's been studied enough that we can definitely say that it's no good increasing the dose past a certain amount. Lamictal's general safety and tolerability make it reasonable to consider that higher doses might be beneficial. Just because it's not the primary indication, that doesn't mean that the effective dose is likely to be lower -- it could just as easily be higher.
>
> -elizabeth
Posted by Elizabeth on April 7, 2002, at 19:26:14
In reply to Re: high-dose Lamictal: why not? » Elizabeth, posted by JohnX2 on April 4, 2002, at 10:05:35
> The doctor tried to titrate the dose to 600 mg in just a *few weeks*.
How many weeks? I had no trouble getting up to 500 within a month or so.
When titrating a medication (in either direction), the phrase to remember is: "as tolerated!"
-elizabeth
Posted by Zo on April 8, 2002, at 21:45:10
In reply to Re: high-dose Lamictal: why not? » JohnX2, posted by Elizabeth on April 7, 2002, at 19:26:14
Yes-- but I think the inability to tolerate is, unfortunately, quite confusing. One must sort out, while in a confused and confusing state, whether this is due to drug or dose, whether these side effets will or will not go away.
n general, I think that creeping up on doses is the only rational way to get on a med and be also capable of making these crucial decisions as symptoms occur.
Zo
Posted by Bob on April 9, 2002, at 1:33:47
In reply to Re: high-dose Lamictal: why not? » Elizabeth, posted by Zo on April 8, 2002, at 21:45:10
> Yes-- but I think the inability to tolerate is, unfortunately, quite confusing. One must sort out, while in a confused and confusing state, whether this is due to drug or dose, whether these side effets will or will not go away.
>
> n general, I think that creeping up on doses is the only rational way to get on a med and be also capable of making these crucial decisions as symptoms occur.
>
> ZoVery well said, Zo! Sorting out what side effects might pass and which ones will not is quite a daunting task; actually it's not really possible. The only thing you can do is see if you can stand the side effect long enough for it to go away. Unfortunately, sometimes this can get you in trouble. The drug lottery is not a fun game.
Posted by Elizabeth on April 11, 2002, at 8:37:29
In reply to Re: high-dose Lamictal: why not? » Elizabeth, posted by Zo on April 8, 2002, at 21:45:10
> Yes-- but I think the inability to tolerate is, unfortunately, quite confusing. One must sort out, while in a confused and confusing state, whether this is due to drug or dose, whether these side effets will or will not go away.
What I mean by "as tolerated" is that one should increase the dose only if:
1) you haven't yet reached the target dose (or an effective dose)
2) the side effects are at worst mild and easily tolerated.
I *don't* mean that you should just put up with any side effect you get and hope that it will go away!
Anyway, I think that a month or so is enough time to reach a highish dose of Lamictal, assuming that the side effects don't get bad (i.e., that you tolerate the dose you're at). If you do have trouble with side effects, of course, you can and should drop back to a dose that is tolerated.
For example, the first time I went from 300 to 375 mg/day of Effexor, I got jittery, so I dropped back to 337.5 mg, where the jitters were at worst mild. I took the 337.5 for a few days, then increased to 375 again, this time without difficulty.
> n general, I think that creeping up on doses is the only rational way to get on a med and be also capable of making these crucial decisions as symptoms occur.
The question is, how slow do you have to creep if you're tolerating the drug? I think that, up to the target dose, it's usually fine to increase every few days (obviously there's some variation depending on the specifics of the drug).
-elizabeth
Posted by Mondeo on April 12, 2002, at 4:56:03
In reply to Re: high-dose Lamictal: why not? » Elizabeth, posted by JohnX2 on April 4, 2002, at 10:05:35
>
> I think you 2 are missing the point of Zo's post.
> The doctor tried to titrate the dose to 600 mg in just a *few weeks*.
>
> John
>
>
>
> > Hardly. I've certainly heard of people taking that much. When I tried Lamictal (for a completely off-label use), I went up to 500 mg. (It didn't do me any good at any dose in that range.)
> >
> > It's not clear how much people need for mood disorders -- it seems to be quite variable, though, and I would certainly allow for the possibility that some need high-end doses. Pharmacokinetic factors may play a role in some cases. Also, remember that the therapeutic serum level range for Depakote goes higher in bipolar d/o than epilepsy -- this could easily be the case for Lamictal as well. Therapeutic levels of Lamictal haven't been established, AFAIK, but it's worth considering the possibility that using higher doses would improve the response rate and the degree of response in mood disorders. I certainly don't think it's been studied enough that we can definitely say that it's no good increasing the dose past a certain amount. Lamictal's general safety and tolerability make it reasonable to consider that higher doses might be beneficial. Just because it's not the primary indication, that doesn't mean that the effective dose is likely to be lower -- it could just as easily be higher.
> >
> > -elizabethDear Elizabeth,
as a Lamictal user(since a couple of months,for BP2),I agree totally with your opinion,being a courageous one,mainly because of the so little professional info.about this promising med,in general and its proposed dosages,in special ; I myself,on my own,have had to go up and up,for the time being up to 400mg(taken in 2 partial dosages each 12 hours) ; there are very few docs taking the responsability advising and ACCEPTING (without too much hesitation)such higher dosages administration
My opinion as a BP2 sufferer since 1972 !(normally and as usually,I haven't been aware of this dx for so many years and as always,resuming myself thenjust to different AD'S,the best PARTIAL results being obtained then,with Celexa ) ; so MY opinion is that Mood Stabilizers are indeed important or even obligatory(not only for BP1,BP2 etc.,but also for UP's) and the most difficult questions are just arising from this point on:
a)which Mood Stabilizer? the old traditional ones with all of their shortcomings,or the newest generation,though lacking info.about
b)which should be the MAXIMAL dosage worth to be checked,tried(normally,presuming no serious side effects encountered ),before deciding(without any doubt) that a specific Mood S.(Lamictal etc.)isn't efficient enaough(or at all)even at that (?)higher dosage
c)should Mood S.be used as a monotherapy(even if still facing mild depr.breakthroughs)or as an adjunctive to the best AD ?I myself(again almost on my own)consider that the correct steps should be according to the 3 ones(the same order)as mentioned above ; Probably,permitting ourselves even dosages high as 500-600mg Lamictal(already acceptable for Epilepsy)before switching to another one and starting the "testings"with another one.
I do hope that such correspondence between us,may overcome the professional shortage I have been referring to; so,let's go ahead and exchange further on as much "trial and error" experiences(sometimes very difficult ones)best luck for ALL of us looking for the BEST solution,on our own
Mondeo
Posted by Mondeo on April 14, 2002, at 23:26:36
In reply to Re: high-dose Lamictal: why not? » Zo, posted by Elizabeth on April 11, 2002, at 8:37:29
HI,Elizabeth,
as a Lamictal user(since a couple of months,for BP2),I agree totally with your opinion,being a courageous one,mainly because of the so little professional info.about this promising med,in general and its proposed dosages,in special ; I myself,on my own,have had to go up and up,for the time being up to 400mg(taken in 2 partial dosages each 12 hours) ; there are very few docs taking the responsability advising and ACCEPTING (without too much hesitation)such higher dosages administration
My opinion as a BP2 sufferer since 1972 !(normally and as usually,I haven't been aware of this dx for so many years and as always,resuming myself thenjust to different AD'S,the best PARTIAL results being obtained then,with Celexa ) ; so MY opinion is that Mood Stabilizers are indeed important or even obligatory(not only for BP1,BP2 etc.,but also for UP's) and the most difficult questions are just arising from this point on:
a)which Mood Stabilizer? the old traditional ones with all of their shortcomings,or the newest generation,though lacking info.about
b)which should be the MAXIMAL dosage worth to be checked,tried(normally,presuming no serious side effects encountered ),before deciding(without any doubt) that a specific Mood S.(Lamictal etc.)isn't efficient enaough(or at all)even at that (?)higher dosage
c)should Mood S.be used as a monotherapy(even if still facing mild depr.breakthroughs)or as an adjunctive to the best AD ?
I myself(again almost on my own)consider that the correct steps should be according to the 3 ones(the same order)as mentioned above ; Probably,permitting ourselves even dosages high as 500-600mg Lamictal(already acceptable for Epilepsy)before switching to another one and starting the "testings"with another one.
I do hope that such correspondence between us,may overcome the professional shortage I have been referring to; so,let's go ahead and exchange further on as much "trial and error" experiences(sometimes very difficult ones)
best luck for ALL of us looking for the BEST solution,on our own
Mondeo
> > Yes-- but I think the inability to tolerate is, unfortunately, quite confusing. One must sort out, while in a confused and confusing state, whether this is due to drug or dose, whether these side effets will or will not go away.
>
> What I mean by "as tolerated" is that one should increase the dose only if:
>
> 1) you haven't yet reached the target dose (or an effective dose)
>
> 2) the side effects are at worst mild and easily tolerated.
>
> I *don't* mean that you should just put up with any side effect you get and hope that it will go away!
>
> Anyway, I think that a month or so is enough time to reach a highish dose of Lamictal, assuming that the side effects don't get bad (i.e., that you tolerate the dose you're at). If you do have trouble with side effects, of course, you can and should drop back to a dose that is tolerated.
>
> For example, the first time I went from 300 to 375 mg/day of Effexor, I got jittery, so I dropped back to 337.5 mg, where the jitters were at worst mild. I took the 337.5 for a few days, then increased to 375 again, this time without difficulty.
>
> > n general, I think that creeping up on doses is the only rational way to get on a med and be also capable of making these crucial decisions as symptoms occur.
>
> The question is, how slow do you have to creep if you're tolerating the drug? I think that, up to the target dose, it's usually fine to increase every few days (obviously there's some variation depending on the specifics of the drug).
>
> -elizabeth
Posted by SLS on April 15, 2002, at 20:53:24
In reply to Re: high-dose Lamictal: why not?, posted by Mondeo on April 14, 2002, at 23:26:36
Hi Mondeo.
> My opinion as a BP2 sufferer since 1972 !(normally and as usually,I haven't been aware of this dx for so many years and as always,resuming myself thenjust to different AD'S,the best PARTIAL results being obtained then,with Celexa )
I have been suffering from a treatment-resistant bipolar depression for many years. Like so many other people on this board, I have tried most of the available medications along with ECT. I have not yet tried Celexa. I am curious to know how you would characterize your partial response to it. Also, would you be kind enough to list the drugs that have benefited you in the past. For me, MAOIs and tricyclics have been helpful, along with Lamictal. Drugs that have made me worse include Wellbutrin, Vivactil (protriptyline), and reboxetine.
> so MY opinion is that Mood Stabilizers are indeed important or even obligatory(not only for BP1,BP2 etc.,but also for UP's)
That's an interesting idea. I don't think I have seen any studies designed specifically to systematically test the use of lithium and mood-stabilizing anticonvulsants in unipolar depression.
I tend to treat Lamictal as a drug that possesses two separate and distinct therapeutic properties. It might be that its mood-stabilizing and antidepressant effects are in dependant of each other and attributable to separate physiological activities. If this is true, I don't think Lamictal can be considered as an example to support an argument to be made for the utility of mood-stabilizing drugs in general to treat unipolar depression.
Supportive of my treatment of Lamictal as a drug possessing dual thymic properties are the observations that it:
1. inhibits voltage-dependent sodium channels and stabilizes neuronal membranes - a property it shares with the mood-stabilizing anticonvulsants like Depakote and Tegretol. This is most likely the mechanism by which it acts as an anticonvulsant and mood-stabilizer.
2. decreases the concentration of extracellular glutamate in the hippocampus by the inhibition of its release, leading to a reduction in the stimulation of the NMDA receptors found there. The reduction of NMDA receptor stimulation has been observed to increase the levels of dopamine and neuronal activity in areas of the limbic system - brain regions known to be involved in motivational drive and reward. Lamotrigine seems to characterized as a potent inhibitor of glutamate release relative to the other AEDs. I am guessing that it is this property that is responsible for the antidepressant effects lamotrigine demonstrates for both bipolar and unipolar depressions.
- Scott
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