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Dr. Bob is Robert Hsiung, MD,
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Posted by yxibow on April 23, 2008, at 15:55:06
In reply to Re: Rash and restarting Lamictal and dosage, posted by Quintal on April 23, 2008, at 11:01:57
> I saw him yesterday and told him I was only taking 50mg as the dose his understudy prescribed was far too much. He seemed okay about it and advised me to either go up to 75mg at the enxt increase, or up to 100mg, whichever I thought best. He's aiming for 150mg as the therapuetic dose.
>
> The downside is that he didn't want to prescribe an antidepressant because we wouldn't know which drug was doing what. Right now I wouldn't be bothered, so long as the combo worked :-(
>
> Q
This is correct -- you don't add two things at once because you'll never know what actually worked. My doctor does the same thing.It's your body and doctor so I can't interfere, but seriously, it is the protocol from what I have heard from another person who is taking far more Lamictal that you ease up by 25s to begin with.
Not to be a scaremonger but you don't want to cook your insides. SJS is one of those intensive-care-at-best scenarios. Yes, I still think about it, but we've now established at 100 for some weeks that I dont react so we've gone up more quickly.
Anyhow, good luck--tidings
Posted by henryo on April 23, 2008, at 16:38:33
In reply to Re: Starting Lamictal » dbc, posted by Quintal on April 11, 2008, at 14:44:09
1 in ten? I don't think so.
Posted by Quintal on April 23, 2008, at 18:25:24
In reply to Re: Starting Lamictal, posted by henryo on April 23, 2008, at 16:38:33
What do you think then?
Q
Posted by Phillipa on April 23, 2008, at 22:02:33
In reply to Re: Starting Lamictal, posted by Quintal on April 23, 2008, at 18:25:24
Q I agree with xiybow. Knows his stuff. Love Phillipa
Posted by henryo on April 24, 2008, at 4:28:43
In reply to Re: Starting Lamictal » Quintal, posted by Phillipa on April 23, 2008, at 22:02:33
List some sources / links, It is nowhere near one in ten.
Posted by undopaminergic on April 24, 2008, at 5:57:00
In reply to Re: Rash and restarting Lamictal and dosage » Quintal, posted by yxibow on April 23, 2008, at 15:55:06
> >
> > The downside is that he didn't want to prescribe an antidepressant because we wouldn't know which drug was doing what. Right now I wouldn't be bothered, so long as the combo worked :-(
> >
> > Q
>
> This is correct -- you don't add two things at once because you'll never know what actually worked. My doctor does the same thing.
>It may be a good idea to use a faster acting drug along with a slow one (eg. SSRI + stimulant). You can always find out which ones are important by removing them one at a time later. This may not be a bad idea anyway as people too often end up taking cocktails where no-one knows what's essential or superfluous. On the other hand, some may not care about such details and prefer to leave a working combination alone.
Posted by Quintal on April 24, 2008, at 8:48:24
In reply to Re: Starting Lamictal, posted by henryo on April 24, 2008, at 4:28:43
I think I got the 1 in 10 figure from here:
____________________________________________________
Dermatological Events (see BOX WARNING, WARNINGS)
Serious rashes associated with hospitalization and discontinuation of LAMICTAL have been reported. Rare deaths have been reported, but their numbers are too few to permit a precise estimate of the rate. There are suggestions, yet to be proven, that the risk of rash may also be increased by (1) coadministration of LAMICTAL with valproate, (2) exceeding the recommended initial dose of LAMICTAL, or (3) exceeding the recommended dose escalation for LAMICTAL. However, cases have been reported in the absence of these factors.
In epilepsy clinical trials, approximately 10% of all patients exposed to LAMICTAL developed a rash. In the Bipolar Disorder clinical trials, 14% of patients exposed to LAMICTAL developed a rash. Rashes associated with LAMICTAL do not appear to have unique identifying features. Typically, rash occurs in the first 2 to 8 weeks following treatment initiation. However, isolated cases have been reported after prolonged treatment (e.g., 6 months). Accordingly, duration of therapy cannot be relied upon as a means to predict the potential risk heralded by the first appearance of a rash.
Although most rashes resolved even with continuation of treatment with LAMICTAL, it is not possible to predict reliably which rashes will prove to be serious or life threatening.
http://www.rxlist.com/cgi/generic/lamotrigine_wcp.htm
__________________________________________________So according to this source, in bipolar trials 14% of patients developed a rash - slightly more than 1 in 10.
Q
Posted by Quintal on April 24, 2008, at 9:00:05
In reply to Re: Rash and restarting Lamictal and dosage, posted by undopaminergic on April 24, 2008, at 5:57:00
I'm not really bothered right now about knowing precisely what drug is doing what. If I were in a clinical trial that would be the priority, but sometimes a patient's suffering should take precedence over the meticulous gathering of scientific evidence. I don't want to watch months of my life disappearing down the plughole just so my pdoc knows for sure what is doing what, although I do agree this is the scientifically correct method of gathering information. I'm taking so much stuff he doesn't know about that whatever evidence he thinks he's gathering is invalid anyway.
I really needed an antidepressant this week because I ran out of tianeptine, but now I'll have to wait at least six weeks to get a second chance, and even then... It was a blow to say the least.
Q
Posted by henryo on April 24, 2008, at 18:36:28
In reply to Re: Starting Lamictal » henryo, posted by Quintal on April 24, 2008, at 8:48:24
Read your own link- it says .03 percent, 11 people out 3,480
NOT 1 in 10
Posted by Quintal on April 24, 2008, at 19:14:36
In reply to Re: Starting Lamictal, posted by henryo on April 24, 2008, at 18:36:28
I don't know why you're continuing with this, but yes, I did read my own link and it does say that 10% of patients in the epilepsy trials developed a rash. 10% is 1 in 10. It also says that 14% of bipolar patients developed a rash, making that slightly higher than 1 in 10.
The figure you quoted at the beginning of the article however, only relates to the incidence of *serious rash* associated with hospitalization and discontinuation from Lamictal. This is *not* the overall incidence of benign rash among Lamictal patients - only the most serious ones. The overall incidence of rash is much higher, and these stats are posted further down under 'Dermatological Events'. I'll post them again:
__________________________________________________In epilepsy clinical trials, approximately 10% of all patients exposed to LAMICTAL developed a rash. In the Bipolar Disorder clinical trials, 14% of patients exposed to LAMICTAL developed a rash.
__________________________________________________
Q
Posted by Quintal on April 25, 2008, at 12:44:00
In reply to Increased to 50mg, posted by Quintal on April 18, 2008, at 13:16:01
I decided to go for the 75mg dose instead of leaping up to 100mg. It seems to be making me feel tired. I had to go and have a lie down earlier, also a few cognitive side effects, but hopefully they'll go away in a few days.
Q
Posted by henryo on April 25, 2008, at 19:34:06
In reply to Re: Increased to 75mg, posted by Quintal on April 25, 2008, at 12:44:00
Where I am going is offering factual information about the incidence of rashes at .03 percent, NOT 8 percent or your previous claim of 10 percent. Lamictal is a great med. Some people insist on scaring others away from using it.
Use the google button on your internet machine, enter-
"lamictal rash percentages"
you will get a few hundred if not a thousand hits
http://www.psycheducation.org/depression/meds/LamRash.htm
http://www.pslgroup.com/dg/eb8ea.htm
The incidence of these rashes, which have included Stevens-Johnson Syndrome, is approximately one percent in pediatric patients (age less than 16 years old) and 0.3 percent in adults. In world-wide post-marketing experience rare cases of toxic epidermal necrolysis and/or rash-related death have been reported, but their numbers are too few to permit a precise estimate of the rate.
Posted by Quintal on April 25, 2008, at 20:41:34
In reply to reality, posted by henryo on April 25, 2008, at 19:34:06
I don't understand why you're holding me personally to account for the statistics printed on a webpage. These are not my own person claims on the incidence of Lamictal rash, not some wild figure I just picked out of hat. Something doesn't seem to be registering here. As I explained, according to the website the one in ten figure is the overall incidence of benign non-serious rash, which seems to be fairly common. The smaller figures are serious SJS-like reactions, which are very rare. It's as simple as that.
Again, I find even on the weblinks you provided, the 0.3% rate you quoted is only for serious rash. Further down he has a chart showing the overall incidence of rash, which is as high as 13% in one dosage range. As the author says below, using slow titration methods they managed to lower the incidence of *benign* rash (author's emphasis) to 3%, as opposed to the typical rate of 10% (1 in 10) usually found in other research studies. There were no *serious* rashes in this group studied.
__________________________________________________
Thus my main strategy on "handling the rash" is to try to avoid it in the first place. [Update 5/2005: Stanford's Bipolar Clinic, led by Dr. Terry Ketter, published their results from a strategy in which they warned patients not to add any new allergens: no new soaps, detergents, cosmetics, shaving creams, deodorants, etc; no new foods; and avoiding sunburn or poison oak. They also waited to start if the patient had recently had a rash, symptoms of a viral infection, or a rash. Using this strategy, they lowered the benign rash rate -- there were no serious rashes in this group of 100 patients -- to 3%, versus the common 10% rate for rash in other lamotrigine research studies.Ketter][Update 2008: when they repeated that strategy with the pharmacist giving the skin instructions, the difference in rash rates was not significant.Ketter (b) Ketter says he still gives the same instructions, despite those data.]
http://www.psycheducation.org/depression/meds/LamRash.htm
__________________________________________________Also, the paragraph above the one you cut & pasted from this webpage (http://www.pslgroup.com/dg/eb8ea.htm) quotes these statistics:
__________________________________________________Nine clinical trial participants discontinued due to rash, seven out of 129 in the lamotrigine group and two out of 66 in the placebo group, although none of the rashes were considered serious nor did patients require hospitalisation.
__________________________________________________So, if we take 7, divide it by 129, multiply the result by 100, that gives us 5.42% for the incidence of benign rash in the lamotrigine group of this study. You seem to have omitted the part that distinguishes between benign and serious rash - indeed you left out the statistics for benign rash altogether.
I'm getting sick of this subject. I had no intention of sparking such a debate when I quoted the figures in my original post, nor was I trying to scare people away from taking lamotrigine. It was just an innocent comment. I never expected it to receive this much scrutiny.
Q
Posted by elanor roosevelt on April 25, 2008, at 22:15:30
In reply to Re: Increased to 75mg, posted by Quintal on April 25, 2008, at 12:44:00
I also chose to up to 75mg rather than the 100mg
i'm thinking perhaps a week to ease into the 100
Posted by yxibow on April 26, 2008, at 0:41:22
In reply to Re: Increased to 75mg, posted by Quintal on April 25, 2008, at 12:44:00
Notice it says "in the first 2 to 8 weeks". This is why Lamictal is titrated slowly. 25mg for 2 weeks, 50mg for 2 weeks, 75mg for 2 weeks, 100mg for 2 weeks. At 100mg if any substantial rash was going to happen it would be extremely low.
This is how psychiatrists and other dispensers of Lamictal dispense Lamictal. Because anything leading towards SJS is not viable.
Posted by undopaminergic on April 26, 2008, at 6:53:15
In reply to Lamictal Rashes » henryo, posted by Quintal on April 25, 2008, at 20:41:34
Are there any data on whether giving lamotrigine with non-sedating antihistamines (e.g. cetirizine, loratadine, fexofenadine) affects the incidence of rash (whether benign or otherwise)?
Posted by Quintal on April 26, 2008, at 10:54:27
In reply to Re: Rashes and Lamictal, posted by yxibow on April 26, 2008, at 0:41:22
I know, but both my pdocs have told me it will be okay to go up to 150mg as fast as I want because I've taken it before. I don't trust this advice because I got a rash on each occasion I tried Lamictal, but for some reason this doesn't seem to register with them - that yes, I have taken Lamictal in the past, but it wasn't okay. They're starting to imply I'm being deliberately difficult for going at a slower rate than they'd prescribed, just like I thought they would. I'm caught in yet another double-bind scenario. That type that can drive people mad.
Same thing with the Lamictal insomnia, I told them I got this side effect last time I took it, and I'm having it again this time. As I was leaving he said "Lamictal will help you sleep better". He just isn't listening to me, but then he never did. It's as if they think I'll be gulled into believing whatever they say just because they're qualified.
Q
Posted by elanor roosevelt on April 26, 2008, at 12:22:25
In reply to Re: Rashes and Lamictal » yxibow, posted by Quintal on April 26, 2008, at 10:54:27
Lamictal titration is normally a doubling of dosage
25mg, 50mg,100mg
according to what i have read
Posted by yxibow on April 27, 2008, at 1:41:08
In reply to Re: Rashes and Lamictal, posted by elanor roosevelt on April 26, 2008, at 12:22:25
> Lamictal titration is normally a doubling of dosage
>
> 25mg, 50mg,100mg
> according to what i have readHowever its done like that, its done sloooooow anyhow.
Posted by elanor roosevelt on April 27, 2008, at 14:18:26
In reply to Re: Rashes and Lamictal » elanor roosevelt, posted by yxibow on April 27, 2008, at 1:41:08
i know titration should go slow but i am not sure about my decision to go slower than recommended
i might be making it harder on myself by prolonging the period before i reach an effective dosage
so i am going up to 100mgs tomorrow
it's also a matter of timing
i have several days at home writing and won't have to deal with clients
there are side effects and there is life
and i am losing my patience over losing my patience
Posted by yxibow on April 29, 2008, at 3:19:56
In reply to Re: Rashes and Lamictal, posted by elanor roosevelt on April 27, 2008, at 14:18:26
> i know titration should go slow but i am not sure about my decision to go slower than recommended
>
> i might be making it harder on myself by prolonging the period before i reach an effective dosage
>
> so i am going up to 100mgs tomorrow
> it's also a matter of timing
> i have several days at home writing and won't have to deal with clients
> there are side effects and there is life
> and i am losing my patience over losing my patience
>As long as you're following at least the package insert (remember there are "generally accepted packages post marketing) then go ahead I guess. Its not side effects, its catastrophic effects that this is done (SJS). Anyhow you know what's best for you so I won't beleaguer this.
Posted by Quintal on May 2, 2008, at 9:07:53
In reply to Re: Rashes and Lamictal » yxibow, posted by Quintal on April 26, 2008, at 10:54:27
We're into the home straits now. So far I feel much calmer. A lot of my intense anger has gone. I just worry that I'm losing my fiestiness - as if a part of my character is fading away, though it's not entirely unpleasent. I'm sort of wonering if I might go up to 150mg then come back down again to a dose where I feel more myself, but still stable.
Q
Posted by elanor roosevelt on May 2, 2008, at 10:40:27
In reply to Increased to 100mg, posted by Quintal on May 2, 2008, at 9:07:53
> We're into the home straits now. So far I feel much calmer. A lot of my intense anger has gone. I just worry that I'm losing my fiestiness - as if a part of my character is fading away, though it's not entirely unpleasent. I'm sort of wonering if I might go up to 150mg then come back down again to a dose where I feel more myself, but still stable.
>
> QAre you aiming for 100mg?
Your theory is that you increase the dosage and then settle in better at the 100mg?do people just end up dulled out on this?
I'm up to 100mgs and i feel lousy and depressed
not feeling rewarded for hanging in
Posted by Quintal on May 2, 2008, at 11:03:19
In reply to Re: Increased to 100mg, posted by elanor roosevelt on May 2, 2008, at 10:40:27
My pdoc wanted me to titrate up to 150mg, which is supposed to be the minimum therapeutic dose. I think I'll go straight up to 150mg next Friday.
>Your theory is that you increase the dosage and then settle in better at the 100mg?
I just think I might lower the dose if I get too spaced-out or anything.
>do people just end up dulled out on this?
I don't think I was dulled out particularly when I last took it (at 200mg).
I'm sorry you haven't had any payback for your determination yet. Maybe things will get better when you reach 150-200mg?
Q
Posted by Quintal on May 9, 2008, at 15:27:35
In reply to Increased to 100mg, posted by Quintal on May 2, 2008, at 9:07:53
....or not at all. My body tells me no, 100mg is enough for now. I'm out of zopiclone and won't get any more for another month, so I have to careful to avoid giving myself insomnia. Lamictal usually gives me insomnia every time I increase the dose, and I just don't want to rock the apple cart at this stage. I've slept pretty well over the last two days without any zopiclone (only because I went to bed in the early hours of the morning and slept till noon), and I don't want to ruin that.
Q
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