[dr. bob]

Dr. Bob's
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Side-effects on lamotrigine

Date: 2 Feb 1996 09:49:50 -0500
From: "Mike Johnson" <mike_johnson@smtpgw.musc.edu>
Subject: Side-effects on lamotrigine

I have used [lamotrigine] as a single agent to treat patients with bipolar disorder [and] have seen a very low rate of side effects...

I have been starting with [25 mg] in the evening and increasing by 25 mg every 5 to 7 days. If you go up too fast there is an increased risk of developing a rash.

From: "Steven L. Dubovsky" <Steven.Dubovsky@UCHSC.edu>
Date: Tue, 6 Feb 1996 07:55:14 MST
Subject: Side-effects on new anticonvulsants

US physicians can look up lamotrigine (Lamictal) and felbamate (Felbatol) in the Physicians' Desk Reference. Of these two presentations, felbamate comes with a patient information/consent form that includes the following terrifying statements: "I understand that there is a serious risk that I could develop aplastic anemia and/or liver failure, both of which are potentially fatal, by using Felbatol. I understand that there are no laboratory tests which will predict if I am at increased risk for one of the potentially fatal conditions." The company includes a "Note to Physician: It is strongly recommended that you retain a signed copy of the informed consent with the patient's medical records."

It sure looks like felbamate can be a killer.

I see no similar level of warning or concern with lamotrigine.

I don't think I'll be prescribing any felbamate soon.


On the other hand, both lamotrigine and gabapentin were associated with unexplained deaths in premarketing trials. It is not clear if this was due to epilepsy, other drugs, or the new meds alone or in interaction.

Date: 7 Feb 1996 16:06:12 -0500
From: "Mike Johnson" <mike_johnson@smtpgw.musc.edu>
Subject: Rash on lamotrigine

Data from the seizure trials suggested that the dose should not be titrated up faster than 50 mg every two weeks -- this minimized the risk of rash.

Date: Wed, 24 Apr 1996 00:48:49 -0400
From: Ivan Goldberg <Psydoc@psycom.net>
Subject: Side-effects on lamotrigine

A rash that may necessitate discontinuation is more likely to develop in patients started on too high a dose or in those patients in whom the dose is increased too rapidly.

There are no reports of major hematological or hepatic adverse drug reactions with this drug. Side-effects have not been a problem as yet with any of my patients.

Date: 24 Apr 1996 14:44:07 -0500
From: "Mike Johnson" <mike_johnson@smtpgw.musc.edu>
Subject: Leukopenia on lamotrigine

There have been a few reports in the European literature of leukopenia. I have been getting baseline WBCs and rechecking in a month. I haven't noticed a problem. If it is related, it appears to be a rare event.

Leucopenia associated with lamotrigine. Nicholson RJ, Kelly KP, Grant IS. BMJ 1995 Feb 25, 310 (6978): 504.

From: "David A. Kahn" <kahndav@cpmc3.cpmc.columbia.edu>
Date: Thu, 25 Apr 1996 08:31:46 EDT
Subject: Side-effects on lamotrigine

Charles Bowden ... says [there is] some tendency to induce hypomania. The manufacturer reportedly is somewhat concerned about the high incidence of rashes...

Date: Wed, 24 Jul 1996 12:16:04 -0400 (EDT)
From: Bill Boyer <wboyer@emory.edu>
Subject: Side-effects on lamotrigine

"Start low and go slow" to minimize the risk of rash or other significant adverse events.

From: dreiser@interserv.com (David E. Reiser, M.D.)
Date: Wed, 28 Aug 1996 04:49:52 -0700
Subject: Side-effects on lamotrigine

I have started five patients on lamotrigine at this point. Four have tolerated it unproblematically. I have one patient, however, the fifth, who has had trouble at doses above 75 mg per day, even after taking 6 weeks to try to work our way up. This is a reliable, non-somatizing patient. She has complained of "lights flashing" in the periphery of her vision, deteriorating memory ("worse than I had with ECT"), and a "clogged feeling in my ears."

From: RMRich1@aol.com (Roberta Richardson)
Date: Thu, 29 Aug 1996 00:16:02 -0400
Subject: Visual problems on lamotrigine

My first patient on lamotrigine 50 mg/d today tells me that since she started it, she has had a blurriness of vision in the outer field of her right eye only. It is more than just blurry, it was hard for her to describe, and she did use the term "bright light", reminiscent of Dr. Reiser's patient with the "lights flashing" in the periphery of her vision.

From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Mon, 21 Oct 1996 08:33:51 -0400
Subject: Irritability or hypomania on lamotrigine

My sense is that activating side effects such as anxiety, irritability, agitation or hypomania are not rare, and their incidence is probably greater than 10% in my own uncontrolled series.

Date: Sun, 17 Nov 1996 01:38:35 -0500
From: Ivan Goldberg <Psydoc@psycom.net>
Subject: Irritability or hypomania on new anticonvulsants

Gabapentin seems less "stimulating" than lamotrigine and has been well tolerated by some patients with mixed bipolar states or rapid cycling bipolar disorder who developed insomnia while taking lamotrigine.

Date: Fri, 13 Dec 1996 14:24:16 -0500
From: Ivan Goldberg <Psydoc@psycom.net>
Subject: Itching on lamotrigine

At 09:14 AM 12/13/96 -0500, William B. Strek wrote:

I have a bipolar male in his 70s now well controlled on lamotrigine 150 mg po qhs. While he has no rash he is now intensely itching from head to foot.

I have had several patients on lamotrigine develop itching without a rash. The itching disappeared after less than a week of continued therapy with no change in the lamotrigine dosage.

Date: Fri, 13 Dec 1996 11:35:39 -0800
From: "Mark I. Levy, M.D." <milevy@itsa.ucsf.edu>
Subject: Itching and arthritis on lamotrigine

I have a male in his 30s on lamotrigine 100 mg with itching all over following onset of treatment.

I also have a male a few years older with recurrent gouty arthritis (not yet confirmed by uric acid levels) associated with lamotrigine rx (he has been on and off the med twice now and both times developed arthritis in his feet).

Date: Tue, 04 Mar 1997 23: 58: 47 -0800
From: Frank Feiner <NFRANK@pol.net>
Subject: Side-effects on lamotrigine

Third Generation Antiepileptic Drugs, 11/3/96

The general consensus on this list, which I have shared, is that both lamotrigine (1-4) and gabapentin (2, 4-8) are safer than their predecessors.

In just the last 3 years there have been 10 case reports of serious adverse lamotrigine reactions. These have included: acute porphyria (in which gabapentin is safe, 9) and multiple organ failure (10); encephalopathy (11); Stevens-Johnson syndrome (12); fatal toxic epidermal necrolysis (13); fulminant hepatic failure (14); detrimental effects in amyotrophic lateral sclerosis (15) (in which gabapentin is helpful, 16); leukopenia (17); "multisystem adverse reaction" (18); supraventricular extrasystoles and 1st degree AV block (19); and "disabling tremor" (in combination with VPA, 20).

Addendum, 3/4/97

In the last 4 months, there has been one more report of toxic epidermal necrolysis from lamotrigine (32), but also a report citing its high dosage safety and tolerability (33).

1. Fitton A, Goa KL: Lamotrigine. An update of its pharmacology and therapeutic use in epilepsy. Drugs 1995; 50: 691-713

2. Patsalos PN, Sander JW: Newer antiepileptic drugs. Towards an improved risk-benefit ratio. Drug Saf 1994; 11: 37-67

3. Richens A: Safety of lamotrigine. Epilepsia 1994; 35 Suppl 5: S37-40

4. Fogel BS: Medical and neuropsychiatric perspectives on antiepileptic drugs. In: Treatment of Complex Medical-Psychiatric Syndromes. American Psychiatric Association Annual Meeting, 1995

9. Krauss GL, Simmons-O'Brien E, Campbell M: Successful treatment of seizures and porphyria with gabapentin. Neurology 1995; 45: 594-5

10. Gregersen H, Nielsen JS, Peterslund NA: (Acute porphyria and multiple organ failure during treatment with lamotrigine.) Ugeskr Laeger 1996; 158: 4091-4092

11. Hennessy MJ, Wiles CM: Lamotrigine encephalopathy. Lancet 1996 Apr 6; 347 (9006): 974-975

12. Campistol J, Geli M, Llistosella E, Molins J, Llobert M: (Stevens-Johnson syndrome after lamotrigine treatment.) Rev Neurol 1995; 23 (124): 1236-1238

13. Sterker M, Berrouschot J, Schneider D: Fatal course of toxic epidermal necrolysis under treatment with lamotrigine. Int J Clin Pharmacol Ther 1995; 33: 595-597

14. Makin AJ, Fitt S, Williams R, Duncan JS: Fulminant hepatic failure induced by lamotrigine. BMJ 1995; 311 (7000): 292

15. Zarranz JJ, Ciordia R: (Possible detrimental effects of lamotrigine in amyotrophic lateral sclerosis.) Neurologia 1995; 10: 116

16. Romano JG: Reduction of fasciculations in patients with amyotrophic lateral sclerosis with the use of gabapentin. Arch Neurol 1996; 53: 716

17. Nicholson RJ, Kelly KP, Grant IS: Leucopenia associated with lamotrigine. BMJ 1995; 310 (6978): 504

18. Schaub JE, Williamson PJ, Barnes EW, Trewby PN: Multisystem adverse reaction to lamotrigine. Lancet 1994; 344 (8920): 481

19. Steinhoff BJ, Stodieck SR, Tiecks FP, Wedel R, Polatschek B: (Cardiac side effects and ECG changes with lamotrigine? -- A clinical study. Schweiz Arch Neurol Psychiatr 1994; 145: 8-12

20. Reutens DC, Duncan JS, Patsalos PN: Disabling tremor after lamotrigine with sodium valproate. Lancet 1993; 342 (8864): 185-186

32. Sullivan JR, Watson A: Lamotrigine-induced toxic epidermal necrolysis treated with intravenous cyclosporin: a discussion of pathogenesis and immunosuppressive management. Australas J Dermatol 1996 Nov; 37 (4): 208-12

33. Matsuo F, Gay P, Madsen J, Tolman KG, Rollins DE, Risner ME, Lai AA: Lamotrigine high-dose tolerability and safety in patients with epilepsy: a double-blind, placebo-controlled, eleven-week study. Epilepsia 1996 Sep; 37 (9): 857-62

Date: Thu, 10 Apr 1997 02:23:42 -0400
From: Ivan Goldberg <Psydoc@PsyCom.Net>
Subject: Rash on lamotrigine

At 11:22 PM 4/9/97 -0400, Richard David Brand, MD wrote:

I received a notice from the manufacturer about life threatening rashes associated with lamotrigine.
The letter reminded me to emphasize the importance of patients' reporting rashes to me ASAP. I have also made it a point to document that I tell patients that there have been some deaths from lamotrigine. I have not been cutting down on using lamotrigine for patients who have not responded to other mood stabilizers or who find their side-effects unacceptable.

From: HRudMD@aol.com (Howard Rudominer)
Date: Sat, 12 Apr 1997 13:36:38 -0400 (EDT)
Subject: Side-effects on new anticonvulsants

Stevens-Johnson syndrome is still a very rare occurrence and if lamotrigine is effective where all else fails, I think most of us would weigh the risk/benefit ratio way to the the side of the benefit.

I concur that lamotrigine seems to be more activating and gabapentin more sedating.

Date: Sun, 13 Apr 1997 21:40:18 -0700
From: "Kathleen Schilli, PharmD." <DrRx@ix.netcom.com>
Subject: Side-effects on new anticonvulsants

At my facility we have used both lamotrigine and gabapentin. The patients do not like lamotrigine because of the rash (even though we start at a low dose and go up slowly on it) and the hair loss. It seems that gabapentin has a lot fewer drug interactions and side effects.

Date: Wed, 23 Apr 1997 13:26:31 -0400
From: Mike Johnson <JohnsoMR@smtpgw2.musc.edu>
Subject: Side-effects on lamotrigine

In response to the recent concerns about the toxicity of lamotrigine I prepared the following summary from a review of the literature and a discussion with the physician at Burroughs Wellcome who has been working with the FDA on this issue. I think you will agree that there is less there than meets the FDA's eye.

Summary of Lamotrigine Toxicity Data

  1. The estimate of a 1/1000 risk of "potentially dangerous" rash is based on 3 patients of 3000 who developed a rash identified by the clinician as "Stevens-Johnson". There was no medical corroboration of this syndrome and all resolved without sequelae. All occurred in trials where lamotrigine was being used in combination with Depakote (divalproex), Tegretol (carbamazepine), or Dilantin (phenytoin).

  2. Of the 443 patients treated with monotherapy in company sponsored trials, there have been no reports of Stevens-Johnson syndrome at all. There are no case reports in the literature of any significant problems in adult patients taking monotherapy.

  3. Toxic epidermal necrolysis (TEN) is the most concerning lamotrigine associated condition and it has never been observed in any clinical trials. In post-marketing reports there have been a total of 26 cases of TEN reported among which there were 2 fatalities. This includes a total treated population of 600,000 to 800,000. This translates into a known rate of TEN of 1 case per 27,000-33,000. The fatality rate can be estimated at 1 case per 300,000-400,000. This is taking all cases no matter what the underlying conditions or combinations of treatments being used.

  4. In children there are data to suggest a more concerning problem. The rate of Stevens-Johnson in clinical trials has been 1 in 500. There have been 220 children and adolescents treated with monotherapy in clinical trials and 2 have had a "serious rash" -- i.e., a rash requiring hospitalization. Both recovered without sequelae. This leaves a rate of monotherapy "serious rash" of 1/110 in children and adolescents. There have been no fatalities in children or adolescents in any clinical trial.

The reason for the apparent increased risk in children and adolescents is unclear although it may have to do with the use of doses which were too high or titrated up too quickly. It may be advisable to initiate therapy in children and adolescents at lower doses (e.g., 12.5 mg/day). Combination therapy with Depakote or Tegretol in children and adolescents should probably be avoided.

Date: Mon, 05 May 1997 18:18:54 -0700
From: "Kathleen Schilli, PharmD." <DrRx@ix.netcom.com>
Subject: Hair loss on lamotrigine

I have had 2 patients that have experienced hair loss shortly after starting lamotrigine. This was disturbing enough to them to stop taking the drug.

Date: Mon, 22 Sep 1997 00:57:20 -0400
From: Ivan Goldberg <Psydoc@PsyCom.Net>
Subject: Irritability on lamotrigine

Over the past few years I have treated about two hundred patients with lamotrigine or gabapentin. Recently I have seen two patients who developed agitation/irritability/hostility from these drugs. This is not totally surprising as such behaviors have been described as uncommon side effects of both of these agents when they are used as antiepileptic drugs.

A woman in her late 40s with Bipolar-II did well on gabapentin for nearly four months. She then rapidly developed increasing amounts of agitation and hostility that got worse when an attempt was made to control it by increasing the dose of gabapentin. After a week off the gabapentin, during which the agitation/hostility diminished, she took 25 mg of lamotrigine and experienced a rapid return of agitation/hostility. In the past she had a partial response to valproate, and she will restart that agent soon.

The second patient is a man in his late 30s who is being seen for the treatment of ADD + Bipolar-II. The second day he took 25 mg of lamotrigine he reported feeling "more irritable and short tempered" than at any previous time in his life. Hhe refused to take additional lamotrigine as he feared that if he did he might lose control and "hurt someone." I will probably start him on lithium next week.

Date: Tue, 23 Sep 1997 23:57:47 -0400
From: William Braden <braden@brown.edu>
Subject: Side-effects on lamotrigine

Here is some data on lamotrigine from my practice. I have follow-up on 31 patients. 9 of them stopped it because of side effects.

N Side effects
3 Rash or itching
2 Nausea
1 Headache
7 Behavioral

N Side effects Diagnosis
2 "Hyper" Bipolar I
1 Hypomania (disliked) Bipolar II
1 Anxiety Depression
1 Sedation/depression Depression
1 Insomnia Bipolar II
0 Hostility

Date: Fri, 03 Oct 1997 23:34:07 +0200
From: Leigh Janet <leigh@lia.net>
Subject: Side-effects on lamotrigine

Even with careful and gradual dose escalation, I estimate the occurrence of skin rashes with lamotrigine to be of the order of 10%. I have been very cautious with regard to skin rashes, preferring to withdraw lamotrigine early rather than to await the onset of fever, etc. Using this cautious approach I have experienced no major adverse reactions. In combination with olanzapine, I have noted a number of cases of facial flushing.

As with gabapentin, serious cognitive side effects seem less frequent with lamotrigine than with lithium or valproate, and the drug is usually well accepted by patients.

As yet, in n > 200, I have not noted weight gain to be a problem with lamotrigine, at least not with monotherapy. Some patients have reported increased appetite, but all have been on combination therapy.

Psychological side effects have included agitation (the commonest problem, in my hands), mania, depression, feeling "spaced out", insomnia, somnolence, cognitive impairment, and a case of paranoia.

I have noted a few cases of transient increases in liver transaminases, so I do tend to monitor these liver enzymes (especially when using lamotrigine in combination with other drugs known to raise liver enzymes) along with the lamotrigine blood levels, which I usually perform when the lamotrigine dose is 100 mg/day. I have not detected any other biochemical or laboratory anomalies with lamotrigine, but note there has been a case of hyperprolactinemia reported.

In addition to the problem with skin rashes, I do have two other concerns about lamotrigine.

Recently I have noted 3 patients to have what appear to be cardiac "symptoms" -- breathlessness, reduced effort tolerance, dizziness -- when adding lamotrigine to existing antidepressants.

Secondly the South African package insert warns that lamotrigine is contraindicated in patients above the age of 65 years. The wording worries me a little. The reason cited is that there is no experience with lamotrigine in people of this age group. One might have expected the wording to caution prescribers about this fact, and to bid them proceed carefully. Contraindicated implies something stronger.

Date: Sun, 16 Nov 1997 20:59:13 -0500 (EST)
From: "Adele Tutter, M.D., Ph.D." <jhudak@pobox.com>
Subject: Cognitive side-effects on lamotrigine

I am using Lamictal (lamotrigine) quite a bit, mostly as monotherapy in depressed patients in the bipolar spectrum. However, I find that many patients complain of short-term memory disturbance, name- and word-finding difficulties, and a sort of overall cognitive blunting. This doesn't seem to be too dose-related, e.g., patients will report it at 100-200 mg and it doesn't seem to worsen with increased dose (or get better with decreased dose). In some people it gets better with time -- or maybe they just get used to it.

Date: Sun, 16 Nov 1997 23:47:26 -0500
From: Ivan Goldberg <Psydoc@PsyCom.Net>
Subject: Cognitive side-effects on lamotrigine

It has been my impression that all mood stabilizing medications induce cognitive changes in many of the patients whom we give such drugs.

Complaints about short-term memory changes or difficulties with word-finding seem common in patients taking lithium, carbamazepine, valproate, gabapentin and lamotrigine.

It seems to me that memory or word-finding changes are no more common with lamotrigine than with other mood stabilizers.

Date: Tue, 18 Nov 1997 21:39:33 -0500 (EST)
From: Adele Tutter <jhudak@pobox.com>
Subject: Cognitive side-effects on lamotrigine

Jane Garland responded:

I did see this very unexpected response in a 14 year old bipolar with rapid cycling. He had profound short-term memory disturbance starting at 25 mg bid and worse at 100 mg daily -- he couldn't go higher than that becuase he was so impaired: he could barely function without constant supervision and was even sent home from a sheltered class as unable to concentrate on anything. But he was not agitated, just perplexed about his inability to think clearly. He had had no similar reaction on other anticonvulsants. He was also on lithum maintenace, risperidone, and chlorpromazine 25-50 mg PRN. We tried to wait it out for 6 weeks, but it did not clear, so we quit.
This is interesting: by far the worst case of cognitive disturbance on Lamictal I have seen was a young woman, like your case also on lithium (she had very minor difficulties on lithium monotherapy). She was also on Nardil (phenelzine). I wonder about additive or synergistic effects.

Date: Wed, 10 Dec 1997 17:34:30 -0500
From: Mike Johnson <johnsomr@smtpgw2.musc.edu>
Subject: Hypomania on lamotrigine

I have found that for some patients, lamotrigine can induce hypomania with increased dose. In my experience, as long as they were having a good response prior to the hypomania, this has always responded to a dose reduction.

From: Peter M. Brigham, MD <PMBrig@aol.com>
Date: Sat, 27 Dec 1997 22:42:33 EST
Subject: Nausea on lamotrigine

In my experience, nausea and vomiting are among the most common side effects experienced on lamotrigine. It is usually exacerbated by too fast a dosage increase (which also is associated with a higher incidence of rash).

I generally increase no faster than 25 mg (12.5 mg if the patient is on valproate) every 5 days. I have found that this very conservative schedule really minimizes nausea -- and I have yet to see a rash on lamotrigine doing it this way.

From: William Boyer <wboyer@emory.edu>
Subject: Rash on lamotrigine
Date: Thu, 22 Jan 1998 14:43:44 -0500

I have a patient whose long standing bipolar disorder is finally -- finally -- coming under decent control with Lamictal. But -- you guessed it -- he is getting an itchy rash.

--George M. Saiger

This is the kind of case which prompted me to ask for guidance. Unless someone more experienced or knowledgeable weighs in on the subject, I would suggest continuing the lamotrigine at what appears to be the minimal effective dose with close observation. If it gets worse, stop it. All this assumes the patient shares your opinion that the lamotrigine has been so helpful.

Date: Sat, 28 Feb 1998 09:55:52 -0500
From: Ivan Goldberg <Psydoc@psycom.net>
Subject: Rash on lamotrigine

I have now treated a number of hundreds of patients with lamotrigine with an incidence of rash well under 5%. I think this is because I have been starting patients on 12.5 mg per day and increasing the dose by 12.5 mg/day every 5 days. After reaching a dose of 100 mg/day I increase the dose by 25 mg/day every 5 days.

Date: Sun, 1 Mar 1998 17:20:23 -0600
Subject: Side-effects on lamotrigine
From: abartists.lex@juno.com (A J Cohen)

I've seen no GI complaints with lamotrigine, and have only seen some dizziness with it when given in conjunction with an MAOI (I did a huge amount of research on that before I dared administer the combination, but it's the only patient who's had real side effects). People tend to tolerate it very well. Also,it doesn't cause the terrific drowsiness that gabapentin can cause, which also means it's not so useful if you're trying to help with sleep.

From: LHSQ76A@prodigy.com (Dr Valerie D Raskin)
Date: Thu, 12 Mar 1998 23:45:57, -0500
Subject: Rash on lamotrigine

The drug company says mild rashes don't predict or rule out severe rashes.

From: "Randy Buzan" <Randy.Buzan@UCHSC.edu>
Date: Fri, 13 Mar 1998 06:38:35 -0700
Subject: Rash on lamotrigine

We just read up on this for a case report of one of our patients. 13/16 patients in the literature with a minor rash have had the drug started more slowly (i.e., 12.5 mg/d/wk) and tolerated it better. Anecdotally, I have two patients who get the rash at 375 mg/d but have no rash back at 350. So it's a risk-benfit thing, but it's not unheard of to decrease the dose and restart more gradually or to wait it out and see if it improves (which happened in one of my cases).

Buzan RD, Dubovsky SL. Recurrence of lamotrigine-associated rash with rechallenge [letter]. Journal of Clinical Psychiatry. 59 (2): 87, 1998 Feb.

From: "Mark I. Levy, M.D." <milevy@itsa.ucsf.edu>
Subject: Rash on lamotrigine
Date: Fri, 13 Mar 1998 11:21:09 -0800

I had a very similar experience. Rather than second guess the rash, I sent him for a dermatology consult. The dermatologist biopsied the rash, said it wasn't a drug rash, and treated it symptomatically, and the patient continued on his happy Lamictal way. The rash later disappeared.

Date: Fri, 13 Mar 1998 20:59:08 -0500
From: Adele Tutter <jhudak@pobox.com>
Subject: Rash on lamotrigine

This rash is common and I've seen it a few times. Each time I lowered the dose by about half right away, waited a weeks or so, and then increased it again very slowly (i.e., by an additional 12.5 mg/week). Each time the rash went away. There was one patient who would predictably get the rash when advanced to a certain dose, thus limiting treatment, but the others were able to increase without further problems.

From: DReiser264 <DReiser264@aol.com>
Date: Fri, 13 Mar 1998 21:30:16 EST
Subject: Rash on lamotrigine

I had one such patient (post-ECT and ADKH (All Drugs Known To Humankind)). She was severely suicidal. She was dying. I put her on lamotrigine and she was another one of those lamotrigine miracle cures. Then she got a very low-grade, non-specific rash. First, I freaked out. Then I sent her to a good dermatologist who didn't know much more about this than I did. I backed off on the dose, gave her a little Benadryl (diphenhydramine), and then slowly crept back up. I am happy to report that a woman who was for ten years psychiatrically disabled is now leading a fulfilling and stable life.

Date: Sat, 14 Mar 1998 15:39:55 -0500
From: Ivan Goldberg <Psydoc@psycom.net>
Subject: Rash on lamotrigine

I have now seen a number of patients who were referred because they did well on lamotrigine but developed a rash that caused the lamotrigine to be stopped and the prescribing psychiatrist was not willing to represcribe the drug.

In a number of such cases, the response to lamotrigine was dramatically better than the response to any other mood stabilizer or combination of mood stabilizers. In most such instances I have decided to represcribe lamotrigine.

When treating such patients I have restarted lamotrigine at a very low dose, 12.5 mg/day, and then increased it at a rate sometimes as slowly as 12.5 mg/day every 10 days. With very few exceptions patients have been successfully retreated with lamotrigine. In the few cases where a rash reappeared the patients were seen by dermatologists. More often than not the dermatologists suggested that the treatment be continued while they monitored the skin lesions. In a few instances, with progression of the rash, the dermatologists have suggested the immediate discontinuation of the lamotrigine.

Date: Mon, 04 May 1998 22:38:08 -0400
From: Ivan Goldberg <Psydoc@psycom.net>
Subject: Headaches on lamotrigine

About 30% of patients taking lamotrigine report headaches as a side-effect. These headaches are frequently migraine-like and may result in the patient refusing to continue taking lamotrigine.

I have recently treated three patients complaining of lamotrigine-induced headaches with gabapentin. As you know, gabapentin is being used to treat various pain syndromes including migraine headaches. In each patient gabapentin, 100 mg t.i.d, lead to the elimination of the lamotrigine-induced headaches within one week.

Date: Wed, 17 Jun 1998 08:07:42 -0400 (EDT)
From: gsaiger@pop.dn.net (George M. Saiger)
Subject: Sore throat on lamotrigine

A 50-ish long-time bipolar patient has been only depressed for the last decade. He started a trial of Lamictal. On 50 mg/d he felt better than he had for years. But after week 2 he got a sore throat and GI distress. Stopped lamictal -- sore throat went away. Rechallenged -- symptoms returned, but were milder and inconstant.

Date: Wed, 17 Jun 1998 12:14:52 -0600
From: "David M. Elwonger" <elwonger@usa.net>
Subject: Sore throat on lamotrigine

I had a very unstable rapid cycling bipolar patient who was doing very well for the first time on Lamictal -- we had cautiously titrated the dose up to 100 mg/d. Then she developed a severe sore throat with what looked like apthous ulcers in her pharynx. She saw her primary care physician, who treated her with an antibiotic, but it didn't go away and patient was losing weight because she couldn't eat. I decreased the dose of lamotrigine, and the sore throat got better but didn't completely clear. We stopped the lamotrigine, and the sore throat went away (in about two weeks). We restarted the lamotrigine, at a low dose, and the sore throat returned. So we stopped the lamotrigine, and the bipolar cycling resumes. Steve Dubovsky suggested a rechallenge at tiny doses, eg, 12.5 mg/d with increases every two weeks, but we haven't tried that yet.

From: "Steven L Dubovsky, M.D." <Steven.Dubovsky@UCHSC.edu>
Date: Mon, 22 Jun 1998 09:23:27 -0700
Subject: Sore throat on lamotrigine

Consulation with an ENT is a good idea in a situation like this.

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