Q:  Retrying Lamictal Advisable?

Dr. Phelps:

First let me congratulate you on your psycheducation website.  It provides extremely valuable information about bipolar II that cannot be found elsewhere on the web.

This is a lamictal related question (and I think perhaps and intersting one), but first let me give you some background.

My girlfriend has recently been diagnosed bipolar II, although other doctors she has seen seem to think she has anxious depression.  After reading your website, it seems to me that these are very similar, or perhaps identical conditions.

Anyway she has really suffered with depression, feeling suicidal (although not acting on it) for the past 7 months.  She did not respond well to wellbutrin or effexor (both making her very anxious without helping her depression at all), but she seemed to improve for a couple of months on a combination of Depakote (500mg) and Zyprexa (1 or 1.5mg).  These are small doses but she seems to be very sensitive to medications and got very sick when she was on 1000mg of depakote.

She became very depressed and suicidal again a couple of months ago and a new psychiatrist we saw felt confident that Lamictal was the answer for her.  She was on it for about 4 weeks, reaching a dose of 75mg (12.5mg-week 1, 25mg-week 2, 50mg-week 3, and 75mg-week 4).  Aditionally she was on Remeron for about two weeks and has been on Klonipan 1mg for the past 7 months.  She really started feeling better by the fourth week on Lamictal and then suddenly came down with a pretty bad rash over most of her body.  It was not Stevens-Johnson but was bad enough that she had to stop the medications.

My question is whether it would be advisable for her to try Lamictal again with a slower increase in dosage, after the rash goes away?  Does the fact that she got the rash once mean that she will definitely get it again?  Do you have any experience reintroducing Lamictal to patients who initially had an allergic reaction to it?  Her psychiatrist intended on introducing it to her very slowly as he was aware of the dangers but perhaps he did not go slow enough?

It seems like Lamictal was exactly the right drug for her and she was finally starting to smile again and feel better and it would be such a shame if she could never take it again.  Please write back, if at all possible, with any information you might be able to offer.  Additionally, if you would rule out Lamictal for her, perhaps you could suggest another option?

Thanking you in advance for all of your help and for your wonderful website.

Brian 

Dear Brian -- 
Thanks for the encouragement regarding my website. You've done a great job educating yourself, I can see -- impressive.  As for your question re: re-trying lamotrigine:  well, only with extreme, extreme caution and very low expectations, unfortunately.  As you've gathered, the problem is getting one's immune system sensitized to the stuff, and once that happens, it is not reversible.  However, I have recently read that the group led in Cleveland by Dr. Joseph Calabrese has been continuing lamotrigine in the face of rash symptoms, as long as it is not approaching Stevens-Johnson proportions, particularly not including mucous membrane involvement or fever and other systemic symptoms.  That seems extremely bold to me, but their group has more experience with this than almost anybody, I think.  

I've had some local neurology colleagues try to get somebody back on Tegretol, which can cause the same kind of problem, after they had a rash, even using Prednisone to suppress the immune system while the medication is increased.  I haven't tried that myself. 

In general, as you've seen, there are other alternatives like trileptal and maybe even thyroid, and verapamil goes under-represented probably.  So it probably makes more sense to tour around through these alternatives before taking the Stevens-J' risk of a retrial.  That's for discussion with her doctor, obviously.  

Dr. Phelps