Asking for Med Suggestions if Lamictal & Lexapro Aren't in the New Provider's Formulary
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Q:  Asking for Med Suggestions if Lamictal & Lexapro Aren't in the New Provider's Formulary

My husband and I are debating changing health (and therefore prescription) providers and the new provider doesn't cover Lamictal, which I currently take (150mg/hs).  I'm Bipolar Type I - but my manic episodes are few and borderline psychotic (not extreme).  I'm currently VERY stable on the Lamictal + Seroquel (100mg bid am and midday, 300mg/hs)+ Lexapro.  My psych MD and I have proved to ourselves that I cannot discontinue the Seroquel without prompting low to mid-level mania.  WHAT WOULD YOU RECOMMEND TO GO WITH MY SEROQUEL IF BOTH LAMICTAL AND LEXAPRO ARE NOT IN THE NEW PROVIDER'S FORMULARY?

The following are what's been tried.
Mood stabilizers:  In the past I've tried Neurontin (taken off because of mouth sores, although taking me off it didn't make the sores go away), Lithium (did nothing for me), trileptal (didn't reduce suicidal urges), and Abilify (stopped because of feeling like I was going to jump out of my skin - more physical than hyper-anxiety, with uncontrollable and constant movement (not TD, I already have that).  Abilify actually put me back in a pschy hospital for two weeks!(I like your "smarmy"comment!)  Anti-depressants:  I've also used bupropion, which works well but was discontinued because I no longer need 2 antidepressants. anit-anxietants: bunches of phenothiazines - Trilofon, Mellaril, thorazine, haldol, ( you get the picture) - long-term high dosage trliafon is what gave me the TD) and most of the benzodiazapines at various times.  I'm off everything except the Seroquel, Lamictal, and Lexapro at this time.  I have prn supplies of atavan, xanax, and valium which I use VERY rarely.

I've educated myself as much as possible about ALL my medications and I am delighted to find a website like your - very thoughtful, very information, very understandable and non-technical in descriptions.  Thank you for your time, experience, and effort in producing this website.

If you've actually read to this point, I'm surprised and grateful.  If the question is too specific to post, I understand, but I ask wherever I see good information.

Jodi,  MA, MA, ESL teacher by profession

Hello Jodi --
Well now, nice to get an easy question once in a while. As you may know, lamotrigine just went generic. In other words, the patent has run out for the original manufacturer and now, other companies can also make the molecule.  The first company to make a generic gets preferential rights for 6-12 months, so the price does not come down very much (during this time, they are only competing with the original tradename version).  However, most insurance companies have a "tier" for generic medications, at the lowest co-pay level.  So now lamotrigine is available at that level, which is affordable for most people.

Is the generic as good as the original?  Well, it will take some time to really know for sure.  So far, no disasters among my patients switching over.  However, some concern has been raised, so I wrote a webpage summarizing the "generic lamotrigine?"  evidence.  My conclusion for now: insufficient evidence to warrant much concern when switching over, and certainly not enough evidence to keep from switching.

Next, Lexapro: here again, this should work out quite smoothly.  Lexapro is actually a direct relative of the original compound, initially marketed as Celexa.  As you may have heard, most pharmaceutical molecules have both a "left-handed" and a "right-handed" version (the molecule can either twist to the left or twist to the right as it forms).  Usually, only one of these two versions is the active one.  When the patent on Celexa was running out, the manufacturer came up with a version that was simply the right-handed form, without the left-handed one (or it may be the other way around, I can't remember).  By creating this version, the company was able to get a new patent and continued to charge tradename prices, after Celexa had gone generic.

Of course the company claimed that Lexapro was much better than Celexa.  That would be a necessary part of the marketing strategy, right?  But the data on that were never very convincing.  Shortly after Lexapro came out, a generic version of Celexa became available.  That molecule is called citalopram.  So, if you're following all this, there is a generic version of your Lexapro -- or very close (it has both the right-handed and the left-handed molecule, whereas your Lexapro has only one of the two).  According to the Lexapro manufacturer,  eliminating that other-handed version decreased some of the side effect potential of Celexa; but many of us had some doubts about that, and as soon as citalopram was available, it rapidly became one of the most widely used generic SRI (serotonin reuptake inhibitor) antidepressants.  So theoretically it is possible that when you switch over to citalopram, you could get some side effects you were not getting from Lexapro, but that in my view is pretty unlikely.  

Your timing was good.  Only six months ago, lamotrigine was still under patent.

I hope the transitions go smoothly.  Basically you're just going to swap your version for the generic version (in the case of Lexapro, the dose will need to be doubled, because citalopram is only half as potent -- because it has one half of the molecules that aren't the active-handed version, right?).  If you can manage to do this so that only one of the two medications is changing over to the generic at a time, that will help you figure out what the problem is, if somehow the generic is not working the same way as the original.  But I doubt that will happen. 

Thanks for the nice comments.  Cheers --

Dr. Phelps

Published January, 2009


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