Expert: Ivan Goldberg, M.D. - 7/1/2007

Question
My 45 yr old husband has been dx with BP-rapid cycler- for 3 years now (but probably had it since high school).  He was put on Lamictal first thing and has been stabile (except gaining weight) at 400 mg for at least 6 months now.  He has not worked for 5 years (long story) but has raised our 4 boys and finished his MPH in that time.  Getting back to work is his goal at this time.
 
Last week, he had an obvious cycle into hypomania and then depression.  It may have been precipitated by starting paralegal coursework.  Anyway, he was put on Abilify but one dose made him anxious, iritable, unable to sleep (2-3 hours) and restless.  Is this an indication that he should stop taking it?
How high a dose of Lamictal can he get up to?
I thought Lamictal didn't cause weight gain but...he sure has been binge eating.  Maybe his symptoms aren't as well controlled as we thought?  Or could it be depression causing the weight gain?
Insights are appreciated!

Answer
Hi Tina . . .

Because of the dangers of tardive dyskinesia (see: http://www.ninds.nih.gov/disorders/tardive/tardive.htm) and neuroleptic malignant syndrome (see: http://www.ninds.nih.gov/disorders/neuroleptic_syndrome/neuroleptic_syndrome.htm) i usually reserve antipsychotic medications such as Abilify for individuals who are actively psychotic. The drug companies have brainwashed many psychiatrists to prescribe these drugs as long-term mood stabilizers.

Some weight gain has been reported with Lamictal, but it is much less likely to cause weight gain than lithium or Depakote.

I do not prescribe any fixed doses of Lamictal, but rather regulate it on the basis of blood level determinations. The following Q&A from a book I am writing will explain my method:

Q: Why do you suggest checking the lamotrigine (Lamictal) blood level in patients who do not improve with standard doses of lamotrigine (Lamictal)?

A: Similar to many other drugs, the blood level of lamotrigine (Lamictal) can be quite different in individuals taking the same dose of lamotrigine. As when managing patients with epilepsy, we find it useful to get a determination of the blood level of lamotrigine 12-hours after the last dose. It has been our experience that many patients who have only partially responded to lamotrigine, with blood levels less than 4 mcg/ml, improve when they increase their lamotrigine dose to increase their plasma level to a level of  6-12 mcg/ml. In some individuals, these plasma levels are only achieved when they take much more lamotrigine than the amounts usually prescribed by psychiatrists.

Refs: Kilpatrick ES, Forrest G, Brodie MJ. Concentration--effect and concentration--toxicity relations with lamotrigine: A prospective study. Epilepsia, 1996, 37, 534-538. Morris RG, Black AB, Harris AL, et al. Lamotrigine and therapeutic drug monitoring: Retrospective survey following the introduction of a routine service. British Journal of Clinical Pharmacology, 1998, 46, 547-551.

People who binge eat often respond to treatment with Topamax.

Best regards . . .
Ivan
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