Rash from Lamictal . . . do you have to stop it?

This letter brings up an important question about Lamictal . . .

I’m a 45 y/o female properly diagnosed and treated as bipolar for 1 & 1/2 years. Prior to this diagnosis, I was treated soley for depression for 10 years (the last 5 as refractory.) I am presently doing GREAT on Lamictal 200mg daily and Effexor 300mg daily. The problem? I’ve had a rash on my leg for 2 weeks and only today made the connection to Lamictal’s potential for a life-threatening rash. I can rule out contact dermatitis. I’m not experiencing SJS symptomes. I will contact my ANP on Tuesday for evaluation and probably drug discontinuation. My question? What titration schedule do you use to discontinue Lamictal? What titration schedule do you use to concurrently add another AED such as Topamax? I really appreciate your time and dedication to this topic! Have you had particular success with another AED? I can’t begin to tell you how well I have been doing since the addition of Lamictal. It changed my life. I hate to give it up.

It can be very discouraging to FINALLY find the medicine that works well, only to have that medicine turn on you.  As you know, this is more likely to occur with Lamictal than it is with other medicines.  The quick answer to the title question is . . . “yes, of course”.  But lets look at the issues involved in this medicine and the rash.  As is true with much of psychiatry, there is grey area that must be explored and considered.  

You can read the information in the dreaded “Black Box” yourself, the risk of serious rash in patients taking Lamictal for Bipolar Disorder is approximately 8 in 10,000 (0.08%).  The conventional wisdom is that there are certain factors that may increase your risk.  These include concomitant use of Depakote, exceeding the initial dose recommendations, and titrating up too quickly.  If there is any concern about a Stevens-Johnson reaction, the medicine must be stopped and immediate medical attention sought.  The more you read about this condition, the scarier it becomes.  Just to scare the crap out of you completely . . . here is a link:


Read at your own risk.

That said, what do we do with the young lady above?  

Most of the cases of rash and, especially, the serious varieties of the rash, occur in the first weeks and months of treatment with Lamictal.  The rash that is especially concerning is that which is associated with mucus membrane. Here, we have a rash that is occurring 18 months into treatment (unusual), and only on the leg (also unusual).  Given how this medicine has turned your life around, I would not be so quick to stop it.  The area of rash should be seen by someone who is experienced in rashes (often NOT the psychiatrist).  This may be a case for one of those rare emergency appointments with a dermatologist.  At the very least, I would get in to see your family doctor.  Rashes are kind of like headaches.  There are so many reasons for them, it is often hard to pin down the exact reason with any clarity.  It would be a shame (to say the least) to move away from what has been a life altering treatment for your Bipolar Disorder and not be certain that it is required.  If the pattern of the rash is static (not worsening) it may be reasonable to wait and watch.  It may be caused by something you were not aware of (it may be a contact dermatitis after all).  So, I’ll talk about the taper below, but, please, get in to see someone (not on the phone) and have the rash evaluated.  Make sure that the doc doing the evaluation clearly understands that taking you off the Lamictal may cause a return of serious depression.  It is a decision that cannot be made lightly.

Tapering the Lamictal can be done quickly or slowly without significant physical symptoms for most people.  As a general precaution, it is recommended that a taper be done over the course of two weeks or so (there were a couple of people in the initial Bipolar trials who had seizures on discontinuation but there were confounding factors that made it unclear if the removal of Lamictal was to blame).  When I am not in a hurry, I can sometimes take a couple of months.  I know you are looking for specifics, so I could guestimate that I might take off 50 mg every 5 days or so if I was in a hurry.  Now, what to do next . . . 

Tough call.  Plus, I have no other information about you except what is above.  Generally speaking, if Lamictal does not work, we use standard antidepressants along with mood stabilizers to help decrease the risk of hypomanic or manic episodes.  You are already on an antidepressant (Effexor).  You could add in an AED (anti-epilepsy drug) such as Depakote, but more and more I am adding in Abilify.  It is a great mood stabilizer, has a low risk of causing weight gain, and has been shown to augment the benefits of antidepressants.  There are some difficulties with it that I have outlined in other blarticles, but, overall, it is a great medicine for most people.  You can also add Wellbutrin in to the Effexor, but I would not do that unless you are on a mood stabilizer.  

Remember, you must be well monitored by your doc during this transition period, whether it is monitoring this rash or transitioning to other medicines.  

Let me know how things go.

–Dan Hartman, MD

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