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depakote + lamictal

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Is anyone using this combo?  My primary issue is with psychotic mania so I want depakote for maintenance but I'm thinking of adding lamictal for the depression or anhedonia I'm experiencing.  I'm currently using 1000 mg Depakote ER and am 1 year out from my last episode.

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I did recently for about eight months but eventually went off the Depakote because I gained 40 pounds in six months. At the peak I was on 750mg Depakote and 150mg Lamotrigine. We added in Vraylar after two months or so because the Lamictal did not seem to bring my depression under control, but I had been in a bad depressive episode. Full blown mania with psychosis is not an issue for me.

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Thanks very much, that gives me an idea of dosages that might be tolerable.  My psychiatrist has left the state and I'm currently being seen by a psych nurse practitioner.  The NP mentioned trying Vraylar, with the idea of furnishing me some samples because it is expensive and I want to see if it has any effect.

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2 hours ago, Will said:

Thanks very much, that gives me an idea of dosages that might be tolerable.  My psychiatrist has left the state and I'm currently being seen by a psych nurse practitioner.  The NP mentioned trying Vraylar, with the idea of furnishing me some samples because it is expensive and I want to see if it has any effect.

On this site-, I have seen a lot of people who don’t like vraylar since it came out a few years ago, but personally it was pretty side effect neutral for me and had some success using it as an add on (lamictal was also part of that combo) 

 

Edited by Iceberg

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Lamictal had no effect on me but depakote is a good anti-manic agent. I was scared of trying it for a long time because of people complaining about its side effects but I get little side effects. The only crazy thing that happened was when I first started it I got the the most extreme nightmares and some sedation. 

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I've not had side effects from depakote.  I've only been on it a few months for maintenance purposes, but I took it during an acute episode several years ago and it seemed to help.  

15 hours ago, Iceberg said:

On this site-, I have seen a lot of people who don’t like vraylar since it came out a few years ago, but personally it was pretty side effect neutral for me and had some success using it as an add on (lamictal was also part of that combo) 

I have seen some of those negative comments.  I'm not sure how I feel about another AP for depression, given that I've taken quetiapine for sleep for a long time.  The last manic episode was so bad that I think I want to be nuked with olanzapine next time.

12 hours ago, CeremonyNewOrder said:

Lamictal had no effect on me but depakote is a good anti-manic agen. I was scared of trying it for a long time because of people complaining about its side effects but I get little side effects. The only crazy thing that happened was when I first started it I got the the most extreme nightmares and some sedation. 

I took lamictal for 5-6 years at 300 mg.  Those were pretty good years but I want mainly to guard against the mania, and thus the decision to go with depakote.  I'll probably try to add lamictal back in to the mix.

Edited by Will

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17 hours ago, Will said:

I've not had side effects from depakote.  I've only been on it a few months for maintenance purposes, but I took it during an acute episode several years ago and it seemed to help.  

I have seen some of those negative comments.  I'm not sure how I feel about another AP for depression, given that I've taken quetiapine for sleep for a long time.  The last manic episode was so bad that I think I want to be nuked with olanzapine next time.

I took lamictal for 5-6 years at 300 mg.  Those were pretty good years but I want mainly to guard against the mania, and thus the decision to go with depakote.  I'll probably try to add lamictal back in to the mix.

Although I would keep in mind that Depakote plus zyprexa would be very hard both metabolically and sedation-wise if it does come to that 

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2 hours ago, Iceberg said:

Although I would keep in mind that Depakote plus zyprexa would be very hard both metabolically and sedation-wise if it does come to that 

That is good to know thanks.  I did not have Depakote on-board during the last episode.  It probably would have made a big differenence  

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On 11/17/2020 at 3:05 PM, Will said:

Is anyone using this combo?  My primary issue is with psychotic mania so I want depakote for maintenance but I'm thinking of adding lamictal for the depression or anhedonia I'm experiencing.  I'm currently using 1000 mg Depakote ER and am 1 year out from my last episode.

I did try this combo like a year or so ago. I didn't get very far with it. I love Depakote and Lamictal has worked for me in the past, but I was trying to make Lamictal work IN PLACE of an antidepressant, and that just wasn't the right thing for me. Current combo of Depakote/Trintellix/Rexulti/Vyvanse suits me well.

On 11/17/2020 at 7:58 PM, Iceberg said:

On this site-, I have seen a lot of people who don’t like vraylar since it came out a few years ago, but personally it was pretty side effect neutral for me and had some success using it as an add on (lamictal was also part of that combo) 

Personally took a break from Rexulti last year to try Vraylar and went back to Rexulti after about 6 weeks because I couldn't tolerate Vraylar at 1.5mg. However, if anyone were to try it, my recommendation would be to start with 1.5mg every other day for a good while to get a handle on how it makes you feel before you go to 1.5mg daily. It really threw me for a loop.

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9 hours ago, browri said:

I did try this combo like a year or so ago. I didn't get very far with it. I love Depakote and Lamictal has worked for me in the past, but I was trying to make Lamictal work IN PLACE of an antidepressant, and that just wasn't the right thing for me. Current combo of Depakote/Trintellix/Rexulti/Vyvanse suits me well.

Good to know someone else using depakote for maintenance.  I have tried twice to add in lamictal and both times wound up feeling bad physically, causing some anxiety.  For now, I will stick w/ just the depakote and seroquel and maybe make a third run at lamictal after I get the covid vaccine.

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12 hours ago, Will said:

Good to know someone else using depakote for maintenance.  I have tried twice to add in lamictal and both times wound up feeling bad physically, causing some anxiety.  For now, I will stick w/ just the depakote and seroquel and maybe make a third run at lamictal after I get the covid vaccine.

Yeah I really like Depakote for maintenance and for what it's worth I also really liked Lamictal. It was so mild, but it wasn't calming enough. Hence going to Trileptal and then to Depakote to make my anti-convulsant more calming so I didn't have to rely on antipsychotics so much to settle me. I still need APs but in lower doses.

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Lamictal levels are increased significantly in the presence of depakote. Generally you need to reduce the Lamical by 50%. When you see drug range info you have to halve the numbers. The PI's for both note this interaction and recommend a 50% reduction of Lamictal.

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On 12/27/2020 at 5:09 PM, notloki said:

Lamictal levels are increased significantly in the presence of depakote. Generally you need to reduce the Lamical by 50%. When you see drug range info you have to halve the numbers. The PI's for both note this interaction and recommend a 50% reduction of Lamictal.

This is true. As a general rule, if one is taking a combination of valproate and lamotrigine, the lamotrigine dose shouldn't exceed 100mg unless the doctor is treading very carefully.

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I am confident that any pdoc would be aware of the need for caution in using these two drugs in combination.   I'm not sure what my pdoc had in mind for my lamotrigine dosage but it's moot for the time being because I don't feel that I need for it and I've discontinued .  We were starting very slowly, easing into 25mg daily over a four week period.    If I get depressed again, I may want to give lamotrigine another try.  The depakote will stay because psychotic mania is my biggest risk.

Edited by Will

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On 12/30/2020 at 7:55 PM, Will said:

I am confident that any pdoc would be aware of the need for caution in using these two drugs in combination.  

Guess again. Try to be appreciative of any information you glean from this site.

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What did I say that indicated that I was not "appreciative"?

Just wow.  But thanks

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1 hour ago, notloki said:

Guess again. Try to be appreciative of any information you glean from this site.

Fortunately EMRs these days do help doctors to catch med interactions before they happen, but you certainly can't always count on that. Usually pdocs know about carbamazepine's (CBZ) enzyme induction. They are familiar with the liver CYP isoenzyme system because it metabolizes a vast majority of medications. So with CBZ, double the dose of everything else. Same goes for phenytoin's inhibition of the same enzyme system, half the dose. But lamotrigine is metabolized via glucuronidation, which is sometimes less obvious, and valproate's inhibition of glucuronosyltransferase isn't is commonly known because it doesn't cause a significant amount of other med interactions due to the fact that not a ton of medications go through that process or rely on it exclusively to clear the body as stated above. Really the only reason it's so important in this particular case/context is because of lamotrigine and SJS (Stevens-Johnson Syndrome).

But most importantly, if there's one thing I've learned so far in almost 8 years of bipolar treatment myself is that you can't trust the doctor to know everything. They're only human.

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1 hour ago, browri said:

Fortunately EMRs these days do help doctors to catch med interactions before they happen, but you certainly can't always count on that. Usually pdocs know about carbamazepine's (CBZ) enzyme induction. They are familiar with the liver CYP isoenzyme system because it metabolizes a vast majority of medications. So with CBZ, double the dose of everything else. Same goes for phenytoin's inhibition of the same enzyme system, half the dose. But lamotrigine is metabolized via glucuronidation, which is sometimes less obvious, and valproate's inhibition of glucuronosyltransferase isn't is commonly known because it doesn't cause a significant amount of other med interactions due to the fact that not a ton of medications go through that process or rely on it exclusively to clear the body as stated above. Really the only reason it's so important in this particular case/context is because of lamotrigine and SJS (Stevens-Johnson Syndrome).

But most importantly, if there's one thing I've learned so far in almost 8 years of bipolar treatment myself is that you can't trust the doctor to know everything. They're only human.

When I was a teenager my idiot doc added lamictal to my combo ( nothing like taking 4 mood stabilizers at once!) and explained the SJS thing by saying (I swear this is real) “well they killed a bunch of people in a study in Europe but they eventually discovered the interaction so that doesn’t really happen anymore.” ... one of those mental illness snapshots I will never forget 

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Posted (edited)

I remain confident that any reasonably competent pdoc would be aware of SJS and the clearance issues with the combination of these drugs.  @Iceberg I'm sorry that happened to you.  

Edited by Will

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53 minutes ago, Will said:

I remain confident that any reasonably competent pdoc would be aware of SJS and the clearance issues with the combination of these drugs.  @Iceberg I'm sorry that happened to you.  

To clarify @Will I wasn’t trying to challenge your earlier statement I just thought it was a relevant story 

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