Lamictal - Girl Question

[rowen]

Hey ladies -

Do you take higher doses of Lamictal during certain parts of the month? I've heard that some people do. If so, how much do you take?

I've noticed that my mood now fluctuates more towards that time of the month than when I was on the pill. Hell, maybe that's normal. I went off the pill for a while when I was AD's and didn't have that issue. Although that could have been the AD's helping...I dunno.

Anyway, input is most welcome. Thanks!

[isis]

Hi jenesaisquois

No, i don't take the pill, but i do notice changes in how i feel during the month. but - i did used to take the pill, for quite a while.

Has your dose of lamictal changed since you stopped the pill?

Most meds make the pill less effective however, with lamictal it is the other way around, and i can't exactly remember the science of it - either it affects estrogen or blood level, something - and the estimate is somewhere around 40% reduction in the efficacy of lamictal.

When i started the pill, i was already on lamictal and i increased lamictal dosage to 300mg, then 400mg (from 200mg). I more recently dropped the pill and started tegretol at the same time (tegretol also reduces lamictal in some way).

When i was on the pill - my doctor told me (and other knowledgeable people supported this) that the best way to do it was to skip all the sugar pills to keep my hormones as constant as possible throughout the month. Did you do this?

It is my understanding that, your hormones play a big role (with lamictal level/efficacy) and fluctuation of hormones throughout your cycle would have a significant impact on how lamictal is working for you.

and no, i do not change dosage during the month.

(sorry if this was a long rambling post).

edit: this is from my long thread on crazymeds.

if lamictal has pretty much no more antidepressant help after around 200mg, is that the same if you're on the pill and its not as effective? i mean, when i get up to 300-400mg will that then be equivalent to the 200mg sweet spot or... is that still back at 200mg. (if that makes any sense)?

No.

In clinical trials, Lamictal was found to have decreasing efficacy when used for bipolar/depression once the dose hit 200 mg. Hence, the "therapeutic dose" for non-epileptic patients being pegged at 200 mg.

Are there always people for whom that isn't the case? I'm sure there are.

I am one of them. Until I hit 100 + 150 mg/day, Lamictal would just quit working after a while. At first I thought that maybe the 25 mg increase was just being wimpier than the usual 50 mg increases, but it kept building and I finally remembered that things that I'd never experienced that I knew intellectually were painful were supposed to make my hands feel funny. I'd completely forgotten that. I knew that it wasn't supposed to be a faint, fleeting sensation involving the margins.

My critical thinking skills really came back. Some of my favorite television shows took a huge hit,

There are different theories as to the "how and why" Lamictal messes with a person when that person is on hormonal birth control. As recently as [link=http://www.ncbi.nlm.nih.gov/pubmed/11945109?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum" target="_blank]2002[/link], it was believed that there was no interaction between many AEDs and HBC.

A [link=http://www.ncbi.nlm.nih.gov/pubmed/17190925?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

ugs1" target="_blank]2006 study of HBC and Lamictal[/link] found a 50% decrease in the efficacy of Lamictal, with the placebo week causing an increase in plasma levels of the Lamictal. This study was looking at how the decrease in efficacy would effect seizure control, but I imagine it would also affect mood.

In 2007, researchers found [link=http://www.ncbi.nlm.nih.gov/pubmed/17346247?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

ugs1" target="_blank]"The mean dose-corrected LTG concentration after placebo treatment was 84%"[/link] which was "45-134% higher than after oral contraceptives, signifying an almost doubling of the concentration after cessation of oral contraceptives.

Finally, in 2008, [link=http://www.ncbi.nlm.nih.gov/pubmed/18201913?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum" target="_blank]Effects of pregnancy and contraception on lamotrigine disposition: New insights through analysis of lamotrigine metabolites[/link] found:

There were no significant differences in LTG dose/concentration (D/C), or N-2-GLUC/LTG ratios between women with CIUD and controls. In contrast, compared to controls, the LTG D/C ratio was 56% higher in women taking COC (mean+/-SD, 83+/-47 versus 53.0+/-24.2; p<0.01) and N-2-GLUC/LTG ratio 82% higher in women taking COC (mean 0.477+/-0.212 SD versus 0.262+/-0.127; p<0.0003.

CIUD = contraceptive intrauterine devices containing levonorgestrel

COC = combined oral contraceptives

D/C = dose/concentration

I'd find a neuropsychopharmacologist to answer this question, not a mish-mash of docs who admittedly don't know. It may just be that this isn't the right drug for you (the cessation of benefit).

Dymphna

Actually, that last thing means that the oral contraceptives accelerated the metabolism of lamotrigine. The higher D/C ratio means that the serum concentration decreased. The same goes for the N-2-GLUC/LTG ratios.

if that makes any sense to you... i only kinda got it.

edit again: but i would think that since hormones drop during menstruation (or around that time) the lamictal levels should increase (or be metabolised slower).

someone else may know more, sorry for blabbering on

[Silver]

IIRC, the question of whether endogenous estrogen (your own homemade stuff) affects lamotrigine in normal non-pregnancy quantities was looked at, and the answer was "no." It would be a fairly big deal if it did, as dosing would need to be changed throughout the menstrual cycle.

Ah - here it is.

I'll see if I can find the fulltext articles. My university server is not playing well with others tonight. Apparently late Friday nights during semester breaks is considered to be a safe time for system maintenance. As if.

It is the estrogen in combined estrogen/progesterone pills that increases the clearance of lamotrigine. The progestogen part (some "mini-pills" are composed of progestogen alone) doesn't mess with the lamotrigine.

[isis]

IIRC, the question of whether endogenous estrogen (your own homemade stuff) affects lamotrigine in normal non-pregnancy quantities was looked at, and the answer was "no." It would be a fairly big deal if it did, as dosing would need to be changed throughout the menstrual cycle.

Ah - [link=http://www.ncbi.nlm.nih.gov/pubmed/16772817?ordinalpos=5&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum" target="_blank]here[/link] it is.

I'll see if I can find the fulltext articles. My university server is not playing well with others tonight. Apparently late Friday nights during semester breaks is considered to be a safe time for system maintenance. As if.

It is the estrogen in combined estrogen/progesterone pills that increases the clearance of lamotrigine. The progestogen part (some "mini-pills" are composed of progestogen alone) doesn't mess with the lamotrigine.

good to know

[rowen]

Ah ha! Thank you for your answers. Most helpful.

My dose hasn't changed. Theoretically my serum levels should be higher, then, from what I'm understanding. Hm. I haven't noticed a difference, except I feel pretty low around my period. I had taken the pill before then, and I still had mood fluctuations around that time of the month, even on several different brands of pills. The low feelings started to go away when I started psych meds. But I'm still on psych meds, but now the pill is out of the picture and I feel off.

Looks like I can blame something else on my crappy mood. And it looks like I'm might be stuck putting up with it, as AD's and pills do not agree with me to a certain extent.

I hate being a girl sometimes.

I haven't had PMS-ish stuff in a long time. Can you tell? I feel like I'm being a wimp about it.

Anyway, thanks again!

[GroovyGwen]

OK - for those of us who need a succinct answer:

Does Lamictal make the Pill less effective or does the pill make Lamictal less effective? I was told a few years back that Lamictal reduces the efficacy of the Pill, hence me off pill. The pill messes with my hormones so I don't really want to take it, but I would if I knew that it was effective in preventing pregnancy. I like the idea of not taking the sugar pills, but I would get all crazy in the days leading up to my period even on the pill. It varies month to month now.

[Silver]

THe estrogen part of hormonal contraceptives (the ones that contain estrogens) increases clearance of Lamictal, which functionally makes it less effective. You can adjust dosing for that. This is a pretty clear effect.

The interaction in the local chain pharmacy computer shows up, however, as Lamictal increasing clearance of hormonal contraception, which would render it less effective.

That's not so clear. See Phelps and this article.

Stockley's (my interaction checker) considers the knockout of OCPs to be a possibility but not a high probability, whereas it flags the potential drop in Lamictal three ways from Sunday and warns of risk for breakthrough seizures.

Of course, Stockley's ain't risking being knocked up, now, is it?

[GroovyGwen]

Of course, Stockley's ain't risking being knocked up, now, is it?

That's what I'M saying. Don't give me this possibility/probability shit. (I said that to them, not you) If I'm probably not going to get pregnant, then I probably won't rely on it.

Besides, I'm at 200 of Lamictal and that study somewhere says that over 200 isn't beneficial to bp's. Although maybe I could take more to compensate? I dunno. T he thought of more pills makes me a little ill. I'm so freaking tired of taking pills constantly... sigh...

[Silver]

If I recall, that study didn't track serum levels.

I can't remember enough to find a citation.

[Maychild]

I get cranky like I always have about a week beforehand. I don't take the pill because the hormones made me a bit whacky. My meds take care of birth control for me. We also use other forms of contraception. I don't adjust my levels throughout the month and I don't notice a difference in how Lamictal works. Hope that helps.

[Silver]

My meds take care of birth control for me.

Er... meds that aren't in your sig?

Or in the way that SSRIs took care of birth control for me, by rendering me asexual and snarly?

[Maychild]

My meds take care of birth control for me.

Er... meds that aren't in your sig?

Or in the way that SSRIs took care of birth control for me, by rendering me asexual and snarly?

The latter. I'm feeling like I'm in a constant state of a mixed episode, so my sex drive is nil. Has been that way for almost ten months. Feel bad for my husband...

[Guest Guest]

I take 300mg lamictal and birth control and have for about 2 years. I have noticed that on my "off week" of the pill I feel realy uncomfortable and agitated. My psych says that this could be due to the fact that the pill decreases the potency of Lamictal, and so during the off week I am getting a much higher dose.

I have started to take 50mg less of my lamictal when I am on the off week, and it has seemed to help me. I don't know, it could be a placebo effect, but I think that a slightly lower dose when you aren't getting decreased action because of BC is the way to go. It might be worth it to ask your psychiatrist, as long as they are well versed about lamotrigine research. I go to Stanford for my psychiatric care, and I feel like they know what they are doing.

[Phoenix_Rising]

I can't take birth control either b/c it makes me even crazier.

I do know that med levels change throughout your cycle:

From the book: "Cutting-Edge Medicine: What Psychiatrists Need to Know":

Dr. Miller emphasizes the high prevalence of this disorder and that women with several psychiatric diagnoses experience exacerbations during the premenstrual phase. The reader will not be surprised to learn that pharmacokinetic changes occur across the menstrual cycle, in most cases with lower serum levels of mood stabilizers and antidepressants in the luteal phase, and these changes might explain the persistence of premenstrual psychiatric symptoms after pharmacotherapy in patients with some psychiatric disorders.

(Sorry for the mega-quote. My brain is mush right now)

I've had the problem you're describing since my son was born. I experience a worsening of BPII symptoms starting at ovulation and ending with my period. Depending on your exact symptoms, this can also be considered a separate illness: Premenstrual Dysphoric Disorder (PMDD).

You can use varying doses of meds (the "authorities" suggest trying SSRIs) throughout the month. I vary Provigil from 50 mg to 200 mg through the month depending on my cycle.

The whole thing kind of adds insult to injury, eh?

I agree with susanb. Best to have your pdoc run some serum levels and get a solid answer.

I hope you get some helpful answers!

Peace,

Phoenix