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Lamictal titration - 1 month to recover from each dosage increase???


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All, I am BP2, and I was on 50mg of Lamictal for about 3 yrs.  Overall, I was much more stable and not so up and down, but I still had way too many outbursts of anger, depressive mood swings, etc.  Therefore, I've been titrating up crazy slow at like 12.5mg every 2 months and I'm now at 100mg.  

Essentially it goes like this:  

  • I go up 12.5mg and feel good for 3-5 days, thinking "this must be it"!  
  • Then I feel like crap for a few days (flu like), I'm depressed, very anxious, etc etc.
  • After about 2 weeks the symptoms ease off some, but I am then just a slightly depressed ticking time bomb just waiting on someone to make me mad so that I can explode.  
  • After a month or so, I generally calm down and I'm back to "normal", which means I just don't get angry so quickly, and I am not SO depressed so often.  

To be honest the Lamictal makes me feel flat, and keeps me from being able to concentrate properly, unless I get on loads of caffeine (I know, it's a no-no).  Also, if I wake up in the middle of a sleep cycle, I feel like crap for the rest of the day and I can't get over it.  I keep holding out hope that going up on the Lamictal to 200mg or so will help me out, but I swear I don't know if I (and my family) can make it that high.

Since I feel okay for 3-5 days after going up, should I just keep increasing when I start feeling down again, and just power through the titration up to at least 200mg?
Since I'm not even feeling as good on 100mg as I was on 50mg, should I go back down or assume Lamictal is not for me?

Thanks!
Heygrain

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Never had the flu like symptoms you described,  but I know the exhaustion part. Takes me about 2 weeks to adjust to a dosage increase.  I've never had a problem with hitting the coffee machine up to compensate for lethargy.  For me, the meds keep getting better and better - later on. I would ride it up to 200mg. See if you can schedule your crap feeling phase over a long weekend.  I do have to admit that I seem less interesting now that I'm stable.

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From my experiences with Lamictal, it sounds like it's not really working. I've been on doses from 75-400mg for extended periods of time (as long as a year) and I still had major mood cycles as well as the concentration problems and the flu-like symptoms when moving dosages up or down. That being said, you may not be on a high enough dose yet to really tell. 100mg is pretty low. 

Standard answer: discuss it with your pdoc. It's a tough call because it might work well, but the adjustment period can be hell on your life in the meantime. If it was me, I'd probably stick it out to at least 200mg, but if I wasn't feeling noticeably better, I'd ask to switch then. 

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I had problems with lamotrigine  when I started but if I remember rightly i got to therapeutic doses quite quickly, Every med is different to everyone, Lithium was terrible for me to increase, took me off my feet for a week or two each time. If the side effects are that bad speak to your Pdoc, they might be able to suggest something else

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I've never had a problem with lamictal, but like dtac was saying, discuss it with your pdoc.  Personally I would continue going up, but if you don't feel any better after getting to the 200 mg dose, talk to your pdoc about maybe finding another med that you could try.

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12.5mg every 2 months? Why so slow? It's possible that doing it so slowly is just drawing out the unpleasantness of it all.

When I titrated up, it was in 25-50mg increments. I know you can get the Doom Rash from it so I can understand a psychiatrist being super cautious about dosage increases.

I never had trouble titrating up lamotrigine. Once I got up to 200 mg I had concentration problems, though.

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12 minutes ago, Bubble said:

12.5mg every 2 months? Why so slow? It's possible that doing it so slowly is just drawing out the unpleasantness of it all.

When I titrated up, it was in 25-50mg increments. I know you can get the Doom Rash from it so I can understand a psychiatrist being super cautious about dosage increases.

I never had trouble titrating up lamotrigine. Once I got up to 200 mg I had concentration problems, though.

This was my first thought too. I did 25 mg increases every 2 weeks until I got to 100 mg, then did 150 mg for 2 weeks before going to 200 mg. Most of the time, when starting new meds, including lamotrigine, I seem to recall being told that unless you have intolerable side effects the general strategy is to get to the minimum standard therapeutic dose as quickly as can be done safely and then assess from there is a higher dose is necessary. Often, mood disregulation will be worse at sub-therapeutic doses, and you often have to re-acclimate to side effect at each new dose anyway. 

If you do get to 200 mg (although some people consider 100 or 150 to be a therapeutic dose) and after a few weeks it still feels worse than on 50 mg, I might talk to my pdoc about going back to 50 mg and then trying to find a medication to add on to address the symptoms that remain.

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Thanks for the input everybody.  Essentially when I'd try to go up by 25mg at a time, it would literally almost knock me out.  I'd be so out of it in the beginning that I just quit trying.  I then realized that I was at least semi-stable at 50mg so I just stayed there, fearing how bad I felt going up.  Recently though I've felt like I either need to go up again and see if it works for me, or get off of it altogether.  To be honest I'm more flat on the medicine, along with a little more anxious and probably not quite as interesting to be around as I used to be (like Jean said).  I think it's making me more into a hermit to some extent, which I'm normally a very outgoing person (although I've always had ongoing GAD and some up and downs on depression).  Therefore, it's go up or go off time I think.

I'm going to try and titrate up to 200 soon... maybe over the holidays, although that could ruin some things if I feel bad.  I will try and follow the dosing schedules and just get the bad out of the way quickly.  Like I said, I feel good for the first few days of going up, so maybe as that wears off, I can  just go up to the next dose since I haven't experienced "the rash" any.  

Just looking back at some notes as I titrate up, I always get stuffy headed and sinus headaches, like my allergies are bad.  Anybody else experienced that?  It is fall, so maybe it's just been a coincidence but it also happened over the summer.

Thanks for the input everyone... I'll let you know how the titraton goes!

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4 hours ago, heygrain said:

so I just stayed there, fearing how bad I felt going up

You might have just needed to give the 50 mg more time to get into your system before going to the 100 mg. 

If you want to go up in dose, I'd give it a try.  Sometimes a person can feel worse on lamictal (while titrating up) before they feel a lot better and can see a difference.

 

 

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Seems like a very slow titration. Typically, you start at 25mg and go up by 25mg every 2 weeks. Often, like Thunder mentioned, mood disregulation will be worse at sub-therapeutic doses....The target dose for Bipolar, I believe is 100-200mg, so I wouldn't give up until you are at that dose for awhile (like minimum 6 weeks+ unless it is completely intolerable)  so you give your body time to adjust. I was up to 300mg in the past (which was too high for me) the only negative side effects at the high dose was feeling a bit of cognitive "slowness" like forgetting words and clumsiness.

Otherwise, Lamictal has been the most mild med I've ever been on without many noticeable side effects (and i am very sensitive to side effects usually) It never made me feel "numb" like all of the other SSRIs/SNRI's, or terribly sedated & hungry like A/Ps. Every other medication has been a million times worse as far as sedation, emotional flatness, etc. for me at least) Overall, it seems very well tolerated by most people.

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Are you on a contraindicated medication? I was on Depakote when I started Lamictal, and had to go up more slowly than usual, but still faster than you are doing. 12.5mg every two weeks.

Lamictal often has a ton of side effects while you titrate up that go away once you reach a therapeutic level. These include aches and pains (back and legs especially), flu-like symptoms, nightmares or vivid dreams, anxiety, unstable mood, etc. Those aren't all of them. You can't really tell how you are going to respond until you hit your personal sweet spot. If there was a level that you felt good at, it is possible raising it will make it work less well. And vice-versa, unfortunately. I'm at 400mg, which happened over a few years.

Also, a lot of people feel better at 100mg for a bit, and then it stops working until it is raised again. I definitely felt better at 100mg, but it ended pretty quickly.

I really like Lamictal, so it was worth it, but ymmv.

Are you on a contraindicated medication? I was on Depakote when I started Lamictal, and had to go up more slowly than usual, but still faster than you are doing. 12.5mg every two weeks.

Lamictal often has a ton of side effects while you titrate up that go away once you reach a therapeutic level. These include aches and pains (back and legs especially), flu-like symptoms, nightmares or vivid dreams, anxiety, unstable mood, etc. Those aren't all of them. You can't really tell how you are going to respond until you hit your personal sweet spot. If there was a level that you felt good at, it is possible raising it will make it work less well. And vice-versa, unfortunately. I'm at 400mg, which happened over a few years.

Also, a lot of people feel better at 100mg for a bit, and then it stops working until it is raised again. I definitely felt better at 100mg, but it ended pretty quickly.

I really like Lamictal, so it was worth it, but ymmv.

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crtclms, I'm not sure what " contraindicated medication" means.  I'm not on anything but the Lamictal, D3 and fish oil, so I'm not sure how to answer your question.  I agree, I think I have to keep going up to see what I feel like once I get to the "therapeutic" level.  However, I've always been very sensitive to medicine, so I may not end up needing 200mg.  

Unfortunately I can't plow through the titration right now because I have a lot of training at work that I have to complete by the end of the year, and right now the titration is causing me to not be able to concentrate due to feelings of ADD/anxiety, as well as just an overall tiredness and depressed state.  Just trying to trudge through the next month and a half and then start going up to what I hope will be a good level for me.  Thanks for the reply!

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The lower doses of Lamictal, under about 100mg, can have all sorts of unpleasant effects. You will probably start to feel good now or maybe when you reach 150-200. I find 200mg to be the sweet spot for me. I would power on upwards, as per your pdocs instructions of course. With regards to side-effects, I found I had a variety of minor GI issues like nausea, heartburn, diarrhea which took quite a while but eventually went away. I really think it is the most wonderful medication. Certainly the best I've ever taken, for any dx. I hope it works for you!

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I would really talk your psychiatrist. I take 200 mg of Lamictal and titrated up to it VERY quickly because I was going whole-hog bananas at the time and didn't experience any side effects from the med, so maybe it just isn't something that works for you. I've been told by several doctors (I was hospitalized twice during that time period, so I got several opinions) that Lamictal is most effective at preventing depression, but not as effective at preventing mania. I don't know what other meds you're on, but maybe consider an antipsychotic since you seem to have a lot of trouble with anger. I'm only on Lamictal and Seroquel, and the combination (along with exercise, self-care, journaling, therapy, etc.) works really well for me. Hope you find something that helps!

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I started on I think 25mg or so, then within that week went up to 50mg, then a week or two after that went up to 100mg. Then maybe a month or two later when it still wasn't working quite well enough, I was raised to 200mg straight from 100mg. A year or so after that I was jumped to 300mg, but then I started having trouble taking it consistently and started having mood issues again. I fell off track and stopped taking it. 

 

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On 11/9/2016 at 11:48 PM, ohjustchillin said:

I started on I think 25mg or so, then within that week went up to 50mg, then a week or two after that went up to 100mg. Then maybe a month or two later when it still wasn't working quite well enough, I was raised to 200mg straight from 100mg. A year or so after that I was jumped to 300mg, but then I started having trouble taking it consistently and started having mood issues again. I fell off track and stopped taking it. 

 

ohjustchillin, how did you feel at 200mg for a year, and what made you go up to 300mg before stopping?  Thanks!

 

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7 hours ago, heygrain said:

ohjustchillin, how did you feel at 200mg for a year, and what made you go up to 300mg before stopping?  Thanks!

 

I think I was mostly stable. I wasn't angry all the time, but I still had some delusions and anxiety. Basically just got rid of the really bad depression and the anger. I wasn't quite good enough though. I was still having symptoms so they brought it up to 300mg.

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