Update

Here's What Dr G (webmd doctor) had to say about my pdocs changes and decisions:

Hi Dr. G!

So, my doctor says the reason he wants me on 800 MG of Lamictal is because I seem to be highly hyposensitive to medication. He also said he is going to keep me on 600 MG of Lamictal and increase it after he does the genetic testing to be certain everything is metabolizing correctly (or something of that nature...I hope that makes sense).

I also came out of a manic episode and rather plummeted into a weariness that has me sleeping sometimes 16 to 17 hours night/day again. Again he increased the Vyvanse from 35 MG to 70 MG and promsed me that he WILL be able to keep me out of bed to care for my kiddos every day even if it means mixing with Adderall for a bit.

What are your thoughts on hyposensitivity? What are your thoughts on the Vyvanse (do you remember I was worried that the Vybanse/Zoloft combination either caused or agitated the mania I experienced)?

Thank you,
Sarah

Joseph F Goldberg, MD responded:
Dear Sarah, I know of no scientific basis for pushing lamotrigine's dose as high as 800 mg. at that high a dose I would be watchful for signs of neurotoxicity (unsteadiness when walking, tremor, cognitive problems, darting eye movements called nystagmus). There are certain medicines that get metabolized by specific enzymes in the liver (called cytochrome p450 enzymes) and a select few of them can have genetic variations that make people metabolize drugs too fast when they go through those enzymes. Such people (about 7% of Caucasians) are said to be ultra rapid metabolizers of specific drugs that go through those specific enzymes. Perhaps that's what your doctor meant by "hyposensitive" to medicines. However, lamotrigine doesn't get broken down by those enzymes -- it goes through an entirely different metabolic pathway called glucuronidation and there are no known genetic variants of that enzyme (glucuronidase) so genetic testing won't tell much of anything with respect to lamotrigine. Vyvanse dose go through that cytochrome enzyme. If someone is a fast metabolizer at that enzyme they could need a higher dose. If they are a slow metabolizer at that enzyme then vyvanse likely won't do anything because Vyvanse is what's known as a pro-drug, meaning it's an inactive form of a medicine (amphetamine) that only becomes active once broken down by the enzyme. (And if the enzyme was too slow, it won't ever break down the inactive drug into the active form). I would not be eager to use vyvanse in someone who was recently manic or psychotic because of the likelihood it would reactivate those symptoms. There are several much more traditional medicines both for bipolar depression or for mania which I talked about in previous posts that I myself likely would find to be more compelling and scientifically-based options than these. Dr G

What do I do with this?

Get a new pdoc

That what I think. I start to get cognizant difficulties and headaches at 400 mg. 800 is like crazy high that I've never heard of anyone taking that dose. Be careful hun.

when I asked if I had any room left to go up since I am now at 300, he said the "I think he said neuraligist" have used it up to 1200 ... wtf? I let it go at the time but did think it very odd ..

I would find a new Pdoc. He sounds reckless when you compare his plan and what is already known about Lamictal and the studies back it up.

Trileptal is delicious! Mirapex for dessert!

I take 300mg lamictal and my pdoc said it's a high dose!

i say trash this pdoc girl...dont take the chance of doing something long term to your body or your mind
good luck!

Thanks for the update cash!

Honestly? When I saw one of your posts that said you were on 800mg of lamotrigine some time back ... I was like huh? I've never personally been on higher than 200/300mg, but hey, that's just me and what my pdoc prescribed and I really don't know what the validity of pushing it to 800mg would be? Maybe there's different schools of thought on this. I don't know.

I don't know enough about the other meds to comment on those specific, but doesn't seem like when I follow your posts they did not have quite the effect that one would hope for.

I think that the response to the letter is an indication that some medical professionals would not agree with that dose ... with the lamotrigine dose anyway .... If it were me, personally, as some before me have already suggested, not sure if I'd stay with the pdoc. I'd maybe look into finding a new one.

Are you comfortable taking that high of a dose? If you're not you don't have to take it. Tell your pdoc you're not comfortable with it. He's not going to force it down your throat.

I take 100 lamictal and 30 lexapro. Zolpidem for sleep. My therapist would take me off lamictal it i had to take a dose that high. No antipsychotics now.

I know people have a difference tolerance level. It seems you are on too many that are not working well.

And I am bipolar 1.

I'm on 400 mg Lamictal and that is a high dose. It was increased when I was in the hospital and they told me it tops out at 400 mg. I can't even imagine a pdoc advocating for higher doses than that. I'd start looking for a new one ASAP.

Okay. I understand what all of you are saying, I really do. But, his level of compassion along with our 17 year relationship history, makes this so hard for me. Also, because of my crappy insurance, the soonest I can get a face to face second opinion is September. I already have an appt with a different pdoc and I had planned to cancel but, I am at least going to go and hear what he has to say. In the meantime, my current pdoc is my only option and I am going to start seeing him twice a month because he is also going to do psychotherapy with me.

I did tell him in an email that I was not comfortable with the high dose of Lamictal. He started his explanation with "So, you are afraid of taking the high dose of lamictal." That's when he went on to explain that he thinks I am hypo sensitive to medictions. That is also the reason he said we would stay at the 600 MG until he gets the genetic testing done.

I also am Bipolar 1 and on top of the Lamictal, Vyvanse, and Zoloft, I also take Lithium (1350 MG), Abilify (30 MG) and Klonapin (I'm supposed to take 2.5 MG but I actually only take 1 MG). It does seem a bit senseless.

Oh. Okay.

I mean, if you're okay with it and trust your doctor, do it.

How do you feel at 600? Is it helping?

I also kind of wanted to point out something...

Depending on where you live it's really hard to get a new pdoc! I needed one, called numerous places and they all said they couldn't help me. Had to get a refferal from my GP, had to jump through a million more hoops, and finally got an appointment to see one, and now I'm stuck with this anti-benzo prescribing person, and I literally can not get anyone else!

So...getting a new pdoc can be impossible (depending on your location of course).

End rant. Lol. Sorry.

This does scare me, especially after Dr G. wrote "I would be watchful for signs of neurotoxicity (unsteadiness when walking, tremor, cognitive problems, darting eye movements called nystagmus)." I am perplexed.

I am depressed but not suicidal. That is an amenity, I suppose. Trouble is, I take so many medications it is difficult to know what is doing what to me.

Everyone is telling you the same thing but its your choice. From my outside view...it seems like hes risky and prescribes a lot of meds for one person. I understand you have a long relationship but sometimes you need to move on for your own good.

Agreed. ^

My suggestion is always always research prescribed drugs and dosages before taking..most psych meds r heavy duty meds and can be harmful. If u feel insicure about 800mg..don't take that much..

YOu know what I think about your meds. I'll support you however you go but here's the thing: I know I do not process meds normally. I just gave blood for a clinical trial that is working to help work around this and later will give blood again and get my results for how I process my own meds. I've been on a LOT of meds. I've pushed dose limits as recently as a few days ago and some doctors would still not prescribe my Seroquel dose. I'm ok with it because I know that increasing from 900 mg to 1200 mg really helped me. Each of my now 6 psych meds has a role that makes sense in context. Two low dose mood stabilizers because I don't tolerate either well. High dose Seroquel. Adding in the new AP to help increase my AP coverage enough to make Seroquel a little more flexible. I've been on meds to offset side effects, both provigil and nuvigil. I cannot imagine taking a large dose of a stimulant to counter a sedative dose when I was also taking stimulating meds.

If you look through all the years of meds I've been on an off (65th cocktail right now) it has always been add something because of _____ (specific reason) and usually reduce something else because ________ (specific reason). Like now, I"m fairly sure as my loxapine goes up my Seroquel will come down more and we'll try to get rid of the low dose mood stabilizers. They both help but not a lot and there's no point in being on meds that can be covered by other meds.

Adding, adding and adding without explanations that scientifically make sense and using drugs that can trigger mania, several together, that would make me very anxious. Perhaps I'm just used to the approach my pdoc uses and if I were used to another way I wouldn't feel that way but I doubt it. Logic and explanationw of why and what happens next are really important to me.

Just because a relationship is long doesn't always mean it is healthy. My parents were married 25 years which was about 24.5 years too long.......

Do you have the option to go ip for detox and restart? Lamictal may just not be working anymore. There are other options and fresh eyes may help. Don't wait until something bad happens. After detox and new meds you can continue seeing your current pdoc.

I agree with miguel'smom. Maybe a fresh start would be a good idea.