Lamotrigine for....everything?

[reca]

I'm a PGY-3 and still inheriting a few patients from here and there. Something I've noticed is that lamotrigine seems to be prescribed for literally everything. Bipolar maintenance, bipolar depression, adjunct to SSRI for unipolar depression, monotherapy for unipolar depression, and borderline personality disorder.

I'm wondering if I'm missing something or if there actually is evidence for any of this? My understanding based on didactics and my own reading is that really, the only evidence base for lamotrigine is bipolar maintenance with more evidence for prevention of a depressive episode than prevention of a manic episode (i..e less than lithium but more than placebo in preventing mania). Yet it seems 90% of the people I see on lamotrigine are prescribed it for borderline personality disorder or unipolar depression (either on its own or with an SSRI). When I've asked about this, I'm told, "for mood instability" but that seems like conflating of marketing terminology with what the medication actually does. I'm not sure if I'm missing something crucial here or if there're practice patterns that are established that aren't reported in the literature?

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[NickNaylor]

Apart from SJS, it's a pretty benign medications with minimal side effects. I think the thought process of many folks is "I don't know what's going on, might as well take a shot in the dark." I also see a lot of people on LAM for which there is no clear, evidence-based indication.

I personally don't do this kind of thing.

 

[wolfvgang22]

You aren't wrong.
Lamotrigine is generally lower risk and better tolerated than divalproex and lithium. It won't make you fat, it won't cause tremors, it won't cause kidney or liver damage and doesn't cause a lot of cognitive slowing. If you don't get a rash, it is generally no problem.

Unfortunately, patients are complex and can have comorbidities ( more than one psychiatric diagnosis, multiple social issues, on NSAIDs, etc) and frequently fail to respond to antidepressants, which have a reported 40% to 60% rate of effectiveness. Many, if not most psychiatrists are under intense pressure from all sides to provide effective treatment that for many patients may not exist, or because treatments that would be more effective (i.e. psychotherapy) are not preferred or prioritized by systems and /or patients.

Lamotrigine, as you have witnessed, is frequently used off label as an adjunctive medication to antidepressants in persons who have depression and some mood instability, and there is some limited evidence for that. It is likely lamotrigine is over prescribed and should be used judiciously.
Welcome to practice.

 

[FatherPsychiatry]

Abilify + Lamictal for ALL psych issues!

 

[SourceOfDenial]

I remember the first person I started on lamictal in residency developed SJS. Bad coincidence, but certainly impacted me in developing a ‘lamcital for all’ approach.

 

[st2205]

It’s been one of my most commonly prescribed medications post residency. I almost never use it in bipolar disorder (though I’m pretty selective in who I label as bipolar so perhaps I’m prescribing it to a lot of people who may otherwise get that diagnosis), but it’s usually one of the top go-tos for personality issues because it’s 1) not other mood stabilizers that require monitoring and have nasty side effects that people would otherwise be on and 2) seems to be fairly effective in that population for depressive symptoms as well as mood stability (obviously a medication deficiency isn’t the underlying cause of their dysregulation). I do use it in unipolar depression without personality issues, though less frequently. Decent responses there. As far as the data, there really isn’t great data on it. Clinically it works great. Other things that have data? I’m convinced they don’t work. Such is psychiatry and modern medicine.

 

[wolfvgang22]

Other things that have data? I’m convinced they don’t work. Such is psychiatry and modern medicine.

What do you mean? Any examples?

 

[st2205]

What do you mean? Any examples?

Anything with an FDA indication for bipolar depression.

 

[tr]

I don't think there's any data on this but I have found low dose ltg really useful for irritability. I had a couple of patients with bipolar do where I was cross titrating them to something else, and irritability returned after d/c of Lamictal but then resolved again when 25-100 mg ltg was added back in combination with the other mood stabilizer. I also often see improvements in irritability during early uptitration, before attaining a mood stabilizing dose.

I don't personally use it for people without bipolar disorder or at least cyclothymia though.

 

[clausewitz2]

I don't think there's any data on this but I have found low dose ltg really useful for irritability. I had a couple of patients with bipolar do where I was cross titrating them to something else, and irritability returned after d/c of Lamictal but then resolved again when 25-100 mg ltg was added back in combination with the other mood stabilizer. I also often see improvements in irritability during early uptitration, before attaining a mood stabilizing dose.

I don't personally use it for people without bipolar disorder or at least cyclothymia though.

I use it for excoriation d/o because there is at least some evidence and nothing works amazingly well. Yes, yes, HRT is best, for sure, but if someone can't go to work because when they get in their car they spend the next 7 hours picking it'd be pretty great if there was an option to help out even a little bit more quickl

 

[tr]

I use it for excoriation d/o because there is at least some evidence and nothing works amazingly well. Yes, yes, HRT is best, for sure, but if someone can't go to work because when they get in their car they spend the next 7 hours picking it'd be pretty great if there was an option to help out even a little bit more quickl

Really Lamictal works for skin picking? I always use NAC but it's not infallible, I'd say it works about 60-70% of the time, would be nice to have another option.

 

[nighthawk2551]

Regarding borderline PD, there are two reviews from 2010 (Ingenhoven et al, and Stoffers et al which is a cochrane) that look at meds. Mood stabilizers are the most effective for the most broad range of symptom domains. That being said the 2018 LABILE trial was negative, although this trial didn't break down BPD patients in the way prior data suggested treating BPD symptoms.

Anecdotally most of the faculty in my program still see lamotrigine as most affective for severe irritability/affect dysregulation in BPD. It won't cure it and it won't help with all symptoms, but it's good for certain aspects of the disease.

 

[clausewitz2]

Really Lamictal works for skin picking? I always use NAC but it's not infallible, I'd say it works about 60-70% of the time, would be nice to have another option.

This is an area that really suffers from a paucity of good research but an open label trial showed major improvement for 67% of patients on 25 qOD-300 mg LTG daily. Some of the people in the LTG group went from mean of 118 minutes per day picking to 0 minutes at the end of 8 weeks with dose of 200 mg on average.

There was also an RCT that found positive, nonsignificant trend towards benefit v. placebo with range of 12.5-300 daily. Interestingly, people who responded to LTG v non-response to LTG did really poorly on an adapted Wisconsin Card Sort task, which is supposedly mediated by something something frontal gluatamatergic dysfunction something something. The LTG responders were also quite bad at a go-no task. So maybe benefit depends on cognitive profile? The RCT was hilariously underpowered (n = 16 per arm!), though, so who knows?

A lot of the NAC stuff is either on TTM or is in Prader-Willi kids so I am always uncertain as to how much of an inference to ExD is licensed. Also, concerns about purity and contents of OTC products of any kind etc etc. Totally reasonable choice, though.

 

[clausewitz2]

Regarding borderline PD, there are two reviews from 2010 (Ingenhoven et al, and Stoffers et al which is a cochrane) that look at meds. Mood stabilizers are the most effective for the most broad range of symptom domains. That being said the 2018 LABILE trial was negative, although this trial didn't break down BPD patients in the way prior data suggested treating BPD symptoms.

Anecdotally most of the faculty in my program still see lamotrigine as most affective for severe irritability/affect dysregulation in BPD. It won't cure it and it won't help with all symptoms, but it's good for certain aspects of the disease.

I like that LABILE was done and want more work like it for other meds/indications, but I think there was a serious floor effect. Everyone in the study got visited once every two weeks for dispensing of lamotrigine and assessments for months and months. EVERYONE improved, which should not be a shock wrt BPD. There is a fascinating qualitative paper interviewing participants in LABILE that confirms that many participants felt increased and predictable contact was the most helpful thing about the trial (Sanantinia et al. 2019 in Personality and Mental Health).

In the real clinical world where this doesn't happen, hard to say whether you'd see a med effect.

 

[nighthawk2551]

I like that LABILE was done and want more work like it for other meds/indications, but I think there was a serious floor effect. Everyone in the study got visited once every two weeks for dispensing of lamotrigine and assessments for months and months. EVERYONE improved, which should not be a shock wrt BPD. There is a fascinating qualitative paper interviewing participants in LABILE that confirms that many participants felt increased and predictable contact was the most helpful thing about the trial (Sanantinia et al. 2019 in Personality and Mental Health).

In the real clinical world where this doesn't happen, hard to say whether you'd see a med effect.

Right. There were some serious flaws in the study that were obvious to most practicing psychiatrists. They pretty much designed it like any old medication trial which is not an ideal design for BP disorder.

 

[ara96]

I see this BS all the time on Borderline Personality Patient's. No way am I going to get sued when someone gets SJS without an FDA approved indication.

 

[st2205]

I see this BS all the time on Borderline Personality Patient's. No way am I going to get sued when someone gets SJS without an FDA approved indication.

If a tree falls in the forest and the FDA didn’t approve it, it didn’t happen.