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Most drugs are known for something. If Viagra or Cialis are mentioned what do you think of first? How effective either one is for erectile dysfunction, the pros and cons of each, Viagra’s weird side effect of cyanopsia (where everything you see is tinted blue), or that your hard-on can last over four hours and if it does you’re supposed to call Dr. Buzzkill about it to see if you may need a surgical happy ending.1

Crazy meds are no different. Most of them are notorious for some reason. Lamictal is best known for “The Rash” (or “The Lamictal Rash”), but it’s also the best drug on the planet to treat Bipolar II. Topamax is also known as Dopamax and Stupamax, and here at Crazy Meds we coined the term “supermodel drug” for both Topamax and Zonegran, because they can make you skinny and stupid, yet Topamax is also a Godsend for a lot of people with migraines and/or various forms of epilepsy, and is the first thing a lot of neurologists will prescribe.
This page also has the black box warnings2 i.e. side effects that can be especially hazardous, if not fatal. These are often, but not always, what a med is most notorious for, e.g. The Lamictal Rash is a black box warning.
If a drug has a black box warning here is a verbatim copy of it from its full US PI sheet. We may comment on any black box warning. E.g. Translate doctorese, note just how rare the problem is, or how the warning is the result of the nexus of panic and politics.

1.  Black Box Warnings

WARNING: SERIOUS SKIN RASHES
LAMICTALTM can cause serious rashes requiring hospitalization and discontinuation of treatment. The incidence of these rashes, which have included Stevens-Johnson syndrome, is approximately 0.8% (8 per 1,000) in pediatric patients (2 to 16 years of age) receiving LAMICTAL as adjunctive therapy for epilepsy and 0.3% (3 per 1,000) in adults on adjunctive therapy for epilepsy. In clinical trials of bipolar and other mood disorders, the rate of serious rash was 0.08% (0.8 per 1,000) in adult patients receiving LAMICTAL as initial monotherapy and 0.13% (1.3 per 1,000) in adult patients receiving LAMICTAL as adjunctive therapy. In a prospectively followed cohort of 1,983 pediatric patients (2 to 16 years of age) with epilepsy taking adjunctive LAMICTAL, there was 1 rash-related death. In worldwide postmarketing experience, rare cases of toxic epidermal necrolysis and/or rash-related death have been reported in adult and pediatric patients, but their numbers are too few to permit a precise estimate of the rate. 

 Other than age, there are as yet no factors identified that are known to predict the risk of occurrence or the severity of rash caused by LAMICTAL. There are suggestions, yet to be proven, that the risk of rash may also be increased by (1) coadministration of LAMICTAL with valproate (includes valproic acid and divalproex sodium), (2) exceeding the recommended initial dose of LAMICTAL, or (3) exceeding the recommended dose escalation for LAMICTAL. However, cases have occurred in the absence of these factors.

 Nearly all cases of life-threatening rashes caused by LAMICTAL have occurred within 2 to 8 weeks of treatment initiation. However, isolated cases have occurred after prolonged treatment (e.g., 6 months). Accordingly, duration of therapy cannot be relied upon as means to predict the potential risk heralded by the first appearance of a rash.

 Although benign rashes are also caused by LAMICTAL, it is not possible to predict reliably which rashes will prove to be serious or life threatening. Accordingly, LAMICTAL should ordinarily be discontinued at the first sign of rash, unless the rash is clearly not drug related. Discontinuation of treatment may not prevent a rash from becoming life threatening or permanently disabling or disfiguring.

2.  Black Box Comments

Let’s read this part of the black box warning from the the PI sheet again:

LAMICTAL should ordinarily be discontinued at the first sign of rash, unless the rash is clearly not drug related.

IF the rash doesn’t meet the itchy and fever criteria, AND IF you can find the source of a new or potentially irritating substance that didn’t previously bother you, then maybe you can chalk it up to contact dermatitis - an allergic reaction caused by touching or otherwise coming into contact with something your skin doesn’t like - and a common Lamictal side effect.
If you and your doctor think Lamictal is worth the bother of continuing, talk it over. The last paragraph in the black box warning is clear as mud. Translated from corporate lawyer weasel speak:

“Most rashes are no big deal, but you can never tell. So if you think you might be developing anything that may be a rash, stop taking Lamictal immediately. Because even if you quit taking Lamictal immediately that won’t necessarily prevent the rash from killing you or making you look like Edward James Olmos’ and Amy Winehouse’s love child.”

To make things easier for you, here is a picture of Lamictal-induced Stevens-Johnson Syndrome (SJS). AKA The Lamictal Rash:

The Lamictal Rash
Image from health-pictures.com

3.  What Lamictal (lamotrigine) is Best Known for

  • The Rash. Everyone is scared shitless of The Lamictal Rash.
  • Totally kicking the assess of Symbyax, Seroquel, and whichever atypical antipsychotic has the latest FDA approval / big pharma ad campaign to treat bipolar depression. Despite the fact that Lamictal doesn’t have FDA approval to treat bipolar depression.
  • Working as an antidepressant at 25mg a day for some people.
  • Being the only anticonvulsant (AC) affected by estrogen-based birth control (BCP) while only rarely affecting BCP.

4.  Noted Traits & Effects

Drugs can sometimes have lesser-known traits and effects that make them unique, such as Keppra’s ability to stop mania immediately as if it were an antipsychotic. Some are good, some are bad, some are just weird. Some might be helpful for you to know about in order to make the best use a med, or to help it suck less. Others are meaningful only to pharmacology geeks.

Have I gone on about the rash long enough yet? Thanks to Lamictal kids with Lennox-Gastaut are able to live marginally normal lives, and skads of people with bipolar 2 and otherwise treatment-resistant forms of depressive disorders are able to function. Oh, and many of those depressed people started to feel a hell of a lot better in a couple of days. But when you ask teh intergoogles about it, you’d think the stuff was made out of poison ivy fermented in wet diapers.

All AEDs can make you more susceptible to skin irritants and dermatological problems. Lamictal is just the worst when it comes to that. Contact dermatitis, eczema, and similar problems can be caused by any number of things. Some of the most likely sources are:

  • Soap
  • Cosmetics
  • Household cleaners
  • Fabric softener and dryer sheets
  • Clothing - either the fabrics or something the clothes came in contact with
  • Latex
  • Facial creams
  • Sunscreen

Because they contain:

  • Fragrances. Used in cosmetics, insecticides, antiseptics, soaps, perfumes, and dental products.
  • Formaldehyde. Used as a preservative in fiberboard (that new office smell), paints, medications, household cleaners, cosmetic products, and fabric finishes.
  • Quaternium 15. A preservative in self-tanners, shampoo, nail polish, sunscreen.
  • Neomycin sulfate. An antibiotic in first aid creams and ointments.
  • Several metals, especially cobalt chloride, nickel, and gold. While mostly used in the obvious places, cobalt chloride is also used in hair dyes and antiperspirants.
  • Poison ivy, poison oak, poison sumac, and other natural things that are outdoors and always trying to kill us.

Eliminating common skin irritants from your life may prevent you from needlessly discontinuing Lamictal - or any other drug for that matter - due to something like contact dermatitis.
For even more information about household products, skin allergies and irritants see:

5.  Noted Drug-Whatever Interactions

In case you don’t bother reading the Pharmacokinetics page, here are any really important drug-drug interactions, or the ones that haven’t made it into the PI sheets and/or drug-drug interaction checkers, as these are noted traits as well.

  • Rooibos (Aspalathus linearis)/ red tea may be a potent inducer of UGTs. As such you should probably avoid whatever it’s call where you live if you’re taking Lamictal.
  • Like many crazy meds, especially AEDs, you may need to take more Lamictal and/or take it more often if you smoke.
  • I cannot stress often enough the interaction between Lamictal and anything containing ethinyl estradiol, which is practically every form of pharmacological birth control except the Depo-Provera (medroxyprogesterone) injection.
  • Lamictal’s bioavailability may be affected by food. That’s the only study I’ve found showing any affect food has had on Lamictal, but this med is so screwy it wouldn’t surprise me if it can make enough of a difference for some people.
  • Like most AEDs, Lamictal messes with how your body deals with folate. So you’ll probably need to take a folic acid supplement.

Drugs.com’s drug-drug and drug-food interaction checker

‹ Side Effects | Lamictal Index | Pharmacokinetics & Noted Drug-Drug Interactions ›
Crazy Meds Comprehensive Lamictal pages

Bibliography

1 Fun facts: The cause of your never-ending boner (priapism) the is often a blood clot, which can work its way loose, make its way to your brain or heart, and kill you. So it's not so much about the inconvenience of a tent pole that can never be unpitched, it's about a potentially fatal side effect of ED drugs. As for the surgery that might be required, see Erectile function and dysfunction following low flow priapism: a comparison of distal and proximal shunts* for the gory details, with pictures that will make you lose a few inches.

2 Called "black box warnings" because they appear in a box at the top of the PI sheets, written in big, bold print, and originally surrounded by a thick, black outline. Some companies still put black box warnings in a black box. There is no relationship to the black boxes in airplanes, although I haven't tried burning a number of different PI sheets to see if the black box warnings are still legible in the ashes.


Date created 18 Jan 2011 - 15:16 Page Creator: Jerod Poore Last edited by: JerodPoore

Lamictal Black Box Warnings, Notable Traits & Effects by Jerod Poore is copyright 2011 Jerod Poore


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1 While there are plenty of books to help you with hypochondria, for some reason there’s not much in the way of websites. Then again, staying off of the Internet is a large part of curing/managing the disorder.

2 Have I mentioned how open source operating systems for commercial applications is one of the dumbest ideas in the history of dumb ideas?
[begin rant] I rent a dedicated server for Crazy Meds. It’s sitting on a rack somewhere in Southern California along with a bunch of other servers that other people have rented. The hardware is identical, but no two machines have exactly the same operating systems. I don’t even need to see what is on any of the others to know this. If somebody got their server at the exact same time, with the exact same features as I did, I’m confident that there would be noticeable differences in some aspects of the operating systems. So what does this mean? For one thing it means that no two computers in the same office of a single company have the same operating system, and the techs can spend hours figuring out what the fuck the problem could be based on that alone. It also means that application software like IP board that runs the forum here has to have so many fucking user-configurable bells and whistles that even when I read the manual I can’t find every setting, or every location that every flag needs to be set in order for a feature to run the way I want it to run. And in the real world it means you can get an MBA not only with an emphasis on resource planning, but with an emphasis on using SAP - a piece of software so complex there are now college programs on how to use it. You might think, “But don’t people learn how to use Photoshop or Adobe Illustrator in college?” Sure, in order to create stuff. And in a way you’re creating stuff with SAP. But do you get a Bachelor of Fine Arts degree with an emphasis on Photoshop?
Back in the Big Iron Age the operating systems were proprietary, and every computer that took up an entire room with a raised floor and HVAC system, and had less storage and processing power than an iPhone, had the same operating system as every other one, give or take a release level. But when a company bought application software like SAP, they also got the source code, which was usually documented and written in a way to make it easy to modify the hell out of it. Why? Because accounting principles may be the same the world over, and tax laws the same across each country and state, but no two companies have the same format for their reports, invoices, purchase orders and so forth. Standards existed and were universally ignored. If something went wrong it went wrong the same way for everyone, and was easy to track down. People didn’t need to take a college course to learn how to use a piece of software.
I’m not against the open source concept entirely. Back then all the programmers read the same magazines, so we all had the same homebrew utilities. We even had the forerunner to QR Code to scan the longer source code. Software vendors and computer manufacturers sponsored conventions so we could, among other things, swap recipes for such add-ons and utilities. While those things would make our lives easier, they had nothing to do with critical functions of the operating system. Unless badly implemented they would rarely cause key application software to crash and burn. Whereas today, with open source everything, who the hell knows what could be responsible some part of a system failing. [/end rant]


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