Lamictal & Zyprexa as a Combo
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Q:  Lamictal & Zyprexa as a Combo

I'm staying with my 35 year old son as he tries to get his medications adjusted to deal with Bipolar II.   He's up to 200mg of Lamictal, which has helped with the depression and energy but not the anxiety, which is still extremely high, almost debilitating.  Klonipin, ativan and other benzodiazepines don't seem to cut the anxiety so his psychiatrist is considering adding 2.5mg of Zyprexa, after we discussed your "emergency relief" section on this drug.  I don't see that you have any information on this combination...and I'm aware of the risks with long term use of Zyprexa.  The pharmacist tells me that at lower doses, the weight gain and risk of diabetes are minimized...If you have a moment, I'm hoping to get your take on this.

We'll be moving back home to Kentucky together, and Kevin will be seeing a team of pyschiatrists at the University of Kentucky on March 19, but a month is a long time in dealing with this illness and the anxiety (for both of us).

Many thanks, and thank you for the generous amount of time and effort in maintaining your web site.  You are a true healer....and a wonderful Christian.

Dear Ms. P. --

Thank you for your kind words about my website work. As for the combination of lamotrigine (Lamictal) and olanzapine (Zyprexa) --

This would be a great combination, except for the risks that go along with any use of olanzapine.  It nicely complements the weaknesses of lamotrigine, namely an anti-manic effect (for people whose anxiety symptoms are related to bipolar disorder; it may also have a more non-specific anti-anxiety affect in general, because it does help people with various kinds of anxiety problems who do not have a mood disorder.).

So the big question is, does using a low dose of olanzapine avoid the big risks of weight gain and diabetes which we know go along with standard doses? Answer: I wish.  And, in a few people, I think this might be true -- but if so, this applies to the extremely low dose of 2.5 mg and less.  Doses of 5 mg and up may actually have nearly equivalent risk, or so say the manufacturers representatives, agreeing with my clinical experience.

Nevertheless, there are lots of people who can benefit substantially from 2.5 mg, or even 1.25 mg of olanzapine (intermittently for severe symptoms, or in some cases regularly).

So the trick is, just as we do when olanzapine is used at the higher doses, to monitor glucose and weight very closely.  Indeed, the trickiest part of all is being prepared to stop the medication, if either of these starts going up, when the medication is working beautifully. That can be really difficult when symptoms are finally under control for the first time in years and no alternative is guaranteed to produce the same results (unfortunately, hardly anything in this business comes with a guarantee!).

On the other hand, some mood specialists regard the risk of weight gain and glucose elevations on olanzapine, particularly at these very low doses, as no greater than 50%.  That means a one in two chance of getting a good result without a big problem.  Since the problem doesn't sneak up, but can be monitored, I use olanzapine like this quite often (and then I worry).

Dr. Phelps

Published April, 2009


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