Would a Lower Dose of Lamictal Reduce Risk during Pregnancy & Lactation?
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 Q:  Would a Lower Dose of Lamictal Reduce Risk during Pregnancy & Lactation?

I have Type II Bipolar Disorder.  I am on 200 mg Lamictal and have no symptoms or side effects. 
Because a seizure medication controls my symptoms, is it possible/reasonable to believe that a ketogenic diet would help control symptoms at a lower dose of Lamictal? 

I understand that the (assumed) method that Lamictal works is by inhibiting glutamate.  If this is correct, could an MSG-free diet and choosing foods low in glutamate control symptoms at a lower dose of Lamictal? 

Would a lower dose of Lamictal reduce risk during pregnancy and lactation? 

Thank you!

Dear Anne – (sorry to be so slow in replying this month)

Hmm, 200 mg, no symptoms, no side effects. Mighty hard to beat that, with a medication with no known long term risks (lamotrigine/Lamictal). However, if the questions arise because you’d like to consider pregnancy, off we go --

1. Ketogenic diet: because these diets can have anti-epilepsy effects, and because some anti-epilepsy medications can help in bipolar disorder (but not all of them), might such a diet help control bipolar symptoms? Of course, we’d also have to wonder what effects such a diet might have on a developing fetus, and compare that to the risks of lamotrigine; but first, to see if anyone has studied effectiveness of this approach in bipolar disorder --

Searching ketogenic diet bipolar disorder on Google, a reasonable place to start, oh look, there’s a letter I wrote on this in 2004, first link after the Wikipedia link above.  Darn: I’d have hoped in 6 years there might be more on this subject. So, let’s try PUB MED again, same procedure I outlined in the 2004 letter. No, nothing new there (the letter from Dr. Belmaker to which I referred was published. They tried the ketogenic diet in a patient with bipolar disorder, but it didn’t work; however, they measured whether the patient actually became ketotic with her diet, and found that she did not, so the theory didn’t get a fair trial.)

2. Could an MSG-free diet and choosing foods low in glutamate control bipolar symptoms, perhaps allowing a lower dose of lamotrigine?
Well, again we’d have to wonder about the effects of such a diet on a developing fetus. Perhaps they need a large supply of glutamate for building themselves? I doubt that’s been studied well enough to reassure you.  So again, you’re comparing that unknown risk versus the known risks of lamotrigine in pregnancy, which you’ve probably discovered are not very big, but apparently not quite zero either, because of the recent finding of increased incidence of cleft palate and other related disorders, occurring at a rate statistically greater than in babies of women not taking lamotrigine.

Somewhere along the way here, although you didn’t ask specifically about it, you’d also have to compare the risk to the developing fetus of going without lamotrigine but potentially having your old bipolar symptoms back, and the impact of those symptoms on the fetus – currently thought to be a significant risk, at least for severe symptoms. And then there’s no guarantee that going back on the same dose of lamotrigine will get you the same outcome you’re getting now, if you go off then back on (not to mention the common worsening in symptoms that occurs after a pregnancy; and is that decreased by staying on an effective mood stabilizer through pregnancy and the post-partum period? Again unknown. Why aren’t these things studied, you might ask? Snide answer: because the gender ratio of medical students only recently reached 50/50 (or close; in some schools the women outnumber the guys now). That’s our next generation of researchers…

3. Lower lamotrigine dose, lower risk? That’s a short answer: unknown again. It took years to find the small signal of risk in pregnancy for lamotrigine; to dissect that signal and correlate it with doses used – that’s another long wait. Because, you see, one needs big numbers even just to find the signal, and the only numbers you can really count are women who became pregnant while on lamotrigine and no other medications that might affect risk. That’s a small number. Then you need much bigger numbers to correlate dose (e.g. there might only be a very small number of women who were taking less than 100 mg, and most would be taking 200 or so).

Sorry, you ask very reasonable questions and yet most of the answers boil down to “don’t know”, yet I’m also challenging you with other tricky questions (and the answer to those is also “don’t know”!). Not fair. Sorry that’s the state of things. You might be interested in the story of a glutamate cousin, a related, similar amino acid, that’s been studied as a glutamate opposite (perhaps a similar role as that played by lamotrigine…): cysteine.

Good luck with your research and your decision-making.

Dr. Phelps

Published June, 2010


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