Lamotrigine and the PBS
Posted on Jun 28 2011 at 09:48:15 PM in Medicine
Last night I took my first lamotrigine tablet and I would have to say it is the most disgusting tasting tablet I have probably ever had!! You can either chew it, dissolve it in a little water, or swallow it whole. I tried chewing and ended up racing to the sink so I could swallow the rest of it with water.
So far that is my only complaint. I've not had any adverse reactions. It's the first psych medication I've taken where I haven't felt nauseated and dizzy afterwards (although I did take it about an hour before bed so I may have slept through any effects). However, if taste is the main problem I have with this med, then I would be over the moon. I think I can handle a few moments of an offensive taste.
Lamotrigine is an anti-convulsant, which are traditionally used for epilepsy. However most anti-convulsants also act as a mood-stabiliser and are therefore also used to treat bipolar disorder. It is a little different from the more common anti-convulsants such as valproate, in that it doesn't appear to have as much of an effect on hypomania or mania. Research has shown however, that it can be quite powerful in the treatment of bipolar depression(1), which is my main problem.
What I don't understand however, is why it is not on the Australian Pharmaceuticals Benefit Scheme (PBS, clicking on the 'authority required' shows this) for bipolar disorder. You can only get it at the discounted rate if you have been diagnosed with epilepsy. I have done quite a lot of research, particularly reading journal articles and found that lamotrigine has a lot of benefits over either valproate or lithium(1), which are probably the two most common mood-stabilisers used in place of lamotrigine (note lithium is not an anti-convulsant).
Possibly the most important of these is that it seems to be the safest drug out of the three. You do not need to have blood levels of the drug checked as it is much harder to reach toxic levels. It has less side-effects and something that is quite important for me is that it is the least likely of all of them to cause weight gain, which I understand is very common with valproate and fairly common with lithium(1). I have put on a lot of weight on other meds in the past and am having a very hard time loosing it, which is making my depression worse.
Putting my own research aside, especially as I am not a doctor, what stuns me the most about lamotrigine not being available on the PBS is the fact that it is recommended by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in their Clinical Practice Guidelines as a "first-line option" (2) for treating bipolar depression. How can the organisation that governs psychiatry in Australia recommend a particular medication as a first-line treatment and the Australian government not subsidise it like most other medications on the PBS? I am astounded by this and my psychiatrist also has a somewhat cynical view and blames the RANZCP for not lobbying the PBS for its inclusion.
The pharmacy that I usually go to was going to charge approximately $58 per 50mg. That may not sound like a lot but I will be increasing the dose to 200mg which would cost $232 a month, when I am already paying over $100 per month for other medications, and am unable to work because of my illness, yet am not entitled to government assistance, it adds up rather quickly.
I am however lucky that I live in a capital city and can shop around. I was able to find a discount pharmacy that sells lamotrigine for $30 per 50mg. This is much better and a similar price to what I pay for my other medications which are on the PBS.
So why am I complaining if I can purchase lamotrigine for a reasonable price? Technically the price is only low for 50mg, once my dose has reached 200mg I will be paying $120 per month. Additionally, not everyone lives somewhere near a pharmacy that discounts private prescriptions; most of such pharmacies are located in capital cities and the 'very large' towns. Mental illness is rife within smaller rural and remote towns and services are scarcely available for such people, and even medication is harder to access.
While it was my psychiatrist that suggested the discount pharmacy as a cheaper source of the medication, even he expected it to cost more than I paid. As it was I almost wasn't going to get the lamotrigine because of it's expected high cost. It makes me wonder how many people are not prescribed this medication because of it's perceived cost.
Research shows that more people commit suicide whilst in the midst of a bipolar depression or mixed episode than any other condition or state(3), indicating that bipolar depression is a MAJOR concern. If lamotrigine really is as helpful as the research suggests, then I am disgusted that so many people may not be able to access it.
I realise that it is not a wonder drug capable of producing a cure. And while it seems to be much safer than other mood-stabilisers, it can in rare cases lead to Stevens-Johnson syndrome (SJS), which can occasionally be fatal. However, this is minimalised by slowly increasing the dosage to the right amount, rather than just starting on a high dose(1). And I am yet to hear of a psych medication that you don't have to titrateSJS can be dealt with.
*steps off soap box*
Now I get to play the waiting game...
1. Calabrese, J. R., Rapport, D. J., Shelton, M. D., & Kimmel, S. E. (1998). Clinical studies on the use of lamotrigine in bipolar disorder. Neuropsychobiology, 38, 185-191.
2. Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Bipolar Disorder (2004). Australian and New Zealand clinical practice guidelines for the treatment of bipolar disorder. . 38, 280-305 (p. 294).
3. Mantere, O., Suominen, K., Valtonen, H. M., Arvilommi, P., Leppamaki, S., Melartin, T., & Isometsa, E. (2008). Differences in outcome of DSM-IV bipolar I and II disorders. Bipolar Disorders, 10, 413-425.