Management of Lamotrigine-Induced Skin Rash in BPD Patient
Lamotrigine should be immediately discontinued due to the skin rash, and transitioning to aripiprazole for anger management in BPD is appropriate.
Assessment of the Current Situation
The patient presents with:
- Borderline personality disorder (BPD)
- Current treatment: Lamotrigine 100mg daily for 4 years
- Developed hives and skin rash since May (ongoing for several months)
- Already seeing dermatologist and PCP
- Has completed courses of antibiotics without resolution
- Anger issues requiring management
Risk Assessment of Lamotrigine Rash
Lamotrigine-associated skin reactions represent a significant concern:
- Any rash occurring during lamotrigine treatment should be considered potentially serious until proven otherwise 1
- Persistent rash lasting several months despite antibiotic treatment suggests a drug-related hypersensitivity reaction rather than infection
- Lamotrigine can cause severe and potentially life-threatening skin reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis
- The risk is highest during initial titration but can occur at any time during treatment
Recommended Management Plan
1. Immediate Actions
- Discontinue lamotrigine immediately - do not attempt to maintain at a lower dose of 25mg as suggested
- Document the adverse reaction in the patient's medical record
- Consider dermatology consultation for skin biopsy if not already done
2. Symptomatic Management of Rash
- For urticaria/hives:
3. Alternative Treatment for BPD and Anger Issues
- Initiate aripiprazole for management of anger and impulsivity in BPD
- Start at a low dose (2.5-5mg daily) and titrate gradually
- Monitor closely for emergence of akathisia, increased anxiety, or suicidal thoughts 3
- Target dose should be individualized based on response and tolerability
4. Monitoring and Follow-up
- Weekly follow-up for the first month to monitor:
- Resolution of skin rash
- Response to aripiprazole
- Emergence of any new side effects
- Educate patient about warning signs requiring immediate attention:
- Worsening rash
- Fever
- Mucosal involvement
- Akathisia symptoms (inner restlessness, inability to remain still)
- Increased suicidal thoughts
Evidence for Treatment Decisions
Discontinuation of Lamotrigine
The decision to discontinue lamotrigine is based on safety concerns. While lamotrigine has shown some efficacy in BPD 4, the presence of a persistent rash necessitates discontinuation rather than dose reduction. The British Journal of Pharmacology guidelines emphasize that any rash during lamotrigine treatment should be taken seriously 1.
Aripiprazole for BPD
Aripiprazole represents a reasonable alternative for managing anger and impulsivity in BPD:
- Atypical antipsychotics have shown efficacy for impulsivity and anger in BPD
- Lower risk of serious cutaneous adverse reactions compared to lamotrigine
- Can be effective as monotherapy for BPD symptoms
Important Cautions
- Monitor closely for akathisia with aripiprazole, especially when initiating treatment 3
- Be vigilant for increased anxiety or emergence of suicidal thoughts, particularly in the transition period between medications
- Avoid reintroducing lamotrigine in the future as patients with previous cutaneous reactions are at higher risk for more severe reactions upon rechallenge
- Consider psychological approaches (dialectical behavior therapy or mentalization-based therapy) as adjunctive treatment for BPD
By discontinuing lamotrigine and transitioning to aripiprazole, you can address both the safety concern of the skin rash and provide treatment for the patient's anger issues in BPD.