The Case of the M&M Interactions

I had a psychiatrist once tell me that the psych meds were all “M&M’s a different color”.  Doctorspeak for, “Same thing, different packaging.”  How refreshing.  At least she was honest about it and didn’t make it seem like one thing was going to be the miracle cure.  That’s now how I refer to my cornucopia of medications.  M&M’s of a different color.  I’ve got my big white ones, little white ones, my shelled white ones, the big bulky blue breathey one, and the mac-daddy of suppliments I take to keep everything else under control.

I’ll take you through a quick run-through of the normal of chronic ailments and then medications.

Bipolar II
Mood Stabilizer:
Lamictal (lamotragine) – 100 mg twice daily = 200 mg

Wellbutrin XL (bupropion) – 150 mg once daily

Sleep Aid: (insomnia)
L-Glutithoine (nutraceutical)
L-Theanine (nutraceutical)

Generalized Anxiety Disorder
Anti-anxiety (benzodiazepine):
Ativan (lorazepam): 1 mg, three times daily = 3 mg

Ventolin (no generic)- 2 puffs every 4 to 6 hours or as needed

Maxalt (no generic)- 5 mg when you feel a migraine coming on

Tendonitis of the Knee and Genu valgum (Knock Knee):
Ibuprofin – 200 mg every 4 to 6 hours or as needed

High Cholesterol:
Garlic (nutraceutical)
Omega3 Fish Oil with DHA and EPA (nutraceutical)
L-carnatine (nutraceutical)

Regular Suppliments
Vitamin C
Vitamin E
Vitamin B-12 with Folic acid
Pantothenic Acid
Bioflaviniod Complex
Bromeline 3000
Ubiqinol (I highly recommend this one for fatigue but it’s pretty expensive)
And probably like 10 others I’m not thinking of right now.

And of course, I am a woman of childbearing age, so throw in an oral, hormonal contraceptive.

Throw in 60 mg of prednizone, and a Z-pak and you’ve got a medicine soup.

Think about all of the doctors we have. Pdoc, PCP, OB/Gyn, Neurologist, Orthapedic, etc. Now, consider that despite the hundreds of times I relay the medications from one doc to another, it probably widens the margin of error.

I’m finishing this on my phone so I have to put the full link on. This is a comprehensive multi-drug interaction checker. Slap ’em all in there and it’ll tell you. Of course with a little doctorspeak.

Turns out azithromycin (z-pak) doesn’t play well with hormonal bc. Pregnancy risk. Hormonal bc doesn’t play well with lamictal and prednizone by increasing the metabolism rate and having higher concentrations in the blood.

Who knew?

8 thoughts on “The Case of the M&M Interactions

  1. Honestly, the MINUTE I saw this in my inbox, I though, ‘Oh God, she’s pregnant!’ I knew though, because my shrink and I had this conversation about many meds. Still, the Medscape Drug Interaction Checker is literally first on my bookmarks – just in case.

    I’ll try and catch up on other posts soon, and also, please email me at as far as contacting you privately – I have an idea I think you’ll like regarding start-up blogs and bipolar bloggers and getting more traffic and all of that stuff! xoxoxo

  2. So, two questions: Why is your Lamictal dose split (I used to take 400mg, all at once), and why is your doctor prescribing you Ativan for GAD??? You need something long acting, like Klonopin, that you can take once, at bed time (Ativan is for Panic Disorder). This also makes most people pretty sleepy, so you also wouldn’t need a sleep aid.

    As for interactions, I have been on Ortho Evra (the patch) for years. My shrink put me on Zanaflex (tizanidine) for my insomnia. It isn’t any kind of sleep aid, traditional or otherwise, but I am harder to take down than a horse. Once in my life I did not check the interactions. Turns out it is a bright red no-no (not even a “Monitor Closely,” but a “Prescribe Different Medication”). Hormonal birth control reduces the body’s ability to clear tizanidine by 50% – which is why it worked for me! Also why it could very easily have killed anyone else in the world but me!

    I informed my psychiatrist, my ob-gyn, and my PCP about the interaction, because they all knew my complete regimen. NONE OF THE THREE OF THEM HAD EVER HEARD OF THIS! And at least two of the three are excellent doctors.

    • Lamictal is split in half for monetary purposes. It’s cheaper to pay for 100mg tablets than 200mg tablets. Honestly, I take them all at once. Ativan started out as the answer to what they thought was a reaction to the Lamictal.

      And then, once the Lamictal titrated, that’s when the GAD surfaced. But it’s not without a panic feature. It has phobias. I have really irrational fears, and they have all come true in the last year. Kind of adds fuel to the fire. I’m a clausterphobe with mild agoraphobia. When I first started taking the Wellbutrin to control depressive episodes, I didn’t need the ativan as much. So I’m thinking I either need more Wellbutrin or something like xanax. Ativan is nice for panic in the day because it doesn’t disable me.

      When I first started the Lamictal, the pdoc told me that Lamictal would affect the ortho cept and suggested a higher hormone bc. I called the gyn who said bc clears Lamictal too fast and I’d have to talk to my pdoc about being prescribed a higher dose. What neither of them told me was that on the off week, I’d turn nutty because the Lamictal levels in my blood would be off kilter. So now I’m on continuous cycle.

      The prednizone isn’t working as well as it should be because bc clears that out too fast too. So I’m only getting about 12 hours out of it, and can’t breathe at night. They should have given me a higher dose. But now I’m hypomanic and I should have expected it. Z-pak is done and I still feel like total crap.

      What do you think? I see the doc in two weeks. What should I tell him about my meds based on these blogs and this new evidence?

  3. Thank you SO much for sharing that website! I’ve bookmarked it and downloaded the mobile app. Awesome!

    Doctors are human. They make mistakes. And I swear they don’t look at anything that isn’t shoved directly under their nose. I’ve been called OCD, but I make lists (and draw diagrams if necessary) because even though I never went to medical school, I’ve lived in this body for 40 years and the doctor has not. It’s his job to help you, but if you can provide him with enough information it should help him do his job better.

    Just my 2 cents.

    • I try to make that as plain as possible to people. Doctors are humans – not gods. Yes, sometimes they are the difference between life and death, for better and worst. But that does not mean they execute their decisions based on divine judgment.

      People with specialists, and we have a ton of them, really get the shaft. None of them really keep track, although they ask you every time you go in. Did you know that I didn’t know until about the antibiotic – bc effect until I had already been sexually active for 6 years?! And it was a pharmacist at Walmart that told me, for gods sake!

  4. Okay. Keeping in mind that while I’ve read your blogs, my memory is for shit anymore, so I’m going primarily by your comment above (and I actually have this page open in two tabs, because scrolling up and down takes a tiny bit longer, and I could actually forget or mis-remember that quickly), these are my thoughts, given my (factual, book-type) knowledge, as well as personal experience and the experiences of friends.

    I just did some brief research to confirm what I do remember, and oh honey, I’ve got some information for you. Lamictal can not only cause anxiety, it can also cause insomnia (which has a very high probability of inducing hypomania, as I’m sure you know). Wellbutrin can cause Panic Disorder. It’s a rare side effect, but it happens. Prednisone can cause mood swings. Mayo says this is only the case with the oral, but I’m guessing that’s how you’re taking it, based on your wording. Also, many asthma medications can be very activating (more on that in a sec).

    Now, my personal experience (caveats included). Lamictal I was good with, I didn’t notice any insomnia from it (but you can’t go by me, because I have had insomnia since I was probably five, and as an adult, we have tried everything for it – literally – and in massive doses, and nothing has helped). I d/c it because after three years, it just didn’t do much anymore (also a me thing, not usual). Wellbutrin I wasn’t on for long, because any and all anti-depressants make me wildly manic, even in the presence of a mood stabilizer. However, when I was younger and not so severe (also undiagnosed), I did take Zoloft briefly as a prophylactic for migraines. I developed panic attacks, which at that point I had never had in my life. I said something to my doctor, and his immediate response was, “That’s the Zoloft,” (it’s also used to control anxiety – fun, huh?). I have not been on Prednisone specifically, but I have taken multiple asthma medications (in inhaler form, mine is only exercise-induced), and all of them make me high as for at least six hours afterwards, even the ones that are supposed to be “non-activating” (but as I have referenced, I am highly sensitive).

    All of that in mind, here’s my opinion. If the Lamictal is working for you, I would try taking it in the morning if you aren’t already (that’s how my doc told me to do it, and it did give me some additional energy). Next, I would go with two specific things for anxiety (I have both GAD and Panic Disorder). First, for the GAD, start with a very small dose of Klonopin at bed time, I think you can go as low as .5 mg. Give yourself a little while to adapt, then go from there. If it doesn’t make you tired, but you don’t feel like it’s got the GAD under control, you can go much higher (I take 4 mg). Obviously, if it knocks you out during the day, you can try something else, and I can tell you the pros and cons of lots of anxiety meds, having tried so many. Added benefit, Klonopin is great for me at controlling mood instability (and that isn’t just me, it’s not uncommon for bipolar patients). But keep in mind that with long-term, daily use of any benzo, you have to taper slowly or you could induce seizures. For the PD, I much prefer Xanax to Ativan (Ativan did nothing for me). Completely safe to take with Klonopin, although you might get a little more drowsy from the combo. I would tread lightly with the Wellbutrin, because it may help you, or it may induce full-blown mania, even if you’re BD II. The thing I forgot to mention as far as Lamictal is concerned, despite what was previously thought, it is NOT a mood stabilizer. It’s clinically proven very effective for bipolar depression, but does not help control or prevent mania or hypomania, so your biggest problem may be that you aren’t actually treating that aspect, at all. As for the Prednisone, I can’t really help. Like I said, my asthma is exercise-induced, so I can plan around the effects of the inhaler. Asthma you can’t really play around with like other medical problems whose treatments may exacerbate your bipolar. Finally, were I you, I would opt for an IUD as birth control. I have a very good friend, SEVERELY bipolar, who had one put in after she had her daughter, and she said the first week or so she had pain and bleeding – also that it hurt like hell when they put it in – but she loves it now. My reasoning is this. They now make a non-hormonal IUD. The hormones in your bc may be messing with your moods without you realizing. Everything but the patch did a total number on me. Also, I did the continuous cycle, and it was good for awhile, but them I developed spotting and bleeding between periods, which is not uncommon. It won’t effect your moods, but having to wear a pantyliner every single day, just in case, SUCKS (also it cut my underwear options in half, because of the thong aspect, but that’s me). Further, the IUD is good for 7-10 years, it’s one less pill to take, and it’s one of (actually my friend says its the MOST, but not having looked it up, I won’t say it for sure) the most effective forms of bc. If you don’t like the idea of an IUD, I would want to know whether you’re on tri-cyclic or mono-cyclic bc, because that had an enormous impact on me.

    All of that having been said, I would still tell you this as your cardinal rule regarding medication adjustments: Only ever change thing at a time. Doesn’t matter if it’s a new med, a dosage adjustment, whatever. It’s maddeningly frustrating to try something, wait and see, try something else, wait and see, and on and on. But you will wind up being better off in the long run, because when you change up more than one aspect of your cocktail at a time, you introduce variables. Certainly you can deduce what is more LIKELY to have been helpful/unhelpful, good/bad, or caused a particular side effect, but you will never be 100% certain. Which, sooner or later, will more than likely lead to additional fun times with medication roulette.

    Please let me know if you have any questions or need clarifications. I’ve pretty much taken everything there is, in every dose and combination, and if I haven’t, I know someone who has. I also have a fantastic medical dictionary, a PDR (Physician’s Desk Reference) Guide to Prescription Drugs, a PDR Guide to Psych Meds, a Merck Manual, and the Jamison-Goodwin “Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression” text (the second edition from about four years ago) – which is basically regarded as the Bipolar Bible in the psychiatric community.

    I know this is the longest comment ever, but I wanted to include every aspect I could think of. In six years, I have been through every treatment imaginable – medical, therapeutic, holistic, lifestyle changes, and the wonderful shocks to my brain, of course – and so much of it I learned the hard way. Very, very hard. I don’t ever want anyone else to have to go through what I have, if I can prevent it in any way. The only two things I haven’t done are light box therapy (because of my extreme sensitivity to everything potentially mania-inducing) and rTMS (I was evaluated and found to be a poor candidate). But I can still explain to you everything the literature says!

    And Lulu, you don’t strike me as the type who needs this advice, but I’m going to give it to you anyway. Never be hesitant about contradicting, questioning, and if necessary badgering your doctor to get a sufficient explanation. If they won’t explain to your satisfaction, find a new one (insurance permitting). And it never, ever hurts to get a second or even third opinion.

    Keep on swinging, sister. 😉

    (And if I get a moment to breathe where I don’t suffer severe trauma, I’ll email you about my other idea. I haven’t forgotten, things have just been all over lately, which I know that you get.)

    • I’m not surprised about those side effects of Lamictal. The main problem I had when I first started the medicine was the drowsiness and loss of short term memory. Lamictal really killed my brain for the first two months I took it. But everything after that was pretty great. It’s a remarkable mood stabilizer for me when I’m at the right dose. And I know when I”m not, because my mood will go from the smaller spectrum of human emotion, what the norms call normal, to a much broader spectrum where the extremes become very extreme. The Wellbutrin was a miracle when I first started taking it. Yes, I had some hypomania, but it was manageable with the Ativan. It seemed that about six months into the Lamictal, it had shifted me to a smaller spectrum that was primarily located on the depressive side. I described it as, “My normal days are what I could consider my great days.” This after I was stricken with constant fatigue – and I don’t mean from the Ativan. I know the difference between drugged sleepiness and the feeling that my body and mind are going to give out because they seem to think I’m not getting enough rest. So I did great on Wellbutrin for about six months, and then I was hit with the longest hypomanic episode I had ever had, followed by a period of pretty severe depression. It’s been up and down since then. I’m sure that the medications are effective because I’m not nearly as bad as I am unmedicated. I probably just need a dose adjusted, but I’m not sure which one. And I think I need to switch benzos.

      I’ve been through tons of medications, especially when I was misdiagnosed as having Major Depressive Disorder. It started out with Zoloft and I went way beyond max therapeutic dose because my doctor was an idiot. To combat sleeping 14 hours, she teamed it up with Provigil. I gained 35 lbs. Now I have a permanent motion sickness. Then they put me on Lexapro. Within two weeks of starting Lexapro, I attempted suicide twice. I hated that medication, and they just kept increasing it. And worse, when I tried to get off of it, I had withdrawal unlike anything I’ve ever experienced. This was all because my parents and a team of doctors screwed up.

      The only thing that’s pushing and pulling me around is the addition of the prednisone and the constant albuterol dosing. I have asthma, and generally it’s not terrible. I have maybe one attack a year and carry a rescue inhaler for just that purpose. I’m not used to having so much steroid in my system at one time. I can’t complain too much though. I’m getting done what I wanted to. But that’s for a different post.

      Thanks for the post! I gotta run and take carry of my little B (T.D.). I’ll be around later.

  5. Pingback: Called Off?!?! « As the Pendulum Swings

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