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TAKEZAKI AND HANAOKA first observed carbamazepine's antimanic efficacy in Tottoriken in 1971.1 The US Food and Drug Administration (FDA) approved lamotrigine's maintenance indication in 2003, as well as the antimanic indication of valproate in 1995 and slow-release carbamazepine in 2004 (http://www.fda.gov).

Carbamazepine2,3 and lamotrigine can induce Stevens–Johnson syndrome/toxic epidermal necrosis (SJS/TEN) in Taiwanese patients. Here, we present a case of the safe use of lamotrigine in a diabetic bipolar patient with a history of SJS/TEN induced by carbamazepine, to highlight the new advance in managing this side-effect in Taiwan.

A 50-year-old Han ethnic Taiwanese male patient with bipolar I disorder first suffered from a major depressive episode when he was 30 years old. In the next 2 years, he received carbamazepine from two different psychiatrists. On both occasions, in the 2 days after his taking carbamazepine, he suddenly developed fever, generalized rashes and pruritic blisters, as well as erosions of the mucosal membrane causing ocular, urinating and defecation pain. Those clinical images were stored on a CD prepared by his dermatologist, who treated him successfully under the diagnosis of life-threatening carbamazepine-induced SJS/TEN.

Beginning in 2005 when the patient was aged 43 years, we started to see the patient through a consultation request from our medical center due to his diabetic condition. He agreed to have his lithium, valproate, and clozapine switched gradually to aripiprazole and lamotrigine. As an outpatient, he was warned to notify us immediately if he had any skin rashes. After his clozapine was completely replaced with 30 mg/day of aripiprazole, he began to receive lamotrigine starting with 25 mg/day for 2 weeks with a gradual increase up to 200 mg/day (http://www.fda.gov). In 2006, he also started to receive 300 mg/day of bupropion. He has been stable at our clinic and day hospital without skin side-effects, and the patient and his family are satisfied that the 6 years of medication regimens under our care have been better than all his previous drugs controlling bipolar disorder and blood sugar.

HLA-B*1502 has been identified as being associated with carbamazepine-induced SJS/TEN among Han ethnic Chinese in Taiwan.2–4 The prevalence in the population for HLA-B*1502 polymorphism is about 8% in Taiwan, Hong Kong, Malaysia, Thailand and India,3,4 but below 0.1% in Japan and Europe.3

The US FDA has recently updated the prescription information for carbamazepine, and recommended to screen patients' HLA-B*1502 status before prescribing it for those with Asian heritage (http://www.fda.gov).4 Since June 2010, the Taiwan National Health Insurance Bureau has reimbursed patients about $US120 per test for genotyping HLA-B*1502 status for those who are under consideration for receiving carbamazepine.5

Genotyping HLA-B*1502 for this patient was not indicated because he was not expected to receive carbamazepine any more. Based on the case findings, we suggest that patients with a history of SJS/TEN induced by carbamazepine still deserve a chance of receiving lamotrigine if their bipolar disorder drugs are not optimized.

REFERENCES

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  2. REFERENCES
  • 1
    Takezaki H, Hanaoka M. The use of carbamazepine (Tegretol) in the controlled manic-depressive psychosis and other manic, depressive states. Seishin Igaku 1971; 13: 173182 (in Japanese).
  • 2
    Chung WH, Hung SI, Hong HS et al. Medical genetics: A marker for Stevens-Johnson syndrome. Nature 2004; 428: 486.
  • 3
    Hung SI, Chung WH, Jee SH et al. Genetic susceptibility to carbamazepine-induced cutaneous adverse drug reactions. Pharmacogenet. Genomics 2006; 16: 297306.
  • 4
    Chen P, Lin JJ, Lu CS et al. Carbamazepine-induced toxic effects and HLA-B*1502 screening in Taiwan. N. Eng. J. Med. 2011; 364: 11261133.
  • 5
    Chang CJ. Genotyping HLA-B*1502 and the revised act for compensation of drug-induced adverse effects in Taiwan. Taiwan Journal of Psychiatry (Taipei) 2011; 25: 123125.