Transcript Lamotrigine - Induced Lupus: A Case Report

Lamotrigine - Induced
Lupus: A Case Report
Sandra Dirks, Pharm.D.
Assistant Professor
Drake University College of Pharmacy
and Health Sciences
Clinical Specialist – Psychiatry
Broadlawns Medical Center
Des Moines, Iowa
Drug-Induced Lupus (DIL)
 First
case reported 1946
 Sulfadiazine
 Currently
> 100 drugs reported
 Chlorpromazine,
 15-20,000
hydralazine, carbamazepine
new USA cases annually
 Men = Women
 Time of onset 3 months – 7 years
Drug-Induced Lupus
 Symptoms
 Rarely
less severe than SLE
CNS or renal
 Common symptoms include:
 Joint pain and swelling, malar “butterfly” rash,
photosensitive rash, malaise, fever, loss of
appetite, blurred vision and pleuritic chest
pain.
 Symptoms
resolve within days to weeks
after stopping drug
Autoantibodies

DIL




95% cases + antihistone antibody, IgG
H2A-H2B & DNA or H1& H3-H4 complex
Negative antinuclear antibody (ANA)
SLE



20% cases + antihistone antibodies
Restricted to H1 and H2B histone subunits
Usually ANA positive
Case Report

46 year old morbidly obese Caucasian
female, diagnosed with schizoaffective
disorder & borderline personality disorder
 Presents with depressed mood & irritability
 PMH: clozapine induced seizure, GERD,
hiatal hernia, hypothyroidism, stasis edema
and bilateral congenital foot deformities
 History of chlorpromazine & lamotrigine use
Medications at admission :
Risperdal 3mg bid
Benzatropine 2mg bid
Chlorpromazine 50mg tid
Protonix 40mg daily
Ranitidine 150mg bid
Synthroid 0.075mg, daily
Furosemide 80mg daily
Metoclopramide 5mg daily
Spironolactone 25mg daily
KCl 20 mEq bid
DSS 200mg bid
Lamotrigine 25mg hs
Course of Treatment
Day
6
Day
12
Day
16
Day
17
Day
21
Day
25
Day
27
Chlorpromazine increased to
50mg qid
Chlorpromazine changed to
200mg hs
Lamotrigine increased to 50mg
hs
Additional chlorpromazine
50mg bid added
Vioxx 25mg daily added
Chlorpromazine increased to
50mg bid & 250mg hs
Bedtime chlorpromazine
increased to 300mg
Complaints of
daytime drowsiness
Complaints of
arthralgias
Develops malar rash
with photosensitivity
Course of Treatment
Day Vioxx stopped due to recall &
28 Relafen 1000mg daily started
Day
31
Day
33
Day
35
Lamotrigine increased to
100mg hs
Dental consult suggests oral
lesions indicative of lupus
FANA & RF were negative and
anitihistone was 100,000
Lamotrigine was discontinued;
Zoloft added for depression
and titrated up to 100mg daily
Day Antihistone rechecked and
60 level dropped to 39
Develops oral lesions
w/ulcerations
Rash, arthralgias and
photosensitivity
resolved almost
immediately
Patient remains free
of any lupus-like
symptoms
Discussion

DIL not well understood
 Negative ANA with positive antihistone
 Multiple agents confounding
 Chlorpromazine suspected
 Temporal association difficult
 Arthralgias attributed to foot deformities
 R/O Stevens Johnson (oral lesions)
 Antihistone dropped & symptoms resolved
after stopping Lamotrigine
References:
Yung R, Richardson B, “Drug Induced Rheumatic Syndromes”
Bulletin on the Rheumatic Diseases: Vol 51, No 4.
Peng S, “Medical Encyclopedia: Drug-Induced Lupus
Eyrthematosus” Medline Plus: October 2003.
Rubin RL, Drug-induced Lupus Erythematosus, Lupus
Foundation of America, Inc. 2001.
Rubin RL. ELISA assay for anti-DNA and antihistone antibodies
including anti-(H2A-H2B). In Manual of clinical laboratory
immunology, 4th ed. NR Rose, et al, eds. 1992; Washington: Am
Soc Microbiol., 735-740.
Sarzi-Puttini P, et al, Lamotrigine-induced lupus, Lupus.
2000;9(7):555-7.
Echaniz-Laguna A, et al, Lupus anticoagulation induced by the
combination of valproate and lamotrigine, Epilepsia. 1999
Nov;40(11):1661-3.