Pregnant Women Taking Lamictal for Bipolar Disorder

Study Overview
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Brief Summary
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This study seeks to examine how the dose of lamotrigine (Lamictal) should be adjusted during pregnancy for women with Bipolar Disorder. The investigators predict that the concentration of Lamictal in women's blood will decrease during pregnancy, and increase after postpartum. Because the concentration of the medication is likely to decrease during pregnancy, it is important for doctors to know how much they should increase a patient's dose in order to prevent worsening of Bipolar symptoms. In this study, the investigators will ask that participants complete up to five overnight visits to our clinical research unit where their blood will be drawn every couple of hours, through an IV catheter, to measure how the concentration of lamotrigine (Lamictal) changes over time. Participants will be compensated for their time.

Detailed Description
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There is an increased risk of recurrence of Bipolar Disorder (BD) episodes or worsening symptoms in pregnancy after the discontinuation of mood stabilizers. Similarly, changes in medication concentration due to the physiological changes in pregnancy may effectively reduce the medication dose and thus its efficacy in pregnancy. Therapeutic dose monitoring has proven to have great utility in preventing seizure recurrence in women with epilepsy (WWE), specifically, dose monitoring of lamotrigine (LTG). Similar guidelines to that of women with epilepsy would benefit pregnant women with BD who are taking lamotrigine (LTG) in pregnancy. However, the pharmacokinetics as well as the utility of therapeutic dose monitoring of LTG in pregnant patients with Bipolar Disorder has not been well studied. This study is an observational protocol to explore the longitudinal pharmacokinetics (PK) of LTG during pregnancy and postpartum in 10 women with Bipolar Disorder. The correlation between changes in bioavailability and level-to-dose (L/D) ratios and increases in symptoms of depression, mania and anxiety and recurrence of syndromal BD episodes that fulfill Diagnostic and Statistics Manual of Mental Disorders (IV) (DSM4) criteria will be investigated. The primary aims of this study are 1.) To assess the impact of the dynamic physiology of pregnancy on the L/D ratio and bioavailability of LTG in women with BD. 2.) To evaluate the correlations between maternal and umbilical cord LTG serum levels. 3.) To explore the relationship between declining LTG L/D ratios during pregnancy, bioavailability and the increase in psychiatric symptoms and recurrence of syndromal BD. 4.) To explore the relationship between declining LTG L/D ratios during pregnancy, bioavailability and the recurrence of anxiety symptoms. Additionally this study will evaluate correlations between estradiol levels and change in LTG L/D ratios during pregnancy. To optimize the research yield from this investigation, participants will have the option to allow banking of cerebrospinal (CSF) fluid and DNA for future analyses.

Official Title
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Pharmacokinetics of Lamotrigine in Pregnant and Postpartum Women With Bipolar Disorder

Conditions
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Bipolar Disorder

Intervention / Treatment
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* Drug: lamotrigine


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 18 or older If Pregnant, equal to or less than 26 weeks English-speaking DSM-IV Bipolar Disorder, any subtype Able to provide informed consent Daily dosing of Lamictal Exclusion Criteria: Active substance abuse within last 6 months and/or positive urine drug screen Active suicidality No obstetrical care Antiepileptic drugs that affect metabolism of LTG Medications in FDA categories F or X that are not antimanic drugs Liver or kidney disease

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 45 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Lamotrigine for Bipolar<br>antepartum and peripartum women taking lamotrigine for Bipolar Disorder | Drug: lamotrigine<br>* Lamotrigine will be observed in women who have already under the guidance of a physician decide to continue lamotrigine for the treatment of Bipolar Disorder<br>* Other names: Lamictal, Lamiktal, Labileno, Triazines;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Serum concentration/elimination | For patients on 1x day dosing, serum levels will be obtained beginning at time 0 and at hours, 1, 2, 3, 3.5, 4, 5, 6, 7, 8, 10, 12, 16, 20, 24 and L/D ratio will be determined at each time point. This series of serum levels will be completed an average of every 10 weeks across pregnancy, and postpartum. For patients on 2x dosing, serum levels will be obtained at hours 1, 2, 3, 3.5, 4, 5, 6, 7, 8, 10, 12, 13.5, 14.5, and 16 hours. | An average of every 10 weeks; Hours 0, 1, 2, 3, 3.5, 4, 5, 6, 7, 8, 10, 12, 16, 20, 24, or 0, 1, 2, 3, 3.5, 4, 5, 6, 7, 8, 10, 12, 13.5, 14.5, and 16 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Infant (umbilical cord)/Maternal ratio of LTG | Ratio of umbilical cord (infant) LTG serum level to maternal LTG serum level will be determined at delivery. | 30 min | 
| Scores on depression assessment, Inventory of Depression Symptomatology- Self Report (IDS-SR) | To determine if there is a pattern of increasing scores on self-report depression assessment (IDS-SR) and declining L/D ratios. Increasing scores indicate worsening symptoms or depression episode recurrence. | Participants will complete these assessments an average of every 10 weeks from the time they enter the study, up to 12 weeks postpartum. | 
| Scores on mania assessment, Young Mania Reporting Scale (YMRS) | To determine if there is a pattern of increasing scores on clinician administered mania assessment (YMRS) and declining L/D ratios. | Participants will complete these assessments an average of every 10 weeks from the time they enter the study, up to 12 weeks postpartum. | 
| Scores on anxiety scale, Generalized Anxiety Disorder (GAD-7) |  | Participants will complete these assessments an average of every 10 weeks from the time they enter the study, up to 12 weeks postpartum. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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pregnant, bipolar, lamotrigine, lamictal, women, female