Lamictal

US Brand Name: Lamictal

Other Brand Names: Lamictin (South Africa)
Lamogine (Israel)
라믹탈 (Korea)Generic Name: lamotrigine

Other Forms: Chewable Tablets

What is Lamictal: Lamictal is an anticonvulsant
Read up on these sections if you haven’t done so already, because they cover a lot of information about multiple medications that I’m not going to repeat on many pages.  I’m just autistic that way about not repeating myself. 

What are Lamictal’s FDA Approved Uses: Conversion to monotherapy (using it all by itself) for some forms of epilepsy from some types of other anticonvulsants (it is socomplicated).  Adjunctive therapy (using it along with other anticonvulsants) for other forms of epilepsy (because Lamictal is the prima donna of anticonvulsants). Officially Lamictal can be prescribed for:

  • Simple partial seizures – you’re still awake (more or less), with symptoms such as one or two limbs spazzing out or wacky visual or other sensory distortions.  Think Alice in Wonderland, as Lewis Carroll must have had some serious temporal lobe issues.  The fist link will take you to a better explanation.  For a really detailed explanation of what a simple partial seizure is, click here.
  • Complex partial seziures – the people around you think you’re just acting out to get attention.  In reality you have no control over what’s happening.  Again, click there for the basics, click here for what neurologists think about this type of seizure.
  • Lennox-Gastaut syndrome.  If your child has this, my heart goes out to you.  If you don’t know what it is, consider yourself fortunate.  See also Topamax (also approved for Lennox-Gastaut) and  Keppra, which has tested well for Lennox-Gastaut.

Lamictal is also approved to treat Bipolar 1 Disorder, but only if you are already stable on approved medications.  That’s right, officially you can’t start out with Lamictal as your initial treatment for Bipolar disorder.  You can add it on to something or convert to it from something else.

Lamictal is approved for adults and children.

 What are Lamictal’s Off-Label Uses: Other forms of Bipolar Disorder.  Depression (The only studies I could find were using it to augment antidepressants.  Here’s onewith just unipolar participants.)  Schizoaffective Disorder.  SUNCT syndrome headaches. Neuralgia after nerve section.  Diabetic neuropathy.

Lamictal’s pros and cons:

Pros: The best medication on the market to deal with bipolar depression without the risks of mania or lowering the seizure threshold associated with antidepressants. Weight neutral.  Appears to be “relatively safe” to use during pregnancy.

Cons: Takes forever to get up to a therapeutic dosage for mania or seizure control. “Will interact with medications you aren’t even taking.” – Cliff from the about.com bipolar forum.

Lamictal’s Typical Side Effects: The usual for anticonvulsants. More so than any other anticonvulsant Lamictal (lamotrigine) is going to give you rashes. This is a real problem, becauseStevens-Johnson syndrome and assorted other serious rashes are bigger concerns with Lamictal (lamotrigine) than any other anticonvulsant, so often Lamictal (lamotrigine) therapy will end at the first sign of any rash. While any rash with Lamictal (lamotrigine) needs to be closely watched, it’s the combination of an itching rash and fever with any anticonvulsant that needs immediate attention from a doctor, any doctor. Lamictal (lamotrigine) + itching rash + fever = trip to the emergency room with all of your meds in their original bottles. Otherwise it’s just call your regular doctor for the soonest appointment possible.  Still, I wish everyone would just calm the hell down about The Rash.  Yes, it can be fatal, but it usually takes forever to kill you!  And I don’t mean in a movie-of-the-week, slow, painful death way, I mean that the symptoms show up early and you usually have plenty of time to take action before it’s too late.  One member of a bipolar support group walked around with an itchy rash and a fever for two weeks before she saw a doctor and she’s fine.  That was stupid, but not really all that stupid.  The rash is slow to kill.  Once you see the first symptoms and stop taking Lamictal (lamotrigine), The Rash goes away and you’re safe!  Problem solved!  OK, you’ll have truly sucky problem of not being able to take Lamictal (lamotrigine), but that’s something else altogether.  That doesn’t mean you should be lax about any itchy rash and fever, because these skin things have no fixed rate.  But the math is pretty simple – if you live in a country where Lamictal is available, you live where the hospitals can deal with The Rash without it being a big deal.  Really!

I’ve received two e-mails from people who have had to be hospitalized because of Stevens-Johnson syndrome.  One sent repeatedly in an awful blue font on fuchsia (to either get my attention or just give me a headache) relating how this person ignored the combination of itchy rash and fever for more than three days and wound up in the hospital.  And of course blamed Lamictal for all of her woes.  The other person is the reason why there are black-box warnings.  He added a single 25mg dose of Lamictal to his regimen of Depakote and had to be hospitalized immediately because The Rash hit swiftly.  His is the one case in many tens of thousands where it happens that rapidly.  In very rare cases The Rash can be a big fucking deal.  That’s why there’s a black box warning on the PI sheet.  More often than not it’s stupidity that is the main problem people have.  Be annoying with your doctor about rashes and Lamictal.  Better safe than sorry.

Now when you look at the PI sheet and actually look at the odds you have a 1 in 10 chance of getting some  kind of rash with Lamictal (lamotrigine).  Not necessarily The Rash, just some random rash.  So don’t go trying out any new skin products.  In fact you may want to start getting all hypoallergenic before even starting therapy, getting rid of scented soaps, fabric softeners and such like.

The other infamous side effect is the Lamictal Headache. While most anticonvulsants are good for curing headaches, Lamictal (lamotrigine) is great for giving you headaches. These range from something you can ignore to full-blown migraines. There is no telling if this side effect will go away or not. Sometimes it does, sometimes it doesn’t. Like everything with Lamictal (lamotrigine), a change in any other medications, a change in the dosage or pattern of taking it, a change in your diet, a change in your TV viewing patterns (I’m not sure if I’m kidding about this one or not), and a woman’s monthly cycle will influence this side effect.

For tips on how to cope with these side effects, please see our side effects page.

Lamictal’s Not So Common Side Effects: Lamictal (lamotrigine) is earning a reputation for muscle aches, everything from just a twinge in your neck or back to full-body aches that make you wonder if you were possessed by some spirit that made you participate in a triathalon the day before and have no memory of it. Keep the water handy, because Lamictal (lamotrigine) can give you a really dry mouth.  Don’t be surprised if you get anxious or have other hypomanic effects if taking it for bipolar disorder.  Another not-so-common effect is a type of insomnia where you’re tired, but you can’t sleep.
Lamictal’s Freaky Rare Side Effects: Going deaf and the hiccups that won’t stop.
Interesting Stuff Your Doctor Probably Won’t Tell You: This prima donna medication is even picky about your ethnicity. If you’re not White, you might get up to a 25% discount in how much Lamictal (lamotrigine) you might need.

In the clinical trials women had side effects more often than men. This bears out in anecdotal evidence gathered from online support groups. Given the way that birth control pills can sometimes interfere with Lamictal’s effectiveness, or can make it consistently effective throughout the month, my guess is that girly hormones do a number on Lamictal (lamotrigine). Unlike most other anticonvulsants and antipsychotics, where the opposite is the case.

Lamictal’s Dosage and How to Take Lamictal: As usual I’m going to deal only with adults.

Between the freak-out over the rashes and Lamictal (lamotrigine) having the most variable pharmacokinetic data I’ve seen, especially when mixed with other medications, it has the most complicated dosing schedule for a psychiatric medication. Still, at least GlaxoSmithKline have put a lot of work into seeing how well Lamictal (lamotrigine) plays with other meds, and they’ve come up with some of the more honest statements published in a PI sheet:

 

“The effect of AEDs (Anti-Epileptic Drugs) other than EIAEDs (Enzyme-Inducing Anti-Epileptic Drugs) and valproate (i.e. Depakote, Depakene or Depacon) on the metabolism of LAMICTAL is not currently known. Therefore, no specific dosing guidelines can be provided in that situation. Conservative starting doses and dose escalations (as with concomitant valproate) would be prudent; maintenance dosing would be expected to fall between the maintenance dose with valproate and the maintenance dose without valproate, but with an EIAED.”

And, “A therapeutic plasma concentration range has not been established for lamotrigine. Dosing of LAMICTAL should be based on therapeutic response.”

If you really read the pharmacokinetics section you can see that they tried, they really tried to pin some numbers down, but the half-life and plasma concentrations would vary too wildly.

You know what? If your doctor is following Glaxo’s recommendations as spelled out in the latest PI sheet, you really can’t be doing much better than that. I certainly can’t improve on them that much, other than starting at 12.5mg the first week and just being a bit more conservative in the titration for bipolar. But Lamictal (lamotrigine) is complicated enough, so if your doctor just goes along with what’s on the PI sheet, that is far from dangerous. I just tend to be conservative with these meds, and I think doing so helps prevent side effects. However you decide to go with your titration, keep a detailed record of how you proceeded, you’ll need it for future reference.

How often you should take Lamictal (lamotrigine) depends on what other meds you’re taking. If you’re taking an enzyme-inducing anticonvulsant such as Trileptal (oxcarbazepine) or Tegretol (carbamazepine USP) you must take it twice a day. If you’re taking a  valproate medication (Depakene (valproic acid), Depakote (divalproex sodium) or Depacon (valproate sodium)) you must take it once a day. If you’re just taking it by itself or with any other medication once-a-day dosing is recommended, but with the wildly variable half-life you may want to experiment with that to see how it works.

What’s the minimum effective dose? The antidepressant effects can start at 25mg a day, although it usually hits around 100mg a day. No, really, at 25mg a day you may get a lift from Lamictal (lamotrigine). Plenty of people have reported that. Mood stabilization effects begin somewhere between 100 and 200mg a day. Cut those numbers in half if you’re taking Depakene (valproic acid), Depakote (divalproex sodium) or Depacon (valproate sodium) and double them if you’re taking Dilantin (phenytonin), Trileptal (oxcarbazepine) or Tegretol (carbamazepine USP). The maximum dose for bipolar is 400mg a day, as long as you’re not taking Depakene (valproic acid), Depakote (divalproex sodium) or Depacon (valproate sodium), in which case you max out at 200mg a day. GlaxoSmithKline reports that their clinical studies show no effective difference for bipolar disorder above 200mg a day (as monotherapy). In the real world 200mg a day is a standard dosage, but plenty of people do feel a difference when taking more, and often do have to go up to 400mg a day. Lamictal’s antidepressant effects tend to diminish between 150-200mg. That is, you still get an antidepressant effect, it’s just that as you increase the dosage above that point you don’t get that much more of an increase in effect as you increase your dosage.

Note that if you were taking an enzyme-inducing anticonvulsant such as Trileptal (oxcarbazepine), Tegretol (carbamazepine USP) or Dilantin (phenytonin) and had to suddenly stop taking them, you’ll need to decrease the amount of Lamictal (lamotrigine) you take, otherwise you’ll find that you have way too much Lamictal (lamotrigine) in your system all of a sudden. And if you have to suddenly stop taking a valproate medication (Depakene (valproic acid), Depakote (divalproex sodium) or Depacon (valproate sodium)), you’ll have to increase the amount of Lamictal (lamotrigine) to compensate.  If you had a discontinuation plan for those other meds, of course, and it was all planned, then never mind.  Lamictal (lamotrigine) was designed to convert from one of those meds after all.

Epilepsy – it is so damn complicated! What type of epilepsy? Monotherapy or adjunctive therapy? What other meds are you taking? Which medication were you converting from? You’re talking to your doctor about this one. You want a second opinion?  Fine, talk to another doctor.  Read the PI sheet carefully. The same basic rule applies as for bipolar, take it slow and steady. And watch out for any changes to any other medications you’re taking. The therapeutic range for Lamictal (lamotrigine) with a valproate medication is 100-200mg a day, without a valproate it’s 300-500mg a day.

Depression – follow the guidelines for bipolar, but you may as well stop at 200mg a day. There’s rarely a point in going above that amount.  Again, as soon as you stop feeling depressed, hold at whatever dosage you’re at.  Even if it’s just 25mg a day.  You can wait to move up when symptoms return.  A return of symptoms doesn’t mean that the drug has stopped working.  Hardly.  You’re always tweaking the dosage of anticonvulsants.  That’s the nature of them.  You’ll be going up and down on the dosage here and there all the time.  This is way more complicated than rocket science.

For all other applications – as your doctor instructs you, I don’t have a clue.

Days to Reach a Steady State: Hah! Ha-hah. Oh, that’s a good one.

When you’re fully saturated with the medication and less prone to peaks and valleys of effects. You still might have peaks of effect after taking many meds, but with a lot of the meds you’ll have fewer valleys after this point. In theory anyway.

How Long Lamictal Takes to Work: Like all anticonvulsants it works best once you reach the proper dosage, but the proper dosage is especially variable with Lamictal (lamotrigine). Its antidepressant properties will kick in somewhere between 25 and 100mg a day, depending on what other meds you might be taking. Its mood stabilization and anti-epileptic effects will take place between 100 and 400mg a day, again depending on what other medications you’re taking. So it all depends on the titration schedule you and your doctor work out to reach those dosages.

 Lamictal’s Half-Life & Average Time to Clear Out of Your System: Get out a dartboard or some percentile dice, because a random number is going to be just as good as anything. The folks at GSK really tried to pin down a number for Lamictal (lamotrigine), but it so depends on what other medications you’re taking, if you take it once a day or twice a day, how much you’re taking, how old you are and where a woman is in her monthly cycle. Taking Lamictal (lamotrigine) once a day with no other medications produced a range of half-lives from 14 to 103 hours with an average of 32.8 hours. Taking it twice a day produced a range 12 to 62 hours with an average of 25.4 hours. The aggregate half-life given for Lamictal is 26 hours.

If you’re taking a valproate medication (Depakene (valproic acid), Depakote (divalproex sodium) or Depacon (valproate sodium)) the half-life shoots up to 70 hours. If you’re taking an enzyme-inducing anticonvulsant like Dilantin (phenytoin), Tegretol (carbamazepine USP), Trileptal (oxcarbazepine), Mysoline (primidone) or good old phenobarbital the half-life is cut to about 13 hours.

How to Stop Taking Lamictal:  Like everything about this drug, it’s complicated.

So a very simple rule of thumb was developed. If you’re not presenting symptoms of a nasty rash, allergic reaction, weird bruising that can’t be explained or anything else that requires you to stop taking it any faster, you reduce Lamictal (lamotrigine) the same way you increased it. This is where the detailed record of how you increased your dosage comes in.

GSK’s base recommendation for discontinuation is 50% per week, as long as you have something else in place.

If all else fails, 50mg per day every week.

For more information, please see the page on how to safely stop taking these crazy meds. 

Like any anticonvulsant, if you’ve been taking Lamictal (lamotrigine) for more than a couple months and you’re up to or above 100mg a day (give or take, depending on other meds you might be taking) you just can’t stop cold turkey if you’re not at the therapeutic dosage for another anticonvulsant that you know works for you, otherwise you risk partial-complex, absence seizures or even tonic-clonic grand mals, despite your never having had a seizure disorder before!  The risk is worse if you’re taking a lithium variant, and/or any antidepressant, especially Wellbutrin (bupropion hydrochloride). Even if you are taking something else Lamictal (lamotrigine) has its own set of issues with sudden discontinuation, namely intense headaches and sudden, intense and sometimes suicidal depression. That’s right, Lamictal (lamotrigine) will give you headaches when you take it and it will give you headaches it you suddenly stop taking it. Anyone with a history of a seizure disorder who needs to stop taking an anticonvulsant cold turkey needs to be discussing that with two neurologists and not getting your information from some stupid web site. Get off your computer and start making appointments!

If you’ve worked your way up to a particular dosage, it’s usually best to spend this many days at the next lowest dosage before going down the next lowest dosage before that and so forth. This is the least sucky way to avoid problems when stopping any psychiatric medication. Presuming you have the option of slowly tapering off them.

How Lamictal Works in Your Brain:  Lamictal (lamotrigine) works on binding to voltage sensitive sodium and maybe calcium channels in the brain.  The calcium bit is a matter for debate.   It also invokes glutamate which is a major excitatory neurotransmitter in the brain which is responsible for sending messages from neuron to neuron in 85% of the brain. It also lightly brushes the 5-HT3 serotonin receptor and the sigma opioid receptors, which probably account for its lovely antidepressant properties. Nothing like a combined serotonin and opiate reaction. As to precisely where in your brain Lamictal does its sodium and calcium channel magic, that’s a mystery.
Comments: Be sure to read the section on anticonvulsants if you haven’t done so already.
Approved by the FDA to treat epilepsy in 1994 and to treat bipolar disorder in 2003, Lamictal (lamotrigine) is probably the last of the anticonvulsants you’ll see approved to treat bipolar, because all the money is in atypical antipsychotics. Lamictal (lamotrigine) joins lithium in being one of only two meds to date approved to treat both the manic and depression phases of bipolar disorder and essentially to treat the mood swings themselves.

Lamictal (lamotrigine) is the prima donna of anticonvulsants / mood stabilizers. Besides lithium, Lamictal is the only official mood stabilizer proven to have any results with bipolar depression. Personally I find it odd that it’s approved for Bipolar 1 when Lamictal (lamotrigine) is really the med for Bipolar 2! Its CGI-I scores were better than many antidepressants on the market today. Little wonder why Lamictal is becoming popular as a treatment for otherwise treatment-resistant depression. Lamictal is proven to be the best medication for rapid cycling, but it doesn’t handle the nasty ultradian rapid cycling as well as Topamax (topiramate) does. If ultradian rapid cycling is an issue, it’s best to combine Lamictal (lamotrigine) with one of the temporal lobe affecting meds, such as Topamax (topiramate), Trileptal (oxcarbazepine) or Tegretol (carbamazepine USP), although you need to adjust the dosage with the latter two meds.

So that’s why Lamictal (lamotrigine) is worth dealing with. Despite all the rashes, headaches, muscle aches and pains, and slow titration schedule, when Lamictal works people just love it.

You’re just not going to find a pickier, or wackier medication in the psychiatric pharmacopoeia. Anticonvulsants are notorious for reacting to other medications and foods, but Lamictal (lamotrigine) reacts to everything. That’s why you have to titrate so slowly. And if you’re planning on a cocktail of some kind that’s going to include Lamictal (lamotrigine) it’s going to make your life a lot easier if you’re up to whatever dosages you plan on being at with whatever other meds first and then add Lamictal (lamotrigine). Otherwise you have to deal with Lamictal’s variable plasma levels and half-lives. Oh, sure, you and your doctor can check the PI sheet for what supposedly does or doesn’t affect Lamictal (lamotrigine), but too many things do have an effect. I’d just rather put up with whatever I was dealing with, stabilize on the other meds and then add Lamictal (lamotrigine) into the mix.

Where other anticonvulsants can mess with your girly hormones, your girly hormones are more likely to mess with Lamictal (lamotrigine). This means that Lamictal’s efficacy can vary throughout the month. Isn’t that fun? So, no, it’s not your imagination if it seemed to work better last week. If you’ve stabilized at a dosage and you’re noticing a variation throughout the month you may want to consider taking an oral contraceptive to standardize Lamictal’s effect. It may require a dosage adjustment after you start The Pill, but that’s how things are with this med.

There are no good data yet as to whether or not you can stop and start Lamictal again. One small study with epilepsy showed that it might be OK, if you didn’t wait too long. But that’s hardly a real-world application for discontinuation and restarting the med. The anecdotal evidence coming in is that it doesn’t seem to work as well the second time around, but some real evidence is needed.
As to the Lamictal (lamotrigine) muscle ache that is becoming popular, I have a guess as to what that is about. Lamictal (lamotrigine) is one of the few meds approved for Lennox-Gastaut syndrome, an uncommon form of epilepsy that, among other symptoms, presents the atonic seizure, where all your muscles go utterly limp. You’re having yet another relationship argument and you fall into a big pile of being the human turd, unable to move or even look away from the stain on the carpet. I’ve been there with the atonic seizures. Anyway, people seem to like Lamictal (lamotrigine) for Lennox-Gastaut. So if you’ve got a med that keeps your muscles from going limp and normally your muscles don’t go limp all the time, it would follow that muscle aches and pains could be a result.

 

 

Related Posts