F.Y.I.:  Lamictal/ lamotrigine   comes in 2mg and 5mg chewable white tablets

[for children, of course]; it also comes in regular tablets:  25mg white, 100mg peach, 150mg cream, and 100mg blue.   10% of people get a rash with Lamictal and have to stop it, but 1/10,000 are subject to severe rash with fever called SJS [Stephen Johnson Syndrome] and which is a medical emergency necessitating hospitalization. 

Germany has mandatory monitoring of rashes and they recently reported the risk of SJS [Stephen Johnson Syndrome]  is only 1 in 10,000 and 13 other medications that we use are more likely to cause SJS,  including the sulfonamides that are commonly used for urinary tract infections [e.g., sulfisoxizole (Gantrisin) and sulfadiazine].   Actually, the risk of SJS is likely more like 1/40,000 as apparently the Germans often went up faster than the U.S. protocol.

After you have been on Lamictal 4-6 weeks the chance of serious rash becomes minimal.  Remember that if you are off Lamictal more than a few days, especially if off it 5-7 days you should start over at 25mg/day and call me.   If you are running low, and cannot get it, don’t stop it, just lower the dose and stretch it out until you can get a new supply—then you will not have to go up so slowly.

Lamictal lamotrigineDose Schedule for Lamictal/ lamotrigine if not also taking Depakote/ valproate:

Weeks  1 & 2: Start Lamictal  25mg every day       Weeks 3& 4:  ­ to  50mg per day 

Week 5:  ­ to 100mg/day                                           Week 6:  ­ to 200mg/day

  • NOTE : I used to often go to 400 to 500mg with very little side effects, but research revealed that most people only need 200mg for depression.  
  • NOTE : The target blood level of Lamictal in epilepsy is between 4 and 18.   When on 200mg, often the level is only 2-3.  By that standard, 200mg is not a very large dose. 

Instructions for starting   LAMICTAL (lamotrigine)  Usual target dose for depression is  200mg;.  Maximum dose: 500-800mg—but rarely necessary for depression.

Doses available: 25mg (white), 100mg (peach), 150mg (cream), 200mg (blue)

Lamictal chewable:  5mg, 25mg

Orally disintegrating tablets (ODT): 25, 50, 100, 200mg.

The side effect advantages of Lamictal:  no tremor, no weight gain, no cognitive problems, no sexual dysfunction, no decrease in bone density, and it is relatively safe in pregnancy.

  • SIDE EFFECTS: The most common side effects reported in Lamictal maintenance studies are:  headaches [Tylenol or ibuprofen works], rash, dizziness, diarrhea, dream abnormality, and pruritis (itching).  But these are common events  in many people and much of these “side effects” may have been coincidental.   Also, since we now go up on the dose so slowly, side effects are more uncommon.
  1. Drowsiness: The main possible side effect of Lamictal is drowsiness. So, if you suspect it is making you groggy or drowsy or tired, etc, then cut the dose in half for a couple of days to find out.  If you become dramatically more alert, we will then have to decide how to proceed with the dosing. (It is usually the depression making you tired, but you should also check out the Lamictal as a possible cause. Lamictal usually does not cause drowsiness and it does not affect cognition.)
  2. Rash: If you get a rash, stop Lamictal and call me. About 8% of people will get a rash on this medication, but what we are worried about is a rare allergic called op Stevens Johnson Syndrome (SJS) —a life threatening rash.  We try to avoid SJS by going up slowly. In the early 1990’s Lamictal was frequently escalated in dose rapidly in order to treat seizure disorders, and the rate of SJS was 1-2/1000, especially in children. Clinics in Germany went up somewhat more slowly and their rate was ~1/5500.   Now we are mandated to go even slower.  9/12/05:  The risk is only 1/10,000 now.  Germany has mandatory monitoring of rashes and they recently reported the risk of SJS is only 1 in 10,000 and 13 other medications that we use are more likely to cause SJS,  including the sulfonamides that are commonly used for urinary tract infections [e.g., sulfisoxizole (Gantrisin) and sulfadiazine.   After you have been on Lamictal 4-6 weeks the chance of serious rash becomes minimal.

Note #1:   lamotrigine (Lamictal) is an unusual medication because the side effects are usually minimal and the dose range is very large — one person may need only 12.5mg/day and another person may need (and tolerate!)  600mg/day.  It does not cause weight gain, or usually causes no daytime grogginess.

Note #2  Dose: For most mood disorders, my instructions are to increase the medicine slowly at night.  When you reach a dose that leaves you too groggy the next day, then reduce the dose by 1 pill and stay at this lower dose.  For some odd reason it seems that if one takes a dose that is just below the dose when side-effects are bothersome, then this lower, quite tolerable dose will work!  So if you have an extreme side effect of grogginess do not stop the medication, just find a dose you can easily live with.  If even 25 makes you groggy, cut it in ½  or in 1/4.

Note #3:  Because we have to use low doses the 1st month, it can take quite a while to have maximum benefit.    Prior to our finding out about the risk of a bad rash, patients sometimes came out of depression in less than a week, but usually within a month.  . Now it will generally take more than a month.  .  (But it occasionally, in rare cases,  it takes as much as 10 months to have maximum benefit. Even a 1 year wait is not difficult if you take a dose with virtually no side effects and think of it as a sleeping pill or vitamin.)

Note #4:-It does not help acute mania, it only helps depression..  Though we often call it a “mood stabilizer”, it only helps people come out of depression, not out of mania.  It works as well as an “antidepressant” (with less side effects than most antidepressants!) for depression, but has added advantages: it prevents manic and hypomanic episodes, prevents depressions, prevents cycling, and decreases impulsivity, anger and irritability.

Note #3:try never to miss Lamictal more than a couple of days.  Certainly don’t stop it for a full week.   Occasionally a medication will stop working if you are off it.   And if you restart something, you run the risk again of a rash.   So again, we will have to restart it very very slowly.   If you induce a rash, even if it turns out to be a great medication, we might never be able to use it on you again.  Note #4: Drug interactionsMinimal.  **But if it is started while one is on divalproate (Depakote), one has to increase the Lamictal twice as slowly because Depakote can double the Lamictal level. While on Depakote, the maximum dose of Lamictal is usually 200mg. Depakote can raise Lamictal levels by 35% to 200%.

  • About twice the usual dose of Lamictal is necessary when it is used with Tegretol (carbamazepine; long acting forms are: Equetro, Carbitrol), because Tegretol induces the enzymes metabolizing Lamictal, thus reducing the Lamictal
  • Lithium and fluoxetine / Prozac, as well as ethinylestradiol, phenytoin [Dilantin], phenobarbital, and topiramate [Topamax] also reduce the Lamictal

[Reimers, Arne; Drug Interactions Between Lamotrigine and Psychoactive Drugs: Evidence From a Therapeutic Drug Monitoring Service;  Journal of Clinical Psychopharmacology: Volume 25(4) August 2005 pp 342-348]

Note #5:  If you miss a dose one evening, usually you shouldn’t try to make up that dose the next day (unless you know you will get no side effects) because it may over sedate you. Just take your regular dose the next evening.

Remember, APPROXIMATELY 7 to 10% OF PATIENTS GET A RASH ON THIS MEDICATION WHETHER YOU GO UP SLOWLY OR YOU GO UP RAPIDLY—so you can be alarmed, but not excessively alarmed. (There was a rash rate of 2% in the placebo group, so the incidence of rash secondary to Lamictal is probably about 5%).  5 to 7% is a very large percent for a rash in a medication.  Usually the rashes are benign and sometimes one can lower the dose and the rash will remit.  However, if you get a significant rash, stop the medication and call me.

Comparisons with risk in motor vehicle accidents:  By one count, over a lifetime 1 out of every 142 people will die in a car accident.   If you assume people  will live an average of  90 years, then this year you have ~1/12,600 risk of dying in a car accident. (1/140 x 1/90 = 1/12,600).  2001:  Another group of statistics:  42,116  motor vehicle accident deaths in the USA. This includes children 5649, motorcyclists 3181, pedestrians 4882.   In 35% 14,933 (the true # is higher) blood alcohol level of 0.8 or higher was involved in at least one of the drivers.   The total death rate was 1.52 per 100 million miles traveled—out of 2.77 trillion miles traveled. By these statistics, if you spend 10,000 miles [common for some commuters] this year in a car you have 1.5/10,000,000 X10,000 = 1.5/10,000= ~1/6666 chance of dying this year in an auto accident.  If you  drive 5000 miles, then you have 1/3333 chance.

The latest odds of dying in a year per Insurance Institute for Highway safety, 2005:  1/12,900 for cars and light trucks; 1/7750 scooters, 1/1550 motorcycles.  [WSJ, 5/21/08, p D10]

Addendum: Pregnancy registry for physicians:  800 336 2176;

North American Antiepileptic Medication registry for patients: 888 233 2334

DRUG INTERACTIONS:       Tylenol can reduce Lamictal level.

  • Depakote significantly ­’s Lamictal level—by 35% to 200%.
  • Late in pregnancy the Lamictal level ¯‘s significantly b/o the ­’s estrogen.
  • Trileptal is a partial inducer, not as potent as carbamazepine, so adding Lamictal to Trileptal would probably be done at a speed ½ way between using it alone and using it with carbamazepine]

[oral contraceptives, lithium, and Prozac/ fluoxetine, phenytoin, phenobarb and Topamax  are associated with significantly ¯‘d Lamictal levels. 

Topamax/ topiramate lowers Lamictal in some studies, but not others.  It undergoes N-glucuronidation like Lamictal, but to a much lesser degree. Topamax  reduces the clearance of ethinylestradiol.

There are also reports of Zoloft / sertraline and Zyprexa / olanzapine lowering the Lamictal level, but apparently this is not always significant.]

[Drug interactions between Lamotrigine and Psychoactive Drugs, Reimers et al, J of Clin Psychopharmacology, vol 25, #4, Aug, 2005, pp 342-8.]