Academic journal article Current Psychiatry

When Is Lamotrigine a Good Choice? Lamotrigine Does Not Appear to Increase Risk of Hypomania or Mania in Bipolar Patients and Is Well Tolerated

Academic journal article Current Psychiatry

When Is Lamotrigine a Good Choice? Lamotrigine Does Not Appear to Increase Risk of Hypomania or Mania in Bipolar Patients and Is Well Tolerated

Article excerpt

FDA-approved for maintenance treatment of bipolar I disorder, lamotrigine is more effective than lithium for preventing depressive relapses. Lamotrigine combined with lithium, carbamazepine, or valproate provides good protection against recurrences of mania and depression.

Unlike selective serotonin reuptake inhibitors and other antidepressants, lamotrigine does not appear to increase risk of hypomania or mania in bipolar patients. (1) Unlike valproate and lithium, it is weight-neutral and requires no serum level monitoring. (2) Although lamotrigine's slow titration and prolonged period until reaching therapeutic effect limits its efficacy as monotherapy in an inpatient setting, the drug can be initiated along with quicker acting agents in the hospital and then titrated after discharge. This strategy allows close monitoring during initial exposure.

Consider lamotrigine as an adjunct for treatment-resistant major depression. (3) It is useful for treating aggression and agitation in patients with traumatic brain injury (4) or dementia. (5) Borderline personality disorder patients treated with lamotrigine may show less affective lability, impulsivity, or aggression. (6), (7) Lamotrigine can act synergistically with clozapine in some patients with refractory schizophrenia. (8)

Metabolism and drug interactions

Lamotrigine is metabolized via glucuronidation and eliminated renally. Other drugs metabolized by glucuronidation could interact with lamotrigine (Table). (9)

Table Drug interactions associated with lamotrigine

                Effect on
Interacting     lamotrigine  Management
drug

Carbamazepine   Increased    Double dose of
Phenytoin       clearance    lamotrigine when
Phenobarbital                used concomitantly
Primidone
Rifampin

Oral            Increased    Lamotrigine dose
contraceptives  clearance    may need to
containing                   be increased.
estrogen                     Efficacy of oral
                             contraceptives may
                             be decreased; dose
                             modification of
                             oral contraceptive also
                             may be required

Valproic acid   Decreased    Reduce dose by at
                clearance    least half, even if your
                             patient is on a medication
                             with the potential to
                             increase clearance
Source: Reference 9

Lamotrigine is well tolerated chronically, with fewer adverse effects than other mood stabilizers. Serious rashes, including Stevens-Johnson syndrome and toxic epidermal necrolysis, have been reported in 0.08% to 0.13% of patients treated with lamotrigine for bipolar disorder or other mood disorders. (9) The risk of developing a skin rash within 2 to 8 weeks of therapy necessitates starting with a low dose, usually 25 mg/d, and gradually titrating. …

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