Lamotrigine

Aka: Lamotrigine, Lamictal

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II. Indications

  1. Simple Partial Seizures
  2. Complex Partial Seizures
  3. Generalized Tonic Clonic Seizures
  4. Bipolar Disorder

III. Mechanism

  1. Phenyltriazine anticonvulsant

IV. Pharmacokinetics

  1. Oral Bioavailability: 98%
  2. Elimination Half-Life: 22 to 36 hours

V. Adverse Effects: Dose related

  1. Dizziness
  2. Incoordination
  3. Tremor
  4. Ataxia
  5. Diplopia
  6. Headache
  7. Insomnia
  8. Somnolence
  9. Blurred Vision
  10. Nausea or Vomiting

VI. Adverse Effects: Other

  1. Serious skin rash (Incidence 0.08% in adults)
    1. Stevens Johnson Syndrome
    2. Toxic Epidermal Necrolysis
  2. Prolonged QRS Interval
    1. Increased risk of ventricular Arrhythmia or Cardiac Arrest
    2. Mechanism
      1. Sodium Channel Blocker
    3. Higher risk in underlying heart disease
      1. Coronary Artery Disease (prior Myocardial Infarction)
      2. Structural heart disease
      3. Atrioventricular Block
      4. Heart Failure
    4. Approach
      1. Avoid in high risk cardiovascular patients
      2. Consider baseline EKG in age over 60 years or Cardiovascular Risk Factors
      3. Avoid combining with other Sodium Channel Blockers
    5. References
      1. (2021) Presc Lett 28(6):34
  3. Aplastic Anemia
  4. Thrombocytopenia
  5. Neutropenia
  6. Pancytopenia
  7. Aseptic Meningitis
  8. Serotonin Syndrome

VII. Drug Interactions

  1. Valproic Acid
  2. Carbamazepine
  3. Phenytoin
  4. Phenobarbital
  5. Primidone
  6. Rifampin
  7. Oral Contraceptives

VIII. Dosing: Adults

  1. Initial: 25 mg every other day for 2 weeks
  2. Next: 25 mg orally daily for 2 weeks
  3. Target dose: 50-100 mg orally twice daily
  4. Maximum dose: 400 mg/day
  5. Precautions
    1. Slow titration over 6 weeks or more reduces the risk of Stevens-Johnson Syndrome
    2. Dosing adjustments are needed when used with agents listed under Drug Interactions

IX. Monitoring

  1. Obtain labs monthly for the first 2 months and then every 3 to 12 months
  2. Complete Blood Count
  3. Liver Function Test

X. Approach: Toxicity or Overdose

  1. Evaluate as Unknown Ingestion
    1. Obtain other toxicologic screening including Acetaminophen level, Serum Glucose
    2. Electrocardiogram
  2. Effects in Overdose
    1. Ventricular Dysrhythmia
      1. Lamictal inhibits voltage-gated Sodium channels
      2. Wide QRS Complex
        1. Treat with Sodium Bicarbonate ampules until QRS Complex narrows
    2. Serotonin Syndrome
      1. Lamictal inhibits Serotonin reuptake
    3. Neurologic Effects
      1. Sedation (most common finding in Overdose)
      2. Seizures
        1. Paradoxical (as Lamictal is foremost an anticonvulsant)
        2. Children may experience Seizures at doses >30 mg/kg
      3. Agitation
      4. Increased Deep Tendon Reflexes (hyperreflexia)
      5. Myoclonic Jerks
    4. Miscellaneous
      1. Nausea or Vomiting
  3. Management
    1. Activated Charcoal
      1. Consider if <1 hour from time of ingestion, and patient without aspiration risk
    2. QRS Widening
      1. See above (regarding bicarbonate)
    3. Seizures
      1. See Status Epilepticus
      2. Benzodiazepines
      3. Consider Propofol and intubation
      4. Consider Hemodialysis
  4. Disposition
    1. If asymptomatic at 4-6 hours after ingestion, may discharge home
  5. References
    1. Tomaszewski (2020) Crit Dec Emerg Med 34(1): 28

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Related Studies

Cost: Medications

lamotrigine (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
LAMOTRIGINE 100 MG TABLET Generic $0.05 each
LAMOTRIGINE 150 MG TABLET Generic $0.07 each
LAMOTRIGINE 200 MG TABLET Generic $0.08 each
LAMOTRIGINE 25 MG DISPER TAB Generic $0.19 each
LAMOTRIGINE 25 MG TABLET Generic $0.03 each
LAMOTRIGINE 5 MG DISPER TABLET Generic $0.25 each
LAMOTRIGINE ER 100 MG TABLET Generic $1.26 each
LAMOTRIGINE ER 200 MG TABLET Generic $1.08 each
LAMOTRIGINE ER 25 MG TABLET Generic $0.91 each
LAMOTRIGINE ER 250 MG TABLET Generic $3.61 each
LAMOTRIGINE ER 300 MG TABLET Generic $2.99 each
LAMOTRIGINE ER 50 MG TABLET Generic $0.75 each
LAMOTRIGINE ODT 100 MG TABLET Generic $3.05 each
LAMOTRIGINE ODT 200 MG TABLET Generic $4.18 each
LAMOTRIGINE ODT 25 MG TABLET Generic $3.43 each
LAMOTRIGINE ODT 50 MG TABLET Generic $3.57 each
lamictal (on 1/1/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
LAMICTAL 100 MG TABLET Generic $0.05 each
LAMICTAL 150 MG TABLET Generic $0.07 each
LAMICTAL 200 MG TABLET Generic $0.08 each
LAMICTAL 25 MG DISPER TABLET Generic $0.19 each
LAMICTAL 25 MG TABLET Generic $0.03 each
LAMICTAL ODT 100 MG TABLET Generic $3.05 each
LAMICTAL ODT 200 MG TABLET Generic $4.18 each
LAMICTAL ODT 50 MG TABLET Generic $3.57 each
LAMICTAL XR 100 MG TABLET Generic $1.26 each
LAMICTAL XR 200 MG TABLET Generic $1.08 each
LAMICTAL XR 300 MG TABLET Generic $2.99 each
LAMICTAL XR 50 MG TABLET Generic $0.75 each
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

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