From the Guidelines
The starting dose of Lamictal is 6.5 mg/kg as a single oral load if the patient has been on lamotrigine for more than 6 months without a history of rash or intolerance and has only been off lamotrigine for less than 5 days, as indicated in the context of emergency department management 1. When considering the use of Lamictal, particularly in the emergency setting, it's crucial to weigh the benefits of rapid loading against the potential risks, especially the risk of serious rashes. The decision to use an extended-release (ER) formulation of Lamictal would be appropriate in scenarios where once-daily dosing is preferred to enhance medication adherence, or in cases where patients experience breakthrough seizures with the immediate-release formulation, or side effects related to peak concentrations of the immediate-release form. Key considerations for the use of Lamictal include:
- The patient's history with lamotrigine, including any previous rashes or intolerance.
- The duration the patient has been off lamotrigine, with a preference for those who have been off for less than 5 days.
- The potential benefits of rapid loading in the emergency setting, balanced against the risk of adverse effects. Given the information from the study published in the Annals of Emergency Medicine 1, the focus is on the management of adult patients presenting to the emergency department with seizures, highlighting the importance of careful consideration of antiepileptic medication loading doses and routes of administration. In clinical practice, the choice between immediate-release and extended-release formulations, as well as the decision to load or not, should be tailored to the individual patient's needs and medical history, always prioritizing the minimization of morbidity, mortality, and improvement in quality of life.
From the Research
Starting Dose of Lamictal
- The starting dose of lamictal is not explicitly stated in the provided studies, but it can be inferred from the dosage schedules mentioned in the studies.
- For example, one study mentions a dosage schedule of 5 mg every day or every second day for 14 days, increased by 5 mg every 14th day to 25 mg a day 2.
When to Visit the ER
- Patients who experience severe cutaneous adverse effects such as Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) should seek immediate medical attention in the emergency room (ER) 3, 4.
- If a rash appears while taking lamotrigine, treatment should be discontinued and medical attention should be sought 3.
- The ER may also be appropriate for patients who experience hypersensitivity reactions, such as allergic skin rash, especially if they are taking concomitant valproate therapy, as the risk of rash is increased in these patients 5.