From the Guidelines
If a patient on lamotrigine develops oral ulcers, the medication should be immediately discontinued and the patient should seek urgent medical attention. Oral ulcers can be an early sign of Stevens-Johnson Syndrome (SJS) or Toxic Epidermal Necrolysis (TEN), which are rare but potentially life-threatening skin reactions associated with lamotrigine 1. The patient should not wait for additional symptoms to develop before contacting their healthcare provider. While awaiting medical evaluation, the patient can use symptomatic relief measures such as salt water rinses, avoiding spicy or acidic foods, and using topical pain relievers approved for oral use.
Some key points to consider in managing oral ulcers include:
- The use of topical measures such as local corticosteroids as the first line of treatment for isolated oral and genital ulcers 1
- The importance of oral hygiene in managing oral ulcers 1
- The potential use of sucralfate suspension for oral and genital ulcers 1
- The consideration of systemic measures such as azathioprine, IFNa, and TNFa antagonists for resistant cases 1
However, in the context of lamotrigine-induced oral ulcers, the primary concern is the potential for SJS or TEN, and therefore, immediate discontinuation of the medication and urgent medical attention are paramount. The healthcare provider will evaluate the severity of the reaction and determine appropriate next steps, which may include hospitalization in severe cases. The development of this reaction is typically related to immune-mediated hypersensitivity to the medication, and risk factors include rapid dose escalation, concurrent valproate use, and previous history of drug rash. If lamotrigine therapy needs to be resumed in the future, it should be done with extreme caution, slower titration, and only if the benefits clearly outweigh the risks.
From the Research
Lamotrigine-Induced Oral Ulcers
- Oral ulcers can occur in patients taking lamotrigine, especially after the discontinuation or dosage decrease of inducers such as oxcarbazepine or carbamazepine 2.
- The development of oral ulcers may be a sign of lamotrigine toxicity, which can occur several weeks after the discontinuation or dosage decrease of inducers 2.
- Drug-induced oral ulcerations can be caused by direct contact between the drug and the oral mucosa, or as part of a complex reaction with cutaneous or systemic manifestations 3.
- Solitary oral ulcerations usually appear after a few weeks of treatment and may resist conventional treatments, with rapid healing following the suppression of the responsible drug 3.
Management of Lamotrigine-Induced Oral Ulcers
- If a patient on lamotrigine develops oral ulcers, the medication should be discontinued or the dosage adjusted to prevent further toxicity 2, 4.
- Dental medicine professionals should be aware of the risks involved with using lamotrigine and recognize the population at risk among patients suffering from epilepsy, bipolar, and neurologic disorders 4.
- Exfoliative cytology can be performed to reassure the patient that the oral ulcer is not a sign of oral cancer, and to confirm the presence of a nonspecific inflammatory reaction 5.
Importance of Monitoring and Cooperation
- Hospital psychiatrists and dental medicine professionals should be aware of the potential for lamotrigine-induced oral ulcers and monitor patients closely for signs of toxicity 2, 4.
- Cooperation between clinicians and dentists is essential to adjust the prescribed medication and resolve symptoms 5.
- Patients taking lamotrigine should be informed of the potential risks and monitored regularly for signs of oral ulcers or other adverse effects 6.