Is it safe to use alcohol and cannabis while taking lamotrigine?

Safety of Alcohol and Cannabis Use with Lamotrigine

Concurrent use of alcohol or cannabis with lamotrigine is not recommended due to increased risks of adverse effects, including potential for enhanced central nervous system depression, cognitive impairment, and increased stroke risk.

Alcohol and Lamotrigine Interaction

Risks and Concerns

• Alcohol consumption while taking lamotrigine may lead to:
  • Enhanced central nervous system depression
  • Increased risk of adverse effects including dizziness, drowsiness, and impaired coordination
  • Potential for worsened hepatic function, as both substances are metabolized by the liver 1
  • Increased risk of cardiovascular events, particularly stroke 1

Evidence-Based Recommendations

• The British Association of Dermatologists specifically lists "excessive alcohol intake" as a relative contraindication to methotrexate treatment, and similar caution applies to lamotrigine 1
• Patients taking psychotropic medications, including anticonvulsants like lamotrigine, have reported serious adverse effects when combining with alcohol, including:
  • Worsening of psychiatric conditions
  • Hospitalization
  • Increased drowsiness 2

Cannabis and Lamotrigine Interaction

Risks and Concerns

• Cannabis use while taking lamotrigine presents several concerns:
  • Cannabis inhibits cytochrome P450 enzymes (specifically CYP3A4, CYP2C9, and CYP2C19) which are involved in lamotrigine metabolism 1
  • This inhibition could potentially increase lamotrigine blood levels, leading to toxicity
  • Both substances can cause CNS depression, potentially leading to additive effects
  • Cannabis use is associated with increased stroke risk in a dose-dependent relationship 1

Evidence-Based Recommendations

• The American Heart Association/American Stroke Association guidelines specifically note that cannabis use increases stroke risk, with more frequent than once-weekly use associated with significantly elevated risk (adjusted incidence rate ratio of 4.7) 1
• The American College of Chest Physicians notes insufficient evidence to recommend cannabinoids for pain management, citing concerns about memory and concentration impairment 1

Clinical Management Approach

For Patients Currently Using These Substances

1. Assess usage patterns and risks:

   • Frequency and amount of alcohol/cannabis consumption
   • Presence of substance use disorder
   • Current lamotrigine dose and indication

2. Provide clear counseling:

   • Explain the specific risks of combining these substances with lamotrigine
   • Emphasize that both alcohol and cannabis can worsen side effects like dizziness, drowsiness, and cognitive impairment

3. Recommend complete avoidance if possible:

   • For alcohol: Complete abstinence is safest, though very occasional minimal consumption might be tolerated in some patients without liver issues
   • For cannabis: Avoid use, particularly given the potential pharmacokinetic interactions and stroke risk

4. If discontinuation is planned:

   • Never stop lamotrigine abruptly due to seizure risk
   • Follow a gradual tapering schedule over 4-8 weeks with 25-33% reductions every 1-2 weeks 3
   • Monitor closely for emergence of mood symptoms or seizure activity during tapering

Special Considerations

Potential Benefits in Specific Populations

• Limited research suggests lamotrigine may actually reduce alcohol craving and consumption in patients with bipolar disorder and comorbid alcohol dependence 4, 5
• However, these potential benefits do not outweigh the risks of concurrent use in most patients

Monitoring for Patients Who Cannot Abstain

• More frequent monitoring of lamotrigine levels may be needed
• Watch for signs of toxicity: ataxia, blurred vision, dizziness, nausea
• Monitor liver function tests more frequently
• Assess for worsening of underlying psychiatric or seizure conditions

Bottom Line

The safest approach is to avoid both alcohol and cannabis while taking lamotrigine. If complete abstinence is challenging, patients should be counseled about minimizing use and recognizing signs of adverse effects requiring medical attention.