What is the risk of falling associated with lamotrigine (Lamictal) therapy?

Risk of Falling with Lamotrigine

Lamotrigine is associated with an increased risk of falls, primarily due to side effects such as dizziness and ataxia, though this risk appears to be lower than with other antiepileptic medications like carbamazepine. 1

Fall Risk Profile of Lamotrigine

Mechanism of Fall Risk

• Lamotrigine can cause several neurological side effects that contribute to fall risk:
  • Dizziness (common adverse effect) 2, 3
  • Ataxia (impaired coordination) 2, 3
  • Other CNS-related symptoms that may affect balance 2

Comparative Risk

• Quantitative studies show lamotrigine has a more favorable balance profile compared to other antiepileptic drugs:
  • Patients on lamotrigine demonstrated significantly better balance maintenance than those on carbamazepine when tested with challenging dynamic balance measures 1
  • Lamotrigine patients performed better on specific balance tests including:
    • Sharpened Romberg position
    • Standing on one leg with eyes closed
    • Walking in tandem with eyes closed 1

Risk Factors That Increase Fall Potential

The risk of falls with lamotrigine is heightened in certain populations:

• Elderly patients - More susceptible to medication-induced falls 4
• Patients with polypharmacy - Particularly when combined with:
  • Other antiepileptic drugs
  • Psychotropic medications
  • Cardiovascular medications 4
• Patients with renal or hepatic impairment - May have altered drug metabolism 5
• Patients with pre-existing balance issues - Such as those with stroke history 5

Clinical Management to Reduce Fall Risk

Dosing Considerations

• Start with lower doses in elderly or frail patients 5
• Titrate doses slowly to minimize side effects 5
• Consider dose reduction if dizziness or ataxia occurs 6

Monitoring Recommendations

• Assess fall risk before initiating therapy
• Monitor for symptoms of dizziness, ataxia, or imbalance regularly
• Perform standardized balance assessments in high-risk patients 1
• Reassess patients within one month after treatment initiation 5

Environmental Interventions

For patients on lamotrigine with elevated fall risk:

• Ensure clear walking paths (remove loose rugs, clutter)
• Provide adequate lighting
• Recommend appropriate footwear with non-skid soles
• Advise slowing down movements for transfers or walking 5

Special Populations

Stroke Patients

• Stroke patients already have elevated fall risk (up to 70% fall within 6 months post-stroke)
• Adding lamotrigine may further increase this risk, though it may be necessary for seizure control 5
• Balance this risk against the benefit of seizure prevention, as seizures themselves increase mortality risk 5

Elderly Patients

• Falls are a significant concern in elderly patients on antiepileptic medications
• Consider that the American Heart Association/American Stroke Association guidelines note that lamotrigine is a reasonable first-line pharmacological treatment for central poststroke pain, despite potential fall risk 5

Conclusion

When prescribing lamotrigine, clinicians should:

• Be aware of the potential for dizziness and ataxia that may lead to falls
• Recognize that lamotrigine appears to have a more favorable balance profile than some other antiepileptic medications
• Implement appropriate fall prevention strategies for at-risk patients
• Monitor patients closely, especially during dose titration periods