How do I taper off Lamictal (lamotrigine)?

Lamotrigine (Lamictal) Tapering Protocol

Lamotrigine should be tapered gradually over weeks to months rather than discontinued abruptly to prevent withdrawal symptoms and minimize the risk of seizures or mood episode recurrence. 1

Recommended Tapering Approach

• Implement a gradual tapering schedule with dose reductions of approximately 25% of the most recent dose every 1-2 weeks 2, 1
• For patients on higher doses or who have been on lamotrigine long-term, consider an even more gradual taper extending over several months 1
• Slower tapering (reduction of 10% or less of the most recent dose per month) may be appropriate for patients who have difficulty tolerating withdrawal symptoms 3
• Final doses before complete cessation may need to be very small to prevent a large decrease in therapeutic effect when stopped completely 3

Monitoring During Tapering

• Schedule more frequent follow-up appointments during the tapering period to assess for:
  • Return of original symptoms (bipolar disorder, seizures)
  • Emergence of withdrawal symptoms
  • Need for adjustment of the tapering schedule 1
• Be aware that return of symptoms may take weeks to months to emerge after dose reduction or discontinuation 2, 1
• For patients with bipolar disorder, monitor closely for signs of depression or mania during and after tapering 4

Special Considerations

• For patients taking both lamotrigine and benzodiazepines who require tapering of both medications, taper the benzodiazepine first due to greater risks associated with benzodiazepine withdrawal 2
• If lamotrigine is being discontinued due to serious rash or other adverse effects, more rapid discontinuation may be necessary, weighing the risks of withdrawal against the risks of continuing the medication 5, 6
• For patients with a history of bipolar disorder, particularly those with BD-I or manic predominant polarity, be especially vigilant for mood switches during the tapering process 4

Managing Withdrawal Symptoms

• If withdrawal symptoms emerge and are severe, consider temporarily returning to the previous dose and then resuming tapering at a slower rate 7
• Withdrawal symptoms are generally mild and self-limiting but can include:
  • Somatic symptoms: dizziness, nausea, fatigue, sensory disturbances, sleep disturbances
  • Psychological symptoms: anxiety, irritability, mood changes 7

Common Pitfalls to Avoid

• Avoid abrupt discontinuation which can precipitate seizures in patients with epilepsy or mood episodes in patients with bipolar disorder 2, 1
• Do not mistake withdrawal symptoms for physical illness or relapse of the underlying condition 7
• Avoid tapering too quickly in patients with a history of difficult medication transitions or those who have been on high doses for extended periods 3