From the Guidelines
Lamictal should be held in patients with a history of rash or intolerance, those who have been off the medication for more than 5 days, or if they experience severe hypersensitivity reactions, significant worsening of seizures or mood symptoms, suicidal thoughts, severe neurological side effects, or laboratory abnormalities such as elevated liver enzymes or decreased blood cell counts. According to the study published in the Annals of Emergency Medicine 1, lamotrigine has a high risk of serious rashes, and loading should not be done if there is a history of rash or if the patient has not been previously on lamotrigine. The study also notes that lamotrigine should not be loaded if the patient has been off the medication for more than 5 days. Other reasons to hold lamotrigine include:
- Signs of severe hypersensitivity reactions such as fever, lymphadenopathy, facial swelling, blood abnormalities, or liver dysfunction
- Significant worsening of seizures or mood symptoms
- Suicidal thoughts
- Severe neurological side effects like ataxia, dizziness, or vision changes
- Laboratory abnormalities such as elevated liver enzymes or decreased blood cell counts
- Pregnancy, where dose adjustments may be necessary due to altered metabolism, and the medication might need to be held temporarily if blood levels become too low or side effects become problematic. It is essential to carefully evaluate the risks and benefits of holding lamictal, considering the potential consequences of uncontrolled seizures versus the risk of adverse effects, as noted in the study 1.
From the Research
Reasons to Hold Lamictal
- Severe adverse skin reactions such as Stevens-Johnson syndrome and toxic epidermal necrolysis, which can be life-threatening 2, 3, 4, 5, 6
- Delayed hypersensitivity immune response, which can be triggered by the use of lamotrigine 2, 3
- Genetic predisposition, such as certain human leukocyte antigen (HLA) genotypes, which can increase the risk of adverse reactions to lamotrigine 3
- Off-label use of lamotrigine, which can increase the risk of Stevens-Johnson syndrome and toxic epidermal necrolysis 6
- Quality control concerns about some available brands of lamotrigine, which can affect the safety and efficacy of the medication 5
Patient-Specific Factors
- History of severe skin reactions, such as Stevens-Johnson syndrome or toxic epidermal necrolysis, which can contraindicate the use of lamotrigine 3, 5
- Presence of certain HLA genotypes, such as HLA-B15:02, HLA-B31:01, or HLA-B*44:03, which can increase the risk of adverse reactions to lamotrigine 3
- Age, sex, and comorbidities, which can affect the risk of adverse reactions to lamotrigine 6
Clinical Considerations
- Monitoring for signs and symptoms of severe skin reactions, such as Stevens-Johnson syndrome and toxic epidermal necrolysis, which can be life-threatening 2, 3, 4, 5, 6
- Slow dose escalation and careful monitoring of patients who are being re-challenged with lamotrigine after a previous skin reaction 3
- Consideration of alternative medications, which can reduce the risk of adverse reactions 5