From the Guidelines
The therapeutic endpoint for psychiatric use of lamotrigine is symptom remission or significant reduction in mood symptoms, particularly in bipolar disorder, with target blood levels typically between 3-14 mcg/mL.
Key Considerations
- The medication is usually titrated slowly to minimize adverse effects, starting at 25 mg daily for 2 weeks, then 50 mg daily for 2 weeks, followed by 100 mg daily for 1 week, and finally reaching a typical maintenance dose of 200 mg daily (range 100-400 mg daily) 1.
- Effectiveness should be assessed after reaching therapeutic doses, usually within 6-8 weeks.
- Treatment response is primarily evaluated through clinical improvement in mood stability, reduction in depressive episodes, and prevention of mood cycling rather than through blood level monitoring.
- Lamotrigine works by inhibiting voltage-sensitive sodium channels and reducing glutamate release in the brain, which helps stabilize mood.
Monitoring and Safety
- Regular monitoring for adverse effects, particularly skin rashes (which can progress to Stevens-Johnson syndrome), is essential throughout treatment.
- As noted in the practice parameter for the assessment and treatment of children and adolescents with bipolar disorder, lamotrigine is approved for maintenance therapy in adults, and its use in youths is supported by open-label trials and retrospective chart reviews 1.
Clinical Application
- Clinicians should be aware of the potential benefits and risks of lamotrigine in the treatment of bipolar disorder, particularly in youths, and carefully monitor patients for therapeutic effects and adverse reactions.
- The use of lamotrigine should be individualized, taking into account the patient's specific needs, medical history, and response to treatment.
From the Research
Therapeutic End Point for Psychiatric Use of Lamotrigine
The therapeutic end point for the psychiatric use of lamotrigine can be understood by examining its efficacy in various psychiatric disorders.
- Lamotrigine is generally well tolerated, with the best evidence for the maintenance treatment of bipolar disorder, particularly in prevention of depressive episodes 2.
- In acute bipolar depression, meta-analyses suggested a modest benefit, especially for more severely depressed subjects, with switch rates similar to placebo 2.
- Lamotrigine showed efficacy in the prophylaxis of bipolar disorder, more so in depressive than manic episodes 3.
- Sound evidence supports the use of lamotrigine for acute bipolar depression and prophylaxis, treatment-resistant schizophrenia, treatment-resistant obsessive-compulsive disorder, posttraumatic stress disorder, depersonalization disorder, and affective dysregulation and behavioral dyscontrol domains of borderline personality disorder 4.
- Combination therapy with lamotrigine plus divalproex or lithium may be a valuable option for managing symptoms of bipolar disorder, with the combinations being generally well tolerated and apparently effective in improving depression as well as mania 5.
- Lamotrigine is beneficial for both acute treatment of bipolar depression and prevention of recurrent episodes 6.
Key Indications
Key indications for lamotrigine in psychiatric practice include:
- Bipolar disorder, particularly for prevention of depressive episodes
- Acute bipolar depression
- Treatment-resistant schizophrenia
- Treatment-resistant obsessive-compulsive disorder
- Posttraumatic stress disorder
- Depersonalization disorder
- Affective dysregulation and behavioral dyscontrol domains of borderline personality disorder
Limitations
There are limited data to support the use of lamotrigine in other psychiatric disorders, such as: