How to Taper Lamotrigine (Lamictal)
Direct Recommendation
For an adult patient stable on lamotrigine 200 mg daily with no recent seizures or acute mood symptoms, taper by reducing the dose by approximately 25% every 1–2 weeks over a minimum of 4–8 weeks, with close monitoring for symptom recurrence. 1
Evidence-Based Tapering Schedule
Standard Tapering Protocol
Reduce lamotrigine by 50 mg (25% of 200 mg) every 1–2 weeks, following this approximate schedule: 200 mg → 150 mg → 100 mg → 50 mg → 25 mg → discontinue. 1
The entire taper should extend over 4–8 weeks minimum to prevent withdrawal symptoms and minimize risk of mood episode recurrence or seizure breakthrough. 1
Slower tapers extending 8–12 weeks may be prudent for patients with history of rapid relapse, severe episodes, or those who have been on lamotrigine for extended periods (>2 years). 1
Critical Monitoring During Taper
Symptom Surveillance
Schedule follow-up appointments every 1–2 weeks during the tapering period to assess for return of original symptoms (mood instability, depressive episodes, or seizures) and emergence of withdrawal symptoms. 1
Be aware that return of symptoms may take weeks to months to emerge after dose reduction or discontinuation, requiring vigilant monitoring even after the taper is complete. 1
Develop a comprehensive monitoring plan that includes standardized mood rating scales for bipolar patients or seizure diaries for epilepsy patients. 1
Post-Discontinuation Follow-Up
Continue close follow-up for at least 2–3 months after complete discontinuation, as this represents the highest-risk period for relapse. 2
The greatest risk of relapse occurs in the first 8–12 weeks after stopping medication, necessitating careful monitoring during this vulnerable window. 2
Special Considerations
If Withdrawal Symptoms or Mood Destabilization Occur
If symptoms return or worsen during taper, immediately return to the previous stable dose and maintain that level for an additional 2–4 weeks before attempting further reduction. 1
Consider extending the taper duration if the patient experiences any breakthrough symptoms, anxiety, irritability, or sleep disturbance during dose reductions. 1
Patients on Concurrent Medications
If the patient is taking both lamotrigine and a benzodiazepine, taper the benzodiazepine first due to greater risks associated with benzodiazepine withdrawal, then proceed with lamotrigine taper. 1
Patients taking valproate concurrently may have elevated lamotrigine levels; as valproate inhibits lamotrigine metabolism, the taper may need to be even more gradual. 3
Common Pitfalls to Avoid
Never Discontinue Abruptly
Abrupt discontinuation can precipitate seizures in patients with epilepsy or trigger mood episodes (mania, depression, mixed states) in patients with bipolar disorder. 1
Never taper faster than 25% reductions every 1–2 weeks, as rapid discontinuation dramatically increases the risk of withdrawal symptoms and relapse. 1
Premature Discontinuation
Inadequate duration of maintenance therapy leads to high relapse rates—over 90% of noncompliant patients with bipolar disorder relapse versus 37.5% of compliant patients. 2
Patients with multiple severe episodes, rapid cycling, or poor response to alternative agents should be counseled that indefinite treatment may be necessary rather than attempting discontinuation. 2
Restarting After Discontinuation
Critical Safety Warning
If lamotrigine was discontinued for more than 5 days, restart with the full initial titration schedule (starting at 25 mg daily) rather than resuming the previous maintenance dose, to minimize the risk of serious rash including Stevens-Johnson syndrome. 2
Patients with a history of severe rash with lamotrigine require special consideration, as reintroduction after discontinuation carries significant risk and may be contraindicated. 1
Clinical Context for Decision-Making
When Tapering May Be Appropriate
Consider discontinuation after 2 seizure-free years in epilepsy patients, with decision-making involving clinical, social, and personal factors and patient/family involvement. 4
For bipolar disorder, maintenance therapy should continue for at least 12–24 months after mood stabilization; some patients require lifelong treatment. 2
Risk-Benefit Assessment
Withdrawal of maintenance lithium or mood stabilizer therapy is associated with dramatically increased relapse risk, especially within 6 months following discontinuation. 2
More than 90% of adolescents who were noncompliant with mood stabilizer treatment relapsed, compared to 37.5% of compliant patients, underscoring the importance of careful consideration before discontinuation. 2
Expected Timeline and Outcomes
The standard 200 mg daily dose should be tapered over 4–8 weeks minimum, with each dose reduction maintained for 1–2 weeks before proceeding to the next step. 1
Monitor closely during the taper and for 2–3 months post-discontinuation, as symptom recurrence may be delayed. 2, 1
If any breakthrough symptoms occur, immediately restore the previous stable dose and reassess the appropriateness of discontinuation. 1