I just picked up a 38-year-old female with H/O childhood emotional and physical abuse. Mood swings since teen years. She has been dx with Bipolar II disorder but I think she is Cyclothymic with seasonal pattern. She gets more depressed in fall and winter. She seems to only be slightly hypomanic...
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I will die on the hill that the FDA recommended dose is 200 mg of lamictal for bipolar disorder maintenance. It is considered a safe and reasonable dose for BPAD.
It was noted that some improvement can be seen at smaller doses, and that some benefit can be seen at 100 mg, and that this could be taken as a sign of responsiveness, but that the dose should be continued to 200 mg if tolerated and there is still room for improvement.
Then ensued a massive debate about doses higher than 200 mg.
All I can tell you as a
fact is that 500-600 mg is on the higher end for sz, and even up to 800-1000 mg has been studied and safely used for sz, but would be quite unusual. I only mention this to help provide some perspective on how much lamictal is physically safe in humans and from that perspective what "a lot" is from a basic safety perspective.
If it were me, but granted I'm considered a quack on this front, I would titrate with the goal to get to 200 mg in a patient that was tolerating the drug well, and once there I might reassess if the higher dose had more benefit than a lower one - but not before getting to the higher dose of 200 in a patient that might have room for improvement on doses below 200.
I am of the opinion that given the side effect profile and the fact that higher doses are proven safely tolerated at least for another condition for which it is widely used, that I would be willing to go to 300-400 mg. I don't know there is evidence for that, but that's where myself and some other physicians are at with it. I've seen patients managed between 200-400 mg quite successfully, with different outcomes. Some noted improvement from 200-->300 and then no further improvement 300-->400 +/- additional side effects, and I've seen patients titrated back down to 200 after trials higher, vs others that found enough benefit to stay on a higher dose, whether that was 300 or 400.
We can argue about the benefit at going higher doses off-label, and that's fine, but the point is that on some basic level it's not exactly dangerous to prescribe higher doses of lamictal, although it might not be efficacious.
In my opinion, what you are describing are baby doses of lamitcal, and I'm speaking strictly from the fact that you are below the FDA recommended dose. I mentioned higher dosing to say that anecdotally some have found benefit, and I mention dosing in sz to illustrate that the recommended dosing of 200 mg is actually quite small on the scale of how much lamictal has been safely administered and studied in humans. I would say consider using the FDA recommended dose of 200 at the least, and more controversially you could consider off-label going to 300-400 without killing the patient.
