Lamictal dosing for bipolar disorder

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I was reviewing some information about a new patient I will be seeing in a couple of weeks, and was surprised to see that the patient reports taking 500 mg of Lamictal for bipolar disorder. Other current medications include Abilify 15 mg, Elavil 25 mg, Celexa 40 mg, and Adderall 10 mg.

I have several patients on Lamictal, and usually stop around 100-200 mg. I have taken it up to 250 mg on occasion, but I don't think I've ever prescribed higher than that and certainly not 500 mg. I checked to see if maybe there was some drug-drug interaction with the current meds which would effectively lower the Lamictal dose, but couldn't find any.

I'm anticipating that things are not that well controlled, and I'll probably need to taper off Lamictal if it hasn't been helping. I curious what others have prescribed as a maximum dose for this medication.

 

[Sushirolls]

Lamictal can also have a blood level ordered. That will be more informative then daily dose.

 

[wolfvgang22]

I rarely see much improvement after 150mg. I've never prescribed more than 300mg on a patient who came to me on that, and had no difficulty in reducing it.

 

[Crayola227]

Fun Female Patient

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...

forums.studentdoctor.net

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.

 

[NickNaylor]

I've seen total daily doses of 200-400 mg daily with the latter typically divided as 200 mg BID, but 200 mg daily is much more common.

 

[Crayola227]

I'm remembering now splik in another thread bringing up NNT for lamictal compared to some other agents (I can't recall now for what specifically is was treating). In any case, given that many consider lamictal to have a weak effect even at the recommended and studied doses, I wonder what effect prescribing under the recommended dose has and how effective it is at that point. For me this would just be another reason to be willing to take it to 200 mg.

 

[Crayola227]

I know you said you looked at interactions, just wondering if you saw estrogen on the patient's list anywhere. I saw somewhere that can greatly affect levels.

Also to my knowledge there is no study correlating any given lamictal blood level with efficacy in BPAD, and that they are mostly just useful in sz management.

The test result I expect will be in a range that's appropriate for sz therapy as this is a dose in the range of what is used for that, and I don't expect the value to tell you if the patient is tolerating the drug well or not, and to my knowledge there is no guide for bipolar specifically.

Basically, I don't know that it will tell you if the dose is safe or unsafe, or if it is effective. It's possible that the value comes back in a range that is low or high for sz therapy, but again, without a guide for bipolar I'm not sure the utility.

I suppose it doesn't hurt to get a level just to help see if later the patient's mood symptoms change and there's reason to believe it's due to a change in lamictal levels, but I doubt it will tell you much about what to do with this patient's dose of 500 mg.

Otherwise in isolation I've yet to see a single lamictal blood level do much to guide therapy as there is no real guideline to my knowledge. This is why I've personally been told by different providers not to bother with ordering them, even though you can. I know some have used it to track how an individual patient is doing over time and with changes, sorta like following someone's PSA, but much like PSA, within certain reference ranges (below super high) an isolated value has no utility and it's more relative changes in relation to clinical picture that has meaning.

I may be wrong, this is just what I have been taught and I've yet to read something counter to it. I don't have references. If there are references regarding the use of lamictal levels in the management of bipolar, I'd be really interested in seeing them.

 

[Attending1985]

I was reviewing some information about a new patient I will be seeing in a couple of weeks, and was surprised to see that the patient reports taking 500 mg of Lamictal for bipolar disorder. Other current medications include Abilify 15 mg, Elavil 25 mg, Celexa 40 mg, and Adderall 10 mg.

I have several patients on Lamictal, and usually stop around 100-200 mg. I have taken it up to 250 mg on occasion, but I don't think I've ever prescribed higher than that and certainly not 500 mg. I checked to see if maybe there was some drug-drug interaction with the current meds which would effectively lower the Lamictal dose, but couldn't find any.

I'm anticipating that things are not that well controlled, and I'll probably need to taper off Lamictal if it hasn't been helping. I curious what others have prescribed as a maximum dose for this medication.

A patient with “bipolar disorder” taking every class of psychiatric medications save a benzo. Good luck!

 

[clausewitz2]

I know you said you looked at interactions, just wondering if you saw estrogen on the patient's list anywhere. I saw somewhere that can greatly affect levels.

Also to my knowledge there is no study correlating any given lamictal blood level with efficacy in BPAD, and that they are mostly just useful in sz management.

The test result I expect will be in a range that's appropriate for sz therapy as this is a dose in the range of what is used for that, and I don't expect the value to tell you if the patient is tolerating the drug well or not, and to my knowledge there is no guide for bipolar specifically.

Basically, I don't know that it will tell you if the dose is safe or unsafe, or if it is effective. It's possible that the value comes back in a range that is low or high for sz therapy, but again, without a guide for bipolar I'm not sure the utility.

I suppose it doesn't hurt to get a level just to help see if later the patient's mood symptoms change and there's reason to believe it's due to a change in lamictal levels, but I doubt it will tell you much about what to do with this patient's dose of 500 mg.

Otherwise in isolation I've yet to see a single lamictal blood level do much to guide therapy as there is no real guideline to my knowledge. This is why I've personally been told by different providers not to bother with ordering them, even though you can. I know some have used it to track how an individual patient is doing over time and with changes, sorta like following someone's PSA, but much like PSA, within certain reference ranges (below super high) an isolated value has no utility and it's more relative changes in relation to clinical picture that has meaning.

I may be wrong, this is just what I have been taught and I've yet to read something counter to it. I don't have references. If there are references regarding the use of lamictal levels in the management of bipolar, I'd be really interested in seeing them.

Levels have a role in patients who might become pregnant. The hormonal changes of pregnancy can increase clearance of lamotrigine to the point that second trimester serum levels are like 10% of pre-pregnancy levels and so dramatic increases are often called for to maintain the previously effective dose. I have seen people on 200 pre-pregnancy have their dose increased to 900 daily on this basis during pregnancy. The neurology literature has reports of pregnant women requiring 1500 mg daily to control their seizures with tolerable side effects.

Some of the original studies demonstrating efficacy had protocols that allowed doses to be escalated to 600 by clinicians.

Our perinatal specialists are very comfortable with risk and also tend to push for people who stabilized on lithium to stay on it during pregnancy, though.

 

[Stagg737]

Other current medications include Abilify 15 mg, Elavil 25 mg, Celexa 40 mg, and Adderall 10 mg.

I'd be less concerned about the Lamictal dose and more concerned about the rest of the meds. That seems like a very strange med list and I'd be curious to find out how they arrived at that point. What other psych diagnoses does this pt have?

 

[Taddy Mason]

... I'd be curious to find out how they arrived at that point...

Former UHS pt?