I have, on occasion, used doses of Lamictal up to 300mg daily for bipolar patients with success--especially with a bipolar 2 spectrum affective disorder. The FDA recommended max dose is 200mg daily--without other drugs in play. I would rather push the dose of Lamictal as high as possible to achieve remission with monotherapy. Wondering what other attending/resident psychiatrists experience is with high dose Lamictal.
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Lamictal
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Where I come from ( a program that is extremely rich in experience and many attendings that >55 years old) Lamictal is almost never used as monotherapy. Too many of the older, experienced attendings have had their patient develop mania. Almost the only time that it is used is in Bipolar patients that are already on therapeutic doses of mood stabilizers that are in the depressed stage and are not improving. So, someone on depakote you can add some lamictal to help with their depression.
I know some psychiatrists who suggest 300mg as a minimum. I have used up to 600mg in patients who it appeared to help at lower doses and had breakthrough symptoms. 700mg+ are used in epilepsy. The Maudsley Prescribing Guidelines note that doses up to 1200mg have been used in bipolar disorder. The reason for the 200mg dose is that in the RCTs there was no evidence of any further benefit at 400mg. However, it is possible that higher doses are needed for some.
There is limited evidence supporting lamotrigine for the treatment of acute bipolar depression. 4/5 RCTs failed to show efficacy. When pooled together in meta-analysis there is marginal benefit, but the NNT is 12! So you need to treat 12 people for one to have an effect above placebo. Of course the problem could be the problem with dose titration. I don't think it is a good option for monotherapy, but it has a relatively benign side-effect profile, SJS is rare (had a pt who got a big payout for developing SJS and blew it all on crystal!), and patient's like it. Some people complain of horrendous agitation or activation at higher doses. Also it is associated with hypersexuality which is not mood-related (i.e. not as a result of manic induction and occurs in epileptics as well).
There is limited evidence supporting lamotrigine for the treatment of acute bipolar depression. 4/5 RCTs failed to show efficacy. When pooled together in meta-analysis there is marginal benefit, but the NNT is 12! So you need to treat 12 people for one to have an effect above placebo. Of course the problem could be the problem with dose titration. I don't think it is a good option for monotherapy, but it has a relatively benign side-effect profile, SJS is rare (had a pt who got a big payout for developing SJS and blew it all on crystal!), and patient's like it. Some people complain of horrendous agitation or activation at higher doses. Also it is associated with hypersexuality which is not mood-related (i.e. not as a result of manic induction and occurs in epileptics as well).
I would never use is as monotherapy for a bipolar 1 spectrum disorder. It's well known as a very poor antimanic medication. I'm talking about sub threshold or soft hypomanic episodes, with significant depressive episodes. I view bipolar 2 spectrum disorders, whether right or wrong, as MDD with occasional hypomanic like episodes. Most patients don't want the hypomanic episodes taken away from them, but I try to convince them that their brief euphoria is not worth the eventual subsequent depression.
I've used up to 300mg. The highest I've heard of is 3600mg daily. I wouldn't recommend that.
