taking, titrating, and tapering Lamictal (lamotrigine)

> How to Take Lamictal

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Taking & Titration Overview

One of the most important aspects of any medication is how to go about taking it. This includes:

  • how much to take (the dosage or dose)
  • when and how often to take it (dosing schedule or doses)
  • how much to start with and how to increase the dose/dosage until you’re taking the target amount (titration or titration schedule).

Although we often disagree with them, we’ll always give you the manufacturer’s recommendations from Lamictal’s full US Prescribing Information. If, for some reason, that isn’t available, we’ll use information for patients leaflets, SPCs from overseas, or whatever official sources we can find. Most doctors will give you some idea of what it will be like, and this is what every pharmacist is trained and paid to tell you.1 As “often” doesn’t mean “always”, whatever is in the PI sheet works for us a lot of the time.

We usually advocate starting at a lower dosage than recommended. One of our core philosophies is increasing the dosages as slowly as one’s condition allows, and staying at the dosage that works instead of a target dosage2. More and more doctors are agreeing with us3. You and your doctor can always discuss increasing the dosage when you need to in advance.

And since you never really know how a drug might affect you, it’s best to start when you have some time off of work. Like Friday night / Saturday morning, or your equivalent. Better still would be to get someone to stay with you or at least check on you frequently, especially if you’re the primary caretaker of young children and similar critters.4

Lamictal (lamotrigine) Dosage and Doses

Lamictal has the most complicated dosing instruction and schedule to increase the dosage (titration) of any crazy med. They take up 9 pages of the PI sheet.
Normally you would take regular Lamictal twice a day, but if the dosage is small enough, or you find it affects how you sleep, or for whatever reason, you can take it once a day, either in the morning, or at night, or the middle of the day. That’s one thing where Lamictal is really flexible.
Lamictal-XR is supposed to be a once-a-day med regardless. I haven’t collected enough data yet to know if that’s the case or not. Depakote ER is supposed to be once-a-day, but many people find they need to take it twice a day anyway.

As with all meds, taking Lamictal at the same time every day is recommended, and with some people it actually will make a difference if you do that or not.

However, if you scroll down a bit to the titration schedule you’ll see that if you take any other medications, you can be forced to take Lamictal in a particular way.

Special Instructions/Best Way to Take Lamictal (lamotrigine)

There are far too many variables to determine a best way to take Lamictal. Taking it with food doesn’t affect how well it’s absorbed, so if Lamictal causes any gastrointestinal problems, try taking it on a full stomach.

Although regular Lamictal tablets are scored, indicating you can split them in half (Lamictal-XR is NOT scored and, like all extended-release drugs should NEVER be split, cut, chewed, folded, spindled, or mutilated.), throughout the PI sheet GSK indicates that it’s not that good of an idea to split them after all. They crumble easily and are really difficult to cleanly split into two pieces that are close to the same dosage. Most generic lamotrigine tablets are the same way, although Teva’s is fairly robust and splits somewhat cleanly.

Lamictal (lamotrigine) Titration (Dosage Increase)

Living in a Perfect World

GSK has made if very, very simple to start taking Lamictal and increase your dosage on a schedule (titrate) until you reach a target dosage by distributing free starter packs to doctors with two months worth of Lamictal. Two entire months worth of free pills is one of the best medication deals on the planet. And there isn’t just one, but three color-coded starter packs to use depending on the other meds you’re taking. Because Lamictal is only approved to transfer to after your symptoms (bipolar or epilepsy) are under control. Lamictal is NOT approved to take as a drug to get your symptoms under control, but to keep them under control.

Here are some5 of the titration schedules from the PI sheet, along with comments and suggestions. I added the brand names. The different valproates are Depakote (divalproex sodium), Depakene/Stavzor (valproic acid), and whatever they call sodium valproate where you live.
First up, adding Lamictal to an existing drug for bipolar disorder6

 For Patients
TAKING a valproate
(Blue Starter Kit)
For Patients
Tegretol/Equetro (carbamazepine),
Dilantin (phenytoin), phenobarbital,
primidone, or a valproate
(Orange Starter Kit)
For Patients TAKING
Tegretol/Equetro (carbamazepine),
Dilantin (phenytoin), phenobarbital,
primidone and
NOT TAKING a valproate
(Green Starter Kit)
Weeks 1 and 225 mg every other day25 mg daily50 mg daily
Weeks 3 and 425 mg daily50 mg daily100 mg daily,
in divided doses
Week 550 mg daily100 mg daily200 mg daily,
in divided doses
Week 6100 mg daily200 mg daily300 mg daily,
in divided doses
Week 7100 mg daily200 mg dailyup to 400 mg daily,
in divided doses

Whether to cover their asses about doctors going rogue and starting their patients on Lamictal as monotherapy, or just out of incompetence, GSK left out estrogen-based birth control and rifampin (a TB med), from the list of drugs where you need to use the green starter pack7, the instructions in the packs, and the titration schedules. Estrogen-based birth control and rifampin are listed in the drug-drug interactions as affecting Lamictal enough to require dosage increases. Smoking may also speed up the clearance of Lamictal, but the data are still hazy on this one. The data are conflicting if taking 400mg a day or more of Topamax will also cause Lamictal to clear faster. It seems like each edition of the PI sheet has a new opinion as to if there may or may not be enough data to indicate a potential interaction with Topamax.

Let’s take a look at the titration schedule for adding Lamictal to another med for epilepsy. While GSK hasn’t changed the bipolar titration, they’ve certainly rationalized Lamictal’s titration schedule for epilepsy. Since 2010, perhaps earlier (but not before the 2006 edition of the PDR), it’s looked like this:

 For Patients
TAKING a valproate
(Blue Starter Kit)
For Patients
Tegretol/Equetro (carbamazepine),
Dilantin (phenytoin), phenobarbital,
primidone, or a valproate
(Orange Starter Kit)
For Patients TAKING
Tegretol/Equetro (carbamazepine),
Dilantin (phenytoin), phenobarbital,
primidone and
NOT TAKING a valproate
(Green Starter Kit)
Weeks 1 and 225 mg every other day25 mg daily50 mg daily
Weeks 3 and 425 mg daily50 mg daily100 mg daily
in two divided doses
Week 5 onwards
to maintenance
Increase by 25 to 50 mg/day
every 1 to 2 weeks
Increase by 50 mg/day
every 1 to 2 weeks
Increase by 100 mg/day
every 1 to 2 weeks
maintenance dose
100 to 200 mg/day
with valproate alone
100 to 400 mg/day
with valproate and other drugs
that induce glucuronidation
(in 1 or 2 divided doses)
225 to 375 mg/day
in two divided doses
300 to 500 mg/day
in two divided doses

That’s actually slower than for bipolar disorder, and the maintenance dosage is pretty broad, especially since Lamictal is rated for a maximum dosage of 500 mg if you’re not taking a drug that affects its metabolism. I totally agree with their schedule for epilepsy.

You’ll note there is no schedule for anyone taking both an enzyme-inducing AED and a valproate. Why? Do you realize how fucking crazy-making it is to figure that out? Especially since Tegretol and Depakote affect each other’s clearance as it is! And at its maximum dosage Lamictal may slow the clearance of Tegretol and can increase the clearance of Depakote enough to possibly make a difference in both efficacy and the pharmacokinetics of your cocktail. So if you were taking 800mg a day of Lamictal (which is not an uncommon dosage for someone who is epileptic and also taking Tegretol), 1,200mg a day of Tegretol and 1,500mg a day of Depakote the drug-drug interactions of taking just two of those drugs would normally make it look as if you were actually taking:
Lamictal + Tegretol ≈ 400 mg of Lamictal, 1,200 mg (perhaps more) of Tegretol
Lamictal + Depakote ≈ 1,600 mg of Lamictal, 1,800 mg of Depakote
Depakote + Tegretol ≈ 1,800 mg of Tegretol, 1,500 mg of Depakote
So taking all three = you’re going to have to get monthly blood levels for each med until the numbers are consistent, because my head nearly exploded when someone on that cocktail asked me what the dosage equivalents were. She may have been taking birth control as well. It wasn’t until 2009 that GSK addressed that issue (excluding the birth control), as far as you can see in the very last row of the column for taking Lamictal with a valproate: take 400 mg of Lamictal a day, divided into two 200 mg doses.

OK, so if you are taking Lamictal with another med and want to take only Lamictal, how do you go about doing that? According to GSK it depends on what you have. If you’re bipolar it’s fairly easy. Just discontinue whatever you’re taking per that med’s discontinuation instructions, even if it affects Lamictal’s clearance. If you need to adjust your dosage because of the med you were taking, then either increase your dosage by 50mg a day per week if you were taking a valproate, or decrease your dosage by 100mg a day per week if you were taking an enzyme-inducing med, until you reach the target dosage of 200mg a day.
I honestly doubt it’s that easy for everyone. You may want to get a prescription for 25mg of Lamictal in case you need to adjust your dosage of Lamictal as you discontinue the other med(s). You won’t know if you actually need to adjust the Lamictal dosage until you begin to discontinue the other med(s).

As for epilepsy, you and your doctor are going to have to work that one out yourselves. The maintenance dosage of Lamictal is too broad and, unlike bipolar disorder, the odds are a lot better for something to go wrong as you reduce the dosage of one of your other meds.

Living in the Material World

In reality most people who are prescribed Lamictal for bipolar disorder, especially bipolar 2, are probably going to take it as their first or second med. When they’re not stable. Which means they face weeks of being less stable than they were to start with.

This is where I don’t like the starter kits. Why? Because the kits are geared for people with bipolar 1, and Lamictal works best for bipolar 2. Plus, I hate target dosages when you don’t know what the correct dosage is going to be.

Here’s what I suggest you talk to your doctor about: If you’re taking Lamictal for bipolar 2 or depression you want to start at 25mg a day and increase the dosage following the titration schedule until your symptoms stop. Then get a prescription for whatever dosage you’re taking. Better yet, talk to your doctor about stopping at the dosage where your symptoms stop and have prescriptions already written for 25, 50, 100, and, if you’re taking an enzyme-inducing med, 200mg tablets. While Lamictal does work for some people at 25mg a day, even those who are not taking any other med, for most people with bipolar or unipolar depression, 50–100mg is the range where it will start to work.

If you are taking Lamictal for bipolar 1 and are getting hypomanic on the lower dosages, why isn’t your other medication working? You aren’t taking another medication? Then you shouldn’t be taking Lamictal by itself. There’s a reason why it’s not approved to start as monotherapy for bipolar 1.

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One thing PI sheets and doctors infrequently discuss, and don’t go into enough detail about, is how to discontinue a medication. With some meds it’s not too bad, but with others (most notably SNRIs like Effexor and Cymbalta) it can be a nightmare if not done carefully.

How to Stop Taking Lamictal (lamotrigine)

Manufacturer’s Recommendations

Here’s whatGlaxo-Smith Kline’s (GSK) says to do

Discontinuation Strategy:
Epilepsy: For patients receiving LAMICTAL in combination with other AEDs, a reevaluation of all AEDs in the regimen should be considered if a change in seizure control or an appearance or worsening of adverse reactions is observed. If a decision is made to discontinue therapy with LAMICTAL, a step-wise reduction of dose over at least 2 weeks (approximately 50% per week) is recommended unless safety concerns require a more rapid withdrawal [see Warnings and Precautions (5.9)].
Discontinuing carbamazepine, phenytoin, phenobarbital, primidone, or other drugs such as rifampin that induce lamotrigine glucuronidation should prolong the half-life of lamotrigine; discontinuing valproate should shorten the half-life of lamotrigine.

Bipolar Disorder: In the controlled clinical trials, there was no increase in the incidence, type, or severity of adverse reactions following abrupt termination of LAMICTAL. In clinical trials in patients with Bipolar Disorder, 2 patients experienced seizures shortly after abrupt withdrawal of LAMICTAL. However, there were confounding factors that may have contributed to the occurrence of seizures in these bipolar patients. Discontinuation of LAMICTAL should involve a step-wise reduction of dose over at least 2 weeks (approximately 50% per week) unless safety concerns require a more rapid withdrawal [see Warnings and Precautions (5.9)]. --the PI sheet

You know they actually give a damn, or at least want to cover their asses against the inevitable class action lawsuits, when they spell out a “discontinuation strategy.” More manufacturers need to follow GSK’s lead on this.

Crazymeds’ Suggestions

Our rule of thumb: decrease the dosage at the same rate you increased it. Otherwise as slowly as you can. 25–50mg a day every week until you’re down to 100mg a day, then 25mg a day per week. If you have to stop due to a really serious side effect, such as SJS (Stevens-Johnson Syndrome, a.k.a. The Rash or the Lamictal rash), then you and your doctor (or whoever is in the emergency room) will have to figure out a faster schedule.

This is where the starter kit has a huge advantage - you know exactly what your titration schedule was.

Discontinuation Symptoms

Due to its antidepressant effect, Lamictal may have a discontinuation syndrome, similar to that of SSRIs and SNRIs.

Like all AEDs, if you discontinue too rapidly you might start having seizures. Even if you’re not epileptic.

Notes, Tips, Helpful Hints, etc. for Withdrawing Lamictal (lamotrigine)

If you need to rapidly discontinue Lamictal your new best friend will be a benzodiazepine, preferably Klonopin (clonazepam) or Ativan (lorazepam), but good old Valium (diazepam) will work if nothing else is available. If you’re discontinuing because of a rash, your other new best friend will be Benadryl (diphenhydramine HCl).

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  1. Lamictal full US Prescribing Information
  2. Faught, Edward. “Topiramate in the treatment of partial and generalized epilepsy.” Neuropsychiatric disease and treatment 3.6 (2007): 811-821.

How Long & How Likely To Work, Comparisons with Other Meds | Lamictal Index | Pros & Cons, Interesting Stuff Your Doctor Didn’t Tell You

1 And everyone has the time to do their jobs properly, when said time isn't being wasted by idiots asking for grocery store phone numbers** or they aren't playing Angry Farmers on the Faecesbooks.

2 Although not everyone has the luxury of stopping at a dosage when the symptoms abate and not increasing it unless the return. Sometimes you just have to keep going up until you reach that target dosage. E.g. you have a history of seizures that haven't yet responded to several medications.

3 Most notably Dr. Edward Faught, founder and Director of the Epilepsy Center, and vice chairman of the Department of Neurology, at the University of Alabama School of Medicine in Birmingham. His article on new antiepileptic drugs in Volume 7 issue 1 of Peer Review in Review stressed starting at low dosages, doing a slow titration, and stopping at the dosage where symptoms were under control. In Topiramate in the treatment of partial and generalized epilepsy, the one free, full-text article I could find (that's not about geriatric patients), he again stresses the low and slow approach to avoid or lessen most side effects, while still achieving seizure control in the same amount of time.

4 Assuming you have the luxury of a job, being able to cope with your symptoms not being dealt with for however many days you need to wait in order to do this, and/or someone who can and is willing to stay with you for a few days. Read enough of this site and you can tell what sort of fantasy world I live in.

5 Some meaning only those for adults. As I keep writing, Crazymeds is primarily a site for adults.

6 Because there's no way a reputable drug company like GSK is going to give your doctor the means to prescribe Lamictal off-label by starting you on Lamictal when you're not taking any other medication for bipolar disorder or epilepsy. That would be illegal, and GSK could be fined the equivalent of a couple days', or even one or two weeks' worth of profits.

7 That was the case the last time I had access to a bunch of starter packs.

**DrugMonkey, Master of Pharmacy, answers the question “Why your prescription takes so damn long to fill”

If you have any questions not answered here, please see the Crazymeds Lamictal discussion board. We welcome criticisms of the articles, notifications of bad links, site problems, consumer experiences with medications, etc. I’m not always able to write back. Hence I never answer questions about meds via e-mail that are answered by this or other articles. Especially if they have been repeatedly asked on the forum. That’s why we write these damn things. Questions about which meds are best for your condition should also be asked on the forum; because this is a free site, so the price of admission is making things easier for somebody else searching for the same answer. We don’t deal with children on the forum or in private because after doing this for ten years I don’t have the emotional stamina to deal with kids who have brain cooties. How to contact Crazymeds. — Jerod Poore, CME, Publisher Crazymeds (crazymeds.us)

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1 While there are plenty of books to help you with hypochondria, for some reason there’s not much in the way of websites. Then again, staying off of the Internet is a large part of curing/managing the disorder.

2 Remember kids, Microsloth operating systems are like TOS Star Trek movies with in that every other one sucks way, way more. With TOS Star Trek movies you don’t want to bother watching the odd-numbered ones. With Microsloth OS you don’t want to buy and install the even-numbered ones. Anyone who remembers ME and Vista knows what I mean.

3 Have I mentioned how open source operating systems for commercial applications is one of the dumbest ideas in the history of dumb ideas?* I don’t even need my big-ass rant any more. Heartbleed has made my case for me. And that’s just the one that got all the media attention. The very nature of an open source operating system makes security as much of an illusion as anonymity on teh Intergoogles. Before you flip out too much: the domain Crazymeds is hosted on uses a version of SSL that is not affected by the Heartbleed bug. That’s one of the many reasons why I pay a lot of money and keep this site on Lunarpages.

* Yes, I know I’m using open source browsers. I also test the site using the now-defunct IE and Safari browsers. Their popularity - and superiority - killed IE and Safari, so that’s why I rely on the open source browsers. It’s like brand vs. generic meds. Sometimes the generic is better than the brand.

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