Lamictal & High Doses
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Q:  Lamictal & High Doses

Dr. Phelps,

I saw a question that someone had for you about BP and Lamictal-- it addressed Lamictal at about 100mg or so if I remember.

When I got pregnant I was on 800mg a day.  My pdoc wanted me to stay at that dose, but I couldnt' keep the meds down.  I am down to 400mg a day now, but I am still REALLY concerned about that dose.  All the websites I have looked at about Lamictal being safe are only rated at most at 200mg. 

Have you seen ANY research on Lamcital and that high of a dose? I saw another post here a few minutes ago where you recommeded the person only have up to 400.  

Anyway, if you know of ANYONE who would know the complications of such a high dose, please let me know. 

THank you

Dear Ms. J' -- 
In the product information for lamotrigine (the long document the manufacturer is required by the FDA to make available, which the pharmacist will usually give you along with the medication; here's an online version for
lamotrigine), it states that doses up to 700 have been used in epilepsy (page 44 on the scroll bar) and that for bipolar disorder, doses up to 400 mg were tested but not shown to be superior to 200 mg.  

That's probably where the numbers come from that you mention above.  I have not gone above 400 mg but in a few cases, and there only to 500, but I hear from other doctors who've gone higher, 800 in one case (and now yours as well). For people who are also taking carbamazepine (Tegretol, Carbatrol, Equetro), it would be common to use these much higher doses because that medication can lower lamotrigine levels by roughly half.  

There is a blood test for lamotrigine that would allow you to get a measure of how much you're actually absorbing and hanging on to, but we don't get those very often because this is not a medication which requires tight management of dose and level (compared to lithium for example). However, you can use that test to see if you're way above common levels.  On the other hand, at this point we still dial the lamotrigine dose to that which is required to get good symptom control, as long as the patient is not having side effects from it, up to at least 400 if necessary.  Going up to 700 would be reasonable based on the manufacturer's information, and we commonly go a bit higher with other medications because the manufacturer generally does not do a lot of testing to define an "upper limit" we should go by.  

From the product information (the document linked above), I think you can assume that there are quite a few patients with epilepsy who have had doses in the 400-700 mg range, and that we would therefore have at least some basis for being able to detect problems with lamotrigine used long term in that range. Our system is certainly not perfect for detecting long-term risks of medications like this, but at least you can know that there are people out there ahead of you who'd been taking doses like this for years. If there's going to be a major problem, we'd probably be able to detect it before you got there. Not a great way of determining risk, I grant you. As far as I know, there is not another way of determining risk, so I can't refer you to another source (any one person can easily have a wrong impression, either positive or negative, based on their own experience; what we need are large groups and years of experience with higher doses. I suppose you could try to find a neurologist who's used those kinds of doses for years and confirm with her/him that there have been no lasting or severe consequences of using those amounts. As you can see, I hope that information, as much as we can gather, is an antidote of sorts to the understandable anxiety of having to take medications like this.  

Dr. Phelps

Published September, 2005


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