Lamictal Dosage/Direction for Use

LAMICTAL tablets should be swallowed whole, and should not be chewed or crushed.
LAMICTAL dispersible/chewable tablets may be chewed, dispersed in a small volume of water (at least enough to cover the whole tablet) or swallowed whole with a little water.
If the calculated dose of LAMICTAL (for example for treatment of children with epilepsy or patients with hepatic impairment) does not equate to whole tablets, the dose to be administered is that equal to the lower number of whole tablets.
Restarting Therapy: Prescribers should assess the need for escalation to maintenance dose when restarting LAMICTAL in patients who have discontinued LAMICTAL for any reason, since the risk of serious rash is associated with high initial doses and exceeding the recommended dose escalation for LAMICTAL (see Precautions). The greater the interval of time since the previous dose, the more consideration should be given to escalation to the maintenance dose. When the interval since discontinuing LAMICTAL exceeds five half-lives (see Pharmacology: Pharmacokinetics under Actions), LAMICTAL should generally be escalated to the maintenance dose according to the appropriate schedule.
It is recommended that LAMICTAL not be restarted in patients who have discontinued due to rash associated with prior treatment with LAMICTAL unless the potential benefit clearly outweighs the risk.
EPILEPSY: The recommended dose escalation and maintenance doses for adults and adolescents aged 13 years and above (Table 2) and for children and adolescents aged 2 to 12 years (Table 3) are given as follows. Because of a risk of rash the initial dose and subsequent dose escalation should not be exceeded (see Precautions).
When concomitant AEDs are withdrawn or other AEDs/medicinal products are added on to treatment regimes containing lamotrigine, consideration should be given to the effect this may have on lamotrigine pharmacokinetics (see Interactions). (See Tables 2 and 3.)

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To ensure a therapeutic dose is maintained the weight of a child must be monitored and the dose reviewed as weight changes occur. It is likely that patients aged two to six years will require a maintenance dose at the higher end of the recommended range.
If epileptic control is achieved with adjunctive treatment, concomitant AEDs may be withdrawn and patients continued on LAMICTAL monotherapy.
Children below 2 years: There are limited data on the efficacy and safety of lamotrigine for adjunctive therapy of partial seizures in children aged 1 month to 2 years (see Precautions). There are no data in children below 1 month of age. Thus LAMICTAL is not recommended for use in children below 2 years of age. If, based on clinical need, a decision to treat is nevertheless taken, see Precautions and Pharmacology: Pharmacodynamics and Pharmacokinetics under Actions.
BIPOLAR DISORDER: The recommended dose escalation and maintenance doses for adults of 18 years of age and above are given in the tables as follows. The transition regimen involves escalating the dose of LAMICTAL to a maintenance stabilisation dose over six weeks (see Table 4) after which other psychotropic medicinal products and/or AEDs can be withdrawn, if clinically indicated (see Table 5). The dose adjustments following addition of other psychotropic medicinal products and/or AEDs are also provided as follows (Table 6). Because of the risk of rash the initial dose and subsequent dose escalation should not be exceeded (see Precautions). (See Table 4.)

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Once the target daily maintenance stabilisation dose has been achieved, other medicinal products may be withdrawn as shown as follows: See Table 5.

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There is no clinical experience in adjusting the lamotrigine daily dose following the addition of other medicinal products. However, based on interaction studies with other medicinal products, the following recommendations can be made: See Table 6.

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Discontinuation Of LAMICTAL In Patients With Bipolar Disorder: In clinical trials, there was no increase in the incidence, severity or type of adverse reactions following abrupt termination of LAMICTAL versus placebo. Therefore, patients may terminate LAMICTAL without a step-wise reduction of dose.
Children and adolescents below 18 years: LAMICTAL is not recommended for use in children below 18 years of age because a randomised withdrawal study demonstrated no significant efficacy and showed increased reporting of suicidality (see Precautions and Pharmacology: Pharmacodynamics under Actions).
General dosing recommendations for LAMICTAL in special patient populations: Women taking hormonal contraceptives: The use of an ethinyloestradiol/levonorgestrel (30 μg/150 μg) combination increases the clearance of lamotrigine by approximately two-fold, resulting in decreased lamotrigine levels. Following titration, higher maintenance doses of lamotrigine (by as much as two-fold) may be needed to attain a maximal therapeutic response. During the pill-free week, a two-fold increase in lamotrigine levels has been observed. Dose-related adverse events cannot be excluded.
Therefore, consideration should be given to using contraception without a pill-free week, as first-line therapy (for example, continuous hormonal contraceptives or non-hormonal methods; see Precautions and Interactions).
Starting hormonal contraceptives in patients already taking maintenance doses of LAMICTAL and NOT taking inducers of lamotrigine glucuronidation: The maintenance dose of LAMICTAL will in most cases need to be increased by as much as two-fold (see Precautions and Interactions). It is recommended that from the time that the hormonal contraceptive is started, the lamotrigine dose is increased by 50 to 100 mg/day every week, according to the individual clinical response. Dose increases should not exceed this rate, unless the clinical response supports larger increases. Measurement of serum lamotrigine concentrations before and after starting hormonal contraceptives may be considered, as confirmation that the baseline concentration of lamotrigine is being maintained. If necessary, the dose should be adapted. In women taking a hormonal contraceptive that includes one week of inactive treatment ("pill-free week"), serum lamotrigine level monitoring should be conducted during week 3 of active treatment, i.e. on days 15 to 21 of the pill cycle. Therefore, consideration should be given to using contraception without a pill-free week, as first-line therapy (for example, continuous hormonal contraceptives or non-hormonal methods; see Precautions and Interactions).
Stopping hormonal contraceptives in patients already taking maintenance doses of LAMICTAL and NOT taking inducers of lamotrigine glucuronidation: The maintenance dose of LAMICTAL will in most cases need to be decreased by as much as 50% (see Precautions and Interactions). It is recommended to gradually decrease the daily dose of lamotrigine by 50 to 100 mg each week (at a rate not exceeding 25% of the total daily dose per week) over a period of 3 weeks, unless the clinical response indicates otherwise. Measurement of serum lamotrigine concentrations before and after stopping hormonal contraceptives may be considered, as confirmation that the baseline concentration of lamotrigine is being maintained. In women who wish to stop taking a hormonal contraceptive that includes one week of inactive treatment ("pill-free week"), serum lamotrigine level monitoring should be conducted during week 3 of active treatment, i.e. on days 15 to 21 of the pill cycle. Samples for assessment of lamotrigine levels after permanently stopping the contraceptive pill should not be collected during first week after stopping the pill.
Starting LAMICTAL in patients already taking hormonal contraceptives: Dose escalation should follow the normal dose recommendation described in the tables.
Starting and stopping hormonal contraceptives in patients already taking maintenance doses of LAMICTAL and TAKING inducers of lamotrigine glucuronidation: Adjustment to the recommended maintenance dose of lamotrigine may not be required.
Use with atazanavir/ritonavir: No adjustments to the recommended dose escalation of LAMICTAL should be necessary when LAMICTAL is added to the existing atazanavir/ritonavir therapy.
In patients already taking maintenance doses of lamotrigine and not taking glucuronidation inducers, the lamotrigine dose may need to be increased if atazanavir/ritonavir is added, or decreased if atazanavir/ritonavir is discontinued. Plasma lamotrigine monitoring should be conducted before and during 2 weeks after starting or stopping atazanavir/ritonavir, in order to see if LAMICTAL dose adjustment is needed (see Interactions).
Use with lopinavir/ritonavir: No adjustments to the recommended dose escalation of LAMICTAL should be necessary when LAMICTAL is added to the existing lopinavir/ritonavir therapy.
In patients already taking maintenance doses of lamotrigine and not taking glucuronidation inducers, the lamotrigine dose may need to be increased if lopinavir/ritonavir is added, or decreased if lopinavir/ritonavir is discontinued. Plasma lamotrigine monitoring should be conducted before and during 2 weeks after starting or stopping lopinavir/ritonavir, in order to see if LAMICTAL dose adjustment is needed (see Interactions).
Elderly (over 65 years): No dosage adjustment from the recommended schedule is required. The pharmacokinetics of LAMICTAL in this age group do not differ significantly from a non-elderly adult population (see Pharmacology: Pharmacokinetics under Actions).
Renal impairment: Caution should be exercised when administering LAMICTAL to patients with renal failure. For patients with end-stage renal failure, initial doses of LAMICTAL should be based on patients' concomitant medicinal products; reduced maintenance doses may be effective for patients with significant renal functional impairment (see Precautions and Pharmacology: Pharmacokinetics under Actions).
Hepatic impairment: Initial, escalation and maintenance doses should generally be reduced by approximately 50% in patients with moderate (Child-Pugh grade B) and 75% in severe (Child-Pugh grade C) hepatic impairment. Escalation and maintenance doses should be adjusted according to clinical response (see Pharmacology: Pharmacokinetics under Actions).