Lamictal

Lamotrigine.

Excipients/Inactive Ingredients: Tablets: Lactose, Microcrystalline cellulose, Povidone, Sodium starch glycolate, Iron oxide yellow (E172), Magnesium stearate.
Dispersible Tablets: Calcium carbonate, Low substituted hydroxypropyl cellulose, Aluminium magnesium silicate, Sodium starch glycolate, Povidone, Saccharin sodium, Blackcurrant flavour, Magnesium stearate.

ATC Code: N03AX09.
Pharmacology: Pharmacodynamics: Mechanism of Action: The results of pharmacological studies suggest that lamotrigine is a use-dependent blocker of voltage-gated sodium channels. It produces a use- and voltage-dependent block of sustained repetitive firing in cultured neurones and inhibits pathological release of glutamate (the amino acid which plays a key role in the generation of epileptic seizures), as well as inhibiting glutamate-evoked bursts of action potentials.
Pharmacodynamic Effects: Cardiac Electrophysiology: Effect of Lamotrigine: In vitro studies show that lamotrigine exhibits Class IB antiarrhythmic activity at therapeutically relevant concentrations. It inhibits human cardiac sodium channels with rapid onset and offset kinetics and strong voltage dependence, consistent with other Class IB antiarrhythmic agents. At therapeutic doses, LAMICTAL did not slow ventricular conduction (widen QRS) in healthy individuals in a thorough QT study; however, in patients with clinically important structural or functional heart disease (ie., patients with heart failure, valvular heart disease, congenital heart disease, conduction system disease, ventricular arrhythmias, cardiac channelopathies [eg., Brugada syndrome], clinically important ischemic heart disease, or multiple risk factors for coronary artery disease), LAMICTAL could slow ventricular conduction (widen QRS) and induce proarrhythmia, which can lead to sudden death. Elevated heart rates could also increase the risk of ventricular conduction slowing with LAMICTAL.
In tests designed to evaluate the central nervous system effects of drugs, the results obtained using doses of 240 mg lamotrigine administered to healthy volunteers did not differ from placebo, whereas both 1000 mg phenytoin and 10 mg diazepam each significantly impaired fine visual motor coordination and eye movements, increased body sway and produced subjective sedative effects.
In another study, single oral doses of 600 mg carbamazepine significantly impaired fine visual motor coordination and eye movements, while increasing both body sway and heart rate, whereas results with lamotrigine at doses of 150 mg and 300 mg did not differ from placebo.
Clinical Studies: Clinical efficacy in the prevention of depressive episodes in patients with bipolar disorder: Adults (18 years of age and over): Two pivotal studies have demonstrated efficacy in the prevention of depressive episodes in patients with bipolar I disorder.
Clinical study SCAB20003 was a multicentre, double-blind, double dummy, placebo and lithium-controlled, randomised fixed dose evaluation of the long-term prevention of relapse and recurrence of depression and/or mania in patients with bipolar I disorder who had recently or were currently experiencing a major depressive episode. Once stabilised using LAMICTAL monotherapy or LAMICTAL plus psychotropic medication, patients were randomly assigned into one of five treatment groups: LAMICTAL (50, 200, 400 mg/day), lithium (serum levels of 0.8 to 1.1 mMol/L) or placebo for a maximum of 76 weeks (18 months). Treatment regimens were maintained until an emerging mood episode (depressive or manic) deemed it necessary to intervene with additional pharmacotherapy or electroconvulsive therapy (ECT).
The primary endpoint was "Time to Intervention for a Mood Episode (TIME)," where the interventions were either additional pharmacotherapy or ECT. This endpoint was analysed using three methods of handling data from patients who were withdrawn prior to having an intervention. The p-values for these analyses ranged from 0.003 to 0.029. In supportive analyses of time to first depressive episode and time to first manic/hypomanic or mixed episode, the LAMICTAL patients had longer times to first depressive episode than placebo patients (p=0.047), and the treatment difference with respect to time to manic/hypomanic or mixed episodes was not statistically significant.
Clinical study SCAB2006 was a multicentre, double-blind, double dummy, placebo and lithium-controlled, randomised, flexible dose evaluation of LAMICTAL in the long-term prevention of relapse and recurrence of mania and/or depression in patients with bipolar I disorder who had recently or were currently experiencing a manic or hypomanic episode. Once stabilised using LAMICTAL monotherapy or LAMICTAL plus psychotropic medication, patients were randomly assigned into one of three treatment groups: LAMICTAL (100 to 400 mg/day), lithium (serum levels of 0.8 to 1.1 mMol/L) or placebo for a maximum of 76 weeks (18 months). Treatment regimens were maintained until an emerging mood episode (depressive or manic) deemed it necessary to intervene with additional pharmacotherapy or electroconvulsive therapy (ECT).
The primary endpoint was "Time to Intervention for a Mood Episode (TIME)," where the interventions were either additional pharmacotherapy or ECT. This endpoint was analysed using three methods of handling data from patients who were withdrawn prior to having an intervention. The p-values for these analyses ranged from 0.003 to 0.023. In supportive analyses of time to first depressive episode and time to first manic/hypomanic or mixed episode, the LAMICTAL patients had longer times to first depressive episode than placebo patients (p=0.015), and the treatment difference with respect to time to manic/hypomanic or mixed episodes was not statistically significant.
In clinical trials, propensity to induce destabilisation, mania or hypomania whilst on LAMICTAL therapy was not significantly different to placebo.
Pharmacokinetics: Absorption: Lamotrigine is rapidly and completely absorbed from the gut with no significant first pass metabolism. Peak plasma concentrations occur approximately 2.5 hours after oral drug administration. Time to maximum concentration is slightly delayed after food but the extent of absorption is unaffected. The pharmacokinetics are linear up to 450 mg, the highest single dose tested. There is considerable inter-individual variation in steady state maximum concentrations but within an individual concentrations rarely vary.
Distribution: Binding to plasma proteins is about 55%; it is very unlikely that displacement from plasma proteins would result in toxicity.
The volume of distribution is 0.92 to 1.22 L/kg.
Metabolism: UDP-glucuronyl transferases have been identified as the enzymes responsible for metabolism of lamotrigine.
Lamotrigine induces its own metabolism to a modest extent depending on dose. However, there is no evidence that lamotrigine affects the pharmacokinetics of other AEDs and data suggest that interactions between lamotrigine and drugs metabolised by cytochrome P₄₅₀ enzymes are unlikely to occur.
Elimination: The mean steady state clearance in healthy adults is 39 ± 14 mL/min. Clearance of lamotrigine is primarily metabolic with subsequent elimination of glucuronide-conjugated material in urine. Less than 10% is excreted unchanged in the urine. Only about 2% of drug-related material is excreted in faeces. Clearance and half-life are independent of dose. The mean elimination half-life in healthy adults is 24 to 35 hours. In a study of subjects with Gilbert's Syndrome, mean apparent clearance was reduced by 32% compared with normal controls but the values are within the range for the general population.
The half-life of lamotrigine is greatly affected by concomitant medication. Mean half-life is reduced to approximately 14 hours when given with glucuronidation-inducing drugs such as carbamazepine and phenytoin and is increased to a mean of approximately 70 hours when co-administered with valproate alone (see Dosage & Administration and Interactions).
Special Patient Populations: Children: Clearance adjusted for body weight is higher in children than in adults with the highest values in children under five years. The half-life of lamotrigine is generally shorter in children than in adults with a mean value of approximately 7 hours when given with enzyme-inducing drugs such as carbamazepine and phenytoin and increasing to mean values of 45 to 50 hours when co-administered with valproate alone. (see Dosage & Administration).
Elderly: Results of a population pharmacokinetic analysis including both young and elderly patients with epilepsy, enrolled in the same trials, indicated that the clearance of lamotrigine did not change to a clinically relevant extent. After single doses apparent clearance decreased by 12% from 35 mL/min at age 20 to 31 mL/min at 70 years. The decrease after 48 weeks of treatment was 10% from 41 to 37 mL/min between the young and elderly groups. In addition, pharmacokinetics of lamotrigine was studied in 12 healthy elderly subjects following a 150 mg single dose. The mean clearance in the elderly (0.39 mL/min/kg) lies within the range of the mean clearance values (0.31 to 0.65 mL/min/kg) obtained in 9 studies with non-elderly adults after single doses of 30 to 450 mg.
Patients with renal impairment: Twelve volunteers with chronic renal failure, and another 6 individuals undergoing haemodialysis were each given a single 100 mg dose of lamotrigine. Mean CL/F were 0.42 mL/min/kg (chronic renal failure), 0.33 mL/min/kg (between haemodialysis), and 1.57 mL/min/kg (during haemodialysis) compared to 0.58 mL/min/kg in healthy volunteers. Mean plasma half-lives were 42.9 hours (chronic renal failure), 57.4 hours (between haemodialysis) and 13.0 hours (during haemodialysis), compared to 26.2 hours in healthy volunteers. On average, approximately 20% (range = 5.6 to 35.1) of the amount of lamotrigine present in the body was eliminated during a 4 hours haemodialysis session. For this patient population, initial doses of LAMICTAL should be based on patients' AED regimen; reduced maintenance doses may be effective for patients with significant renal functional impairment.
Patients with hepatic impairment: A single-dose pharmacokinetic study was performed in 24 subjects with various degrees of hepatic impairment and 12 healthy subjects as controls. The median apparent clearance of lamotrigine was 0.31, 0.24 or 0.10 mL/min/kg in patients with Grade A, B, or C (Child-Pugh Classification) hepatic impairment, respectively, compared to 0.34 mL/min/kg in the healthy controls. Initial, escalation, and maintenance doses should generally be reduced by approximately 50% in patients with moderate (Child-Pugh Grade B) and 75% in patients with severe (Child-Pugh Grade C) hepatic impairment. Escalation and maintenance doses should be adjusted according to clinical response.
Toxicology: Non-Clinical Information: Reproductive toxicology studies with lamotrigine in animals at doses in excess of the human dose of 400 mg/day [on a body surface area (mg/m²) basis] showed developmental toxicity (increased mortality, decreased body weight, increased structural variations, neurobehavioral abnormalities), but no teratogenic effects. However, as lamotrigine is a weak inhibitor of dihydrofolate reductase, there is a theoretical risk of human foetal malformations when the mother is treated with a folate inhibitor during pregnancy.
The results of a wide range of mutagenicity tests indicate that lamotrigine does not present a genetic risk to man.
Lamotrigine was not carcinogenic in long-term studies in the rat and the mouse.

EPILEPSY: Adults and Adolescents: LAMICTAL is indicated for use as adjunctive or monotherapy in the treatment of epilepsy, for partial seizures and generalised seizures, including tonic-clonic seizures and the seizures associated with Lennox-Gastaut Syndrome.
Children (2 to 12 years of age): LAMICTAL is indicated as adjunctive therapy in the treatment of epilepsy, for partial seizures and generalised seizures including tonic-clonic seizures and the seizures associated with Lennox-Gastaut syndrome (above 3 years of age only).
Initial monotherapy treatment in newly diagnosed paediatric patients is not recommended.
After epileptic control has been achieved during adjunctive therapy, concomitant anti-epileptic drugs (AEDs) may be withdrawn and patients continued on LAMICTAL monotherapy.
If LAMICTAL 2 mg Chewable Dispersible Tablet is not available and the calculated dose in children is less than 2.5 mg daily, then LAMICTAL cannot be used. DO NOT attempt to administer partial quantities of the dispersible tablets.
BIPOLAR DISORDER: Adults (18 years of age and over): LAMICTAL is indicated for the prevention of mood episodes in patients with bipolar disorder, predominantly by preventing depressive episodes.

LAMICTAL tablets should be swallowed whole, and should not be chewed or crushed.
LAMICTAL dispersible tablets may be dispersed in a small volume of water (at least enough to cover the whole tablet) or swallowed whole with a little water. DO NOT attempt to administer partial quantities of the dispersible tablets.
If a calculated dose of LAMICTAL, e.g. for use in children (epilepsy only) or patients with hepatic impairment, cannot be divided into multiple lower strength tablets, the dose to be administered is that equal to the nearest lower strength 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: When concomitant anti-epileptic drugs are withdrawn to achieve LAMICTAL monotherapy or other AEDs are added on to treatment regimes containing lamotrigine, consideration should be given to the effect this may have on lamotrigine pharmacokinetics (see Interactions).
Dosage in Epilepsy Monotherapy: Adults and Adolescents (over 16 years of age) (see Table 1): The initial LAMICTAL dose in monotherapy is 25 mg once a day for two weeks, followed by 50 mg once a day for two weeks. Thereafter, the dose should be increased by a maximum of 50 to 100 mg every one to two weeks until the optimal response is achieved. The usual maintenance dose to achieve optimal response is 100 to 200 mg/day given once a day or as two divided doses. Some patients have required 500 mg/day of LAMICTAL to achieve the desired response.
Because of a risk of rash the initial dose and subsequent dose escalation should not be exceeded (see Precautions).
Dosage in Epilepsy Add-On Therapy: Adults and Adolescents (over 12 years of age) (see Table 1): In patients taking valproate with/without any other AED, the initial LAMICTAL dose is 25 mg every alternate day for two weeks, followed by 25 mg once a day for two weeks.
Thereafter, the dose should be increased by a maximum of 25 to 50 mg every one to two weeks until the optimal response is achieved. The usual maintenance dose to achieve optimal response is 100 to 200 mg/day given once a day or in two divided doses.
In those patients taking concomitant AEDs or other medications (see Interactions) that induce lamotrigine glucuronidation with/without other AEDs (except valproate), the initial LAMICTAL dose is 50 mg once a day for two weeks, followed by 100 mg/day given in two divided doses for two weeks.
Thereafter, the dose should be increased by a maximum of 100 mg every one to two weeks until the optimal response is achieved. The usual maintenance dose to achieve optimal response is 200 to 400 mg/day given in two divided doses.
Some patients have required 700 mg/day of LAMICTAL to achieve the desired response.
In those patients taking other medications that do not significantly inhibit or induce lamotrigine glucuronidation (see Interactions), the initial LAMICTAL dose is 25 mg once a day for two weeks, followed by 50 mg once a day for two weeks. Thereafter, the dose should be increased by a maximum of 50 to 100 mg every one to two weeks until the optimal response is achieved. The usual maintenance dose to achieve an optimal response is 100 to 200 mg/day given once a day or as two divided doses. (See Table 1.)

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Because of a risk of rash the initial dose and subsequent dose escalation should not be exceeded (see Precautions).
Children (2 to 12 years of age) (see Table 2): In patients taking valproate with/without any other AED, the initial LAMICTAL dose is 0.15 mg/kg bodyweight/day given once a day for two weeks, followed by 0.3 mg/kg/day once a day for two weeks. Thereafter, the dose should be increased by a maximum of 0.3 mg/kg every one to two weeks until the optimal response is achieved. The usual maintenance dose to achieve optimal response is 1 to 5 mg/kg/day given once a day or in two divided doses, with a maximum of 200 mg/day.
In those patients taking concomitant AEDs or other medications (see Interactions) that induce lamotrigine glucuronidation with/without other AEDs (except valproate), the initial LAMICTAL dose is 0.6 mg/kg bodyweight/day given in two divided doses for two weeks, followed by 1.2 mg/kg/day given in two divided doses for two weeks. Thereafter, the dose should be increased by a maximum of 1.2 mg/kg every one to two weeks until the optimal response is achieved. The usual maintenance dose to achieve optimal response is 5 to 15 mg/kg/day given in two divided doses, with a maximum of 400 mg/day.
In patients taking other medications that do not significantly inhibit or induce lamotrigine glucuronidation (see Interactions), the initial LAMICTAL dose is 0.3 mg/kg bodyweight/day given once a day or in two divided doses for two weeks, followed by 0.6 mg/kg/day given once a day or in two divided doses for two weeks. Thereafter, the dose should be increased by a maximum of 0.6 mg/kg every one to two weeks until the optimal response is achieved. The usual maintenance dose to achieve optimal response is 1 to 10 mg/kg/day given once a day or in two divided doses, with a maximum of 200 mg/day.
To ensure a therapeutic dose is maintained the weight of a child must be monitored and the dose reviewed as weight changes occur. (See Table 2.)

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Because of a risk of rash the initial dose and subsequent dose escalation should not be exceeded (see Precautions).
It is likely that patients aged two to six years will require a maintenance dose at the higher end of the recommended range.
Children aged less than 2 years: There is insufficient information on the use of LAMICTAL in children aged less than two years.
BIPOLAR DISORDER: Adults (18 years of age and over): Because of the risk of rash, the initial dose and subsequent dose escalation should not be exceeded (see Precautions).
LAMICTAL is recommended for use in bipolar patients at risk for a future depressive episode.
The following transition regimen should be followed to prevent recurrence of depressive episodes. The transition regimen involves escalating the dose of LAMICTAL to a maintenance stabilisation dose over six weeks (see Table 3) after which other psychotropic and/or anti-epileptic drugs can be withdrawn, if clinically indicated (see Table 4).
Adjunctive therapy should be considered for the prevention of manic episodes, as efficacy with LAMICTAL in mania has not been conclusively established. (See Table 3.)

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a) Adjunct therapy with inhibitors of lamotrigine glucuronidation e.g. Valproate: In patients taking glucuronidation inhibiting concomitant drugs such as valproate, the initial LAMICTAL dose is 25 mg every alternate day for two weeks, followed by 25 mg once a day for two weeks. The dose should be increased to 50 mg once a day (or in two divided doses) in week 5. The usual target dose to achieve optimal response is 100 mg/day given once a day or in two divided doses. However, the dose can be increased to a maximum daily dose of 200 mg, depending on clinical response.
b) Adjunct therapy with inducers of lamotrigine glucuronidation in patients NOT taking inhibitors such as Valproate. This dosage regimen should be used with phenytoin, carbamazepine, phenobarbitone, primidone and other drugs known to induce lamotrigine glucuronidation (see Interactions): In those patients currently taking drugs that induce lamotrigine glucuronidation and NOT taking valproate, the initial LAMICTAL dose is 50 mg once a day for two weeks, followed by 100 mg/day given in two divided doses for two weeks. The dose should be increased to 200 mg/day given as two divided doses in week 5. The dose may be increased in week 6 to 300 mg/day however, the usual target dose to achieve optimal response is 400 mg/day given in two divided doses which may be given from week 7.
c) Monotherapy with LAMICTAL OR adjunctive therapy in patients taking other medications that do not significantly induce or inhibit lamotrigine glucuronidation (see Interactions): The initial LAMICTAL dose is 25 mg once a day for two weeks, followed by 50 mg once a day (or in two divided doses) for two weeks. The dose should be increased to 100 mg/day in week 5. The usual target dose to achieve optimal response is 200 mg/day given once a day or as two divided doses. However, a range of 100 to 400 mg was used in clinical trials.
Once the target daily maintenance stabilisation dose has been achieved, other psychotropic medications may be withdrawn as laid out in the dosage schedule as follows (see Table 4).

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(a) Following withdrawal of adjunct therapy with inhibitors of lamotrigine glucuronidation e.g. valproate: The dose of LAMICTAL should be increased to double the original target stabilisation dose and maintained at this, once valproate has been terminated.
(b) Following withdrawal of adjunct therapy with inducers of lamotrigine glucuronidation depending on original maintenance dose. This regimen should be used with phenytoin, carbamazepine, phenobarbitone, primidone or other drugs known to induce LAMICTAL glucuronidation (see Interactions): The dose of LAMICTAL should be gradually reduced over three weeks as the glucuronidation inducer is withdrawn.
(c) Following withdrawal of adjunct therapy with other medications that do not significantly inhibit or induce lamotrigine glucuronidation (see Interactions): The target dose achieved in the dose escalation programme should be maintained throughout withdrawal of the other medication.
Adjustment of LAMICTAL daily dosing in patients with BIPOLAR DISORDER following addition of other medications: There is no clinical experience in adjusting the LAMICTAL daily dose following the addition of other medications. However, based on drug interaction studies, the following recommendations can be made (see Table 5 as follows):

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Discontinuation of LAMICTAL in adult patients with Bipolar Disorder: In clinical trials, there was no increase in the incidence, severity or type of adverse experiences following abrupt termination of LAMICTAL versus placebo. Therefore, patients may terminate LAMICTAL without a step-wise reduction of dose.
Children and adolescents (less than 18 years of age): LAMICTAL is not indicated for use in bipolar disorder in children and adolescents aged less than 18 years (see Precautions). Safety and efficacy of LAMICTAL in bipolar disorder has not been established in this age group. Therefore, a dosage recommendation cannot be made.
General Dosing Recommendations For Lamictal In Special Patient Populations: Women taking hormonal contraceptives: (a) Starting LAMICTAL in patients already taking hormonal contraceptives: Although an oral contraceptive has been shown to increase the clearance of lamotrigine (see Precautions and Interactions), no adjustments to the recommended dose escalation guidelines for LAMICTAL should be necessary solely based on the use of hormonal contraceptives. Dose escalation should follow the recommended guidelines based on whether lamotrigine is added to valproate (an inhibitor of lamotrigine glucuronidation), or to an inducer of lamotrigine glucuronidation, or whether LAMICTAL is added in the absence of valproate or an inducer of lamotrigine glucuronidation (see Table 1 for epilepsy and Table 3 for bipolar disorder patients).
(b) 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.
(c) 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.
Use with atazanavir/ritonavir: Although atazanavir/ritonavir has been shown to reduce lamotrigine plasma concentrations (see Interactions), no adjustments to the recommended dose escalation guidelines for LAMICTAL should be necessary solely based on the use of atazanvir/ritonavir. Dose escalation should follow the recommended guidelines based on whether LAMICTAL is added to valproate (an inhibitor of lamotrigine glucuronidation), or to an inducer of lamotrigine glucuronidation, or whether LAMICTAL is added in the absence of valproate or an inducer of lamotrigine glucuronidation.
In patients already taking maintenance doses of LAMICTAL and not taking glucuronidation inducers, the LAMICTAL dose may need to be increased if atazanavir/ritonavir is added, or decreased if atazanavir/ritonavir is discontinued.
Elderly (over 65 years of age): No dosage adjustment from recommended schedule is required. The pharmacokinetics of LAMICTAL in this age group do not differ significantly from a non-elderly adult population.
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).
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' AED regimen; reduced maintenance doses may be effective for patients with significant renal functional impairment (see Precautions). For more detailed pharmacokinetic information, see Pharmacology: Pharmacokinetics under Actions.

Acute ingestion of doses in excess of 10 to 20 times the maximum therapeutic dose has been reported, including fatal cases. Overdose has resulted in symptoms including nystagmus, ataxia, impaired consciousness, grand mal convulsion and coma. QRS broadening (intraventricular conduction delay) has also been observed in overdose patients.
In the event of overdosage, the patient should be admitted to hospital and given appropriate supportive therapy as clinically indicated or as recommended by the national poisons centre, where available.

LAMICTAL tablets and dispersible tablets are contraindicated in individuals with known hypersensitivity to, lamotrigine or any other ingredient of the preparation.

Skin rash: There have been reports of adverse skin reactions, which have generally occurred within the first eight weeks after initiation of LAMICTAL treatment. The majority of rashes are mild and self limiting, however serious rashes requiring hospitalisation and discontinuation of LAMICTAL have also been reported. These have included potentially life-threatening rashes such as Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) (see Adverse Reactions).
In adults enrolled in studies utilising the current LAMICTAL dosing recommendations, the incidence of serious skin rashes is approximately 1 in 500 in epilepsy patients. Approximately half of these cases have been reported as SJS (1 in 1000).
In clinical trials in patients with bipolar disorder, the incidence of serious rash is approximately 1 in 1000.
The risk of serious skin rashes in children is higher than in adults.
Available data from a number of studies suggest the incidence of rashes associated with hospitalisation in children is from 1 in 300 to 1 in 100.
In children, the initial presentation of a rash can be mistaken for an infection. Physicians should consider the possibility of a drug reaction in children that develop symptoms of rash and fever during the first eight weeks of therapy.
Additionally, the overall risk of rash appears to be strongly associated with: high initial doses of LAMICTAL and exceeding the recommended dose escalation of LAMICTAL therapy (see Dosage & Administration); concomitant use of valproate, (see Dosage & Administration).
Caution is also required when treating patients with a history of allergy or rash to other anti-epileptic drugs as the frequency of non-serious rash after treatment with LAMICTAL was approximately three times higher in these patients than in those without such history.
All patients (adults and children) who develop a rash should be promptly evaluated and LAMICTAL withdrawn immediately unless the rash is clearly not drug related. 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.
Rash has also been reported as part of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS); also known as a hypersensitivity syndrome. This condition is associated with a variable pattern of systemic symptoms including fever, lymphadenopathy, facial oedema, abnormalities of the blood, liver and kidney, and aseptic meningitis (see Adverse Reactions). The syndrome shows a wide spectrum of clinical severity and may, rarely, lead to disseminated intravascular coagulation (DIC) and multi-organ failure. It is important to note that early manifestations of hypersensitivity (e.g. fever, lymphadenopathy) may be present even though rash is not evident. If such signs and symptoms are present, the patient should be evaluated immediately and LAMICTAL discontinued if an alternative aetiology cannot be established.
Aseptic meningitis was reversible on withdrawal of the drug in most cases, but recurred in a number of cases on re-exposure to lamotrigine. Re-exposure resulted in a rapid return of symptoms that were frequently more severe. Lamotrigine should not be restarted in patients who have discontinued due to aseptic meningitis associated with prior treatment of lamotrigine.
Haemophagocytic lymphohistiocytosis (HLH): HLH has occurred in patients taking LAMICTAL (see Adverse Reactions). HLH is a syndrome of pathological immune activation, which can be life-threatening, characterised by clinical signs and symptoms such as fever, rash, neurological symptoms, hepatosplenomegaly, lymphadenopathy, cytopenias, high serum ferritin, hypertriglyceridaemia and abnormalities of liver function and coagulation. Symptoms occur generally within 4 weeks of treatment initiation.
Immediately evaluate patients who develop these signs and symptoms and consider a diagnosis of HLH. LAMICTAL should be discontinued unless an alternative aetiology can be established.
Suicidality in Children and Adolescents: Antidepressants increase the risk of suicidal thinking and behaviour (suicidality) in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders.
Anyone considering the use of an antidepressant in a child or adolescent for any clinical use must balance the risk of increased suicidality with the clinical need.
Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behaviour.
Families and caregivers should be advised to closely observe the patient and to communicate with the prescriber.
The indication(s) approved in paediatric for the particular drug should be clearly stated/included.
Symptoms of depression and/or bipolar disorder may occur in patients with epilepsy, and there is evidence that patients with epilepsy and bipolar disorder have an elevated risk for suicidality.
Twenty-five to 50% of patients with bipolar disorder attempt suicide at least once, and may experience worsening of their depressive symptoms and/or the emergence of suicidal ideation and behaviours (suicidality) whether or not they are taking medications for bipolar disorder, including LAMICTAL.
Suicidal ideation and behaviour have been reported in patients treated with AEDs in several indications, including epilepsy and bipolar disorder. A meta-analysis of randomised placebo-controlled trials of AEDs (including lamotrigine) has also shown a small increased risk of suicidal ideation and behaviour. The mechanism of this risk is not known and the available data do not exclude the possibility of an increased risk for lamotrigine.
Therefore patients should be monitored for signs of suicidal ideation and behaviours. Patients (and caregivers of patients) should be advised to seek medical advice should signs of suicidal ideation or behaviour emerge.
Clinical worsening in bipolar disorder: Patients receiving LAMICTAL for bipolar disorder should be closely monitored for clinical worsening (including development of new symptoms) and suicidality, especially at the beginning of a course of treatment, or at the time of dose changes. Certain patients, such as those with a history of suicidal behaviour or thoughts, young adults, and those patients exhibiting a significant degree of suicidal ideation prior to commencement of treatment, may be at a greater risk of suicidal thoughts or suicide attempts, and should receive careful monitoring during treatment.
Patients (and caregivers of patients) should be alerted about the need to monitor for any worsening of their condition (including development of new symptoms) and/or the emergence of suicidal ideation/behaviour or thoughts of harming themselves and to seek medical advice immediately if these symptoms present.
Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients who experience clinical worsening (including development of new symptoms) and/or the emergence of suicidal ideation/behaviour, especially if these symptoms are severe, abrupt in onset, or were not part of the patient's presenting symptoms.
Hormonal contraceptives: Effects of hormonal contraceptives on LAMICTAL efficacy: An ethinylestradiol/levonorgestrel (30 micrograms/150 micrograms) combination has been demonstrated to increase the clearance of lamotrigine by approximately two-fold resulting in decreased lamotrigine levels (see Interactions). Following titration, higher maintenance doses of lamotrigine (by as much two-fold) will be needed in most cases to attain a maximal therapeutic response. In women not already taking an inducer of lamotrigine glucuronidation and taking a hormonal contraceptive that includes one week of inactive medication (e.g. "pill-free week"), gradual transient increases in lamotrigine levels will occur during the week of inactive medication. These increases will be greater when lamotrigine dose increases are made in the days before or during the week of inactive medication. For dosing instructions, see General Dosing Recommendations for Lamictal in Special Patient Population under Dosage & Administration.
Clinicians should exercise appropriate clinical management of women starting or stopping hormonal contraceptives during LAMICTAL therapy and lamotrigine dosing adjustments will be needed in most cases.
Other oral contraceptive and hormone replacement therapy (HRT) treatments have not been studied, though they may similarly affect lamotrigine pharmacokinetic parameters.
Effects of LAMICTAL on hormonal contraceptive efficacy: An interaction study in 16 healthy volunteers has shown that when lamotrigine and a hormonal contraceptive (ethinylestradiol/levonorgestrel combination) are administered in combination, there is a modest increase in levonorgestrel clearance and changes in serum FSH and LH (see Interactions). The impact of these changes on ovarian ovulatory activity is unknown. However, the possibility of these changes resulting in decreased contraceptive efficacy in some patients taking hormonal preparations with LAMICTAL cannot be excluded. Therefore patients should be instructed to promptly report changes in their menstrual pattern, i.e., breakthrough bleeding.
Effect of lamotrigine on organic cationic transporter 2 (OCT 2) substrates: Lamotrigine is an inhibitor of renal tubular secretion via OCT 2 proteins (see Interactions). This may result in increased plasma levels of certain drugs that are substantially excreted via this route. Co-administration of LAMICTAL with OCT 2 substrates with a narrow therapeutic index e.g. dofetilide is not recommended.
Dihydrofolate reductase: Lamotrigine is a weak inhibitor of dihydrofolate reductase, hence there is a possibility of interference with folate metabolism during long-term therapy. However, during prolonged human dosing, LAMICTAL did not induce significant changes in the haemoglobin concentration, mean corpuscular volume, or serum or red blood cell folate concentrations up to 1 year or red blood cell folate concentrations for up to 5 years.
Renal Failure: In single dose studies in subjects with end-stage renal failure, plasma concentrations of lamotrigine were not significantly altered. However, accumulation of the glucuronide metabolite is to be expected; caution should therefore be exercised in treating patients with renal failure.
Patients taking other preparations containing lamotrigine: LAMICTAL tablets and dispersible tablets should not be administered to patients currently being treated with any other preparation containing lamotrigine without consulting a doctor.
Brugada-type ECG: A very rare association with Brugada-type ECG has been observed, although a causal relationship has not been established. Therefore, careful consideration should be given before using LAMICTAL in patients with Brugada syndrome (see Pharmacology: Pharmacodynamics under Actions).
Cardiac rhythm and conduction abnormalities: In vitro testing showed that LAMICTAL exhibits Class IB antiarrhythmic activity at therapeutically relevant concentrations (see Pharmacology: Pharmacodynamics under Actions). Based on these in vitro findings, LAMICTAL could slow ventricular conduction (widen QRS) and induce proarrhythmia, which can lead to sudden death, in patients with clinically important structural or functional heart disease (i.e., patients with heart failure, valvular heart disease, congenital heart disease, conduction system disease, ventricular arrhythmias, cardiac channelopathies [e.g., Brugada syndrome], clinically important ischemic heart disease, or multiple risk factors for coronary artery disease). Any expected or observed benefit of LAMICTAL in an individual patient with clinically important structural or functional heart disease must be carefully weighed against the risks for serious arrhythmias and/or death for that patient. Concomitant use of other sodium channel blockers may further increase the risk of proarrhythmia.
Epilepsy: As with other AEDs, abrupt withdrawal of LAMICTAL may provoke rebound seizures. Unless safety concerns (for example rash) require an abrupt withdrawal, the dose of LAMICTAL should be gradually decreased over a period of two weeks.
There are reports in the literature that severe convulsive seizures including status epilepticus may lead to rhabdomyolysis, multi-organ dysfunction and disseminated intravascular coagulation, sometimes with fatal outcome. Similar cases have occurred in association with the use of LAMICTAL.
Bipolar Disorder: Children and adolescents (less than 18 years of age): Treatment with antidepressants is associated with an increased risk of suicidal thinking and behaviour in children and adolescents with major depressive disorder and other psychiatric disorders.
Effects on Ability to Drive and Use Machines: Two volunteer studies have demonstrated that the effect of LAMICTAL on fine visual motor coordination, eye movements, body sway and subjective sedative effects did not differ from placebo. In clinical trials with LAMICTAL, adverse events of a neurological character such as dizziness and diplopia have been reported. Therefore, patients should see how LAMICTAL therapy affects them before driving or operating machinery.
Epilepsy: As there is individual variation in response to all anti-epileptic drug therapy, patients should consult their physician on the specific issues of driving and epilepsy.

Fertility: Administration of lamotrigine did not impair fertility in animal reproductive studies.
There is no experience of the effect of LAMICTAL on human fertility.
Pregnancy: Post-marketing data from several prospective pregnancy registries have documented outcomes in over 8,700 women exposed to LAMICTAL monotherapy during the first trimester of pregnancy. Overall, these data do not suggest a substantial increase in the risk for major congenital malformations. Although data from a limited number of registries have reported an increase in the risk of isolated oral cleft malformations, a completed case control study did not demonstrate an increased risk of oral clefts compared to other major congenital malformations following exposure to lamotrigine (see Pharmacology: Toxicology: Non-Clinical Information under Actions).
The data on use of LAMICTAL in polytherapy combinations are insufficient to assess whether the risk of malformation associated with other agents is affected by concomitant LAMICTAL use.
As with other medicines, LAMICTAL should only be used during pregnancy if the expected benefits outweigh the potential risks.
Physiological changes during pregnancy may affect lamotrigine levels and/or therapeutic effect. There have been reports of decreased lamotrigine levels during pregnancy. Appropriate clinical management of pregnant women during LAMICTAL therapy should be ensured.
Lactation: Lamotrigine has been reported to pass into breast milk in highly variable concentrations, resulting in total lamotrigine levels in infants of up to approximately 50% of the mother's. Therefore, in some breastfed infants, serum concentrations of lamotrigine may reach levels at which pharmacological effects occur.
The potential benefits of breastfeeding should be weighed against the potential risk of adverse effects occurring in the infant.

The adverse reactions identified from epilepsy or bipolar disorder clinical trial data have been divided into indication specific sections. Additional adverse reactions identified through post-marketing surveillance for both indications are included in the post-marketing section. All three sections should be consulted when considering the overall safety profile of LAMICTAL.
The following convention has been utilised for the classification of undesirable effects: Very common (≥ 1/10); common (≥ 1/100 to < 1/10); uncommon (≥ 1/1000 to < 1/100); rare (≥ 1/10,000 to < 1/1000); very rare (< 1/10,000).
EPILEPSY: The following adverse reactions were identified during epilepsy clinical trials and should be considered alongside those seen in the bipolar disorder clinical trials and post-marketing sections for an overall safety profile of LAMICTAL.
Skin and subcutaneous tissue disorders: Very common: Skin rash. Rare: Stevens-Johnson syndrome. Very rare: Toxic epidermal necrolysis.
In double-blind, add-on clinical trials in adults, skin rashes occurred in up to 10% of patients taking LAMICTAL and in 5% of patients taking placebo. The skin rashes led to the withdrawal of LAMICTAL treatment in 2% of patients. The rash, usually maculopapular in appearance, generally appears within eight weeks of starting treatment and resolves on withdrawal of LAMICTAL (see Precautions).
Rarely, serious potentially life-threatening skin rashes, including Stevens-Johnson syndrome and toxic epidermal necrolysis (Lyell's syndrome) have been reported. Although the majority recover on drug withdrawal, some patients experience irreversible scarring and there have been rare cases of associated death (see Precautions).
The overall risk of rash, appears to be strongly associated with: high initial doses of LAMICTAL and exceeding the recommended dose escalation of LAMICTAL therapy (see Dosage & Administration); concomitant use of valproate (see Dosage & Administration).
Rash has also been reported as part of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS); also known as hypersensitivity syndrome. This condition is associated with a variable pattern of systemic symptoms (see Precautions and Immune system disorders** as follows).
Blood and lymphatic system disorders: Very rare: Haematological abnormalities (including, neutropenia, leucopenia, anaemia, thrombocytopenia, pancytopenia, aplastic anaemia, agranulocytosis), lymphadenopathy.
Haematological abnormalities and lymphadenopathy may or may not be associated with DRESS/Hypersensitivity Syndrome (see Precautions and Immune system disorders** as follows).
Immune system disorders: Very rare: DRESS/Hypersensitivity syndrome** including such symptoms as, fever, lymphadenopathy, facial oedema, abnormalities of the blood, liver and kidney.
**Rash has also been reported as part of this syndrome which shows a wide spectrum of clinical severity and may, rarely, lead to disseminated intravascular coagulation (DIC) and multi-organ failure. It is important to note that early manifestations of hypersensitivity (e.g., fever, lymphadenopathy) may be present even though rash is not evident. If such signs and symptoms are present, the patient should be evaluated immediately, and LAMICTAL discontinued if an alternative aetiology cannot be established.
Psychiatric disorders: Common: Aggression, irritability. Very rare: Tics, hallucinations, confusion.
Nervous system disorders: Very common: Headache. Common: Somnolence, insomnia, dizziness, tremor. Uncommon: Ataxia. Rare: Nystagmus.
Eye disorders: Uncommon: Diplopia, blurred vision.
Gastrointestinal disorders: Common: Nausea, vomiting, diarrhoea.
Hepatobiliary disorders: Very rare: Increased liver function tests, hepatic dysfunction, hepatic failure.
Hepatic dysfunction usually occurs in association with hypersensitivity reactions but isolated cases have been reported without overt signs of hypersensitivity.
Musculoskeletal and connective tissue disorders: Very rare: Lupus-like reactions.
General disorders and administration site conditions: Common: Tiredness.
BIPOLAR DISORDER: The following adverse reactions were identified during bipolar disorder clinical trials and should be considered alongside those seen in the epilepsy clinical trials and post-marketing sections for an overall safety profile of LAMICTAL.
Skin and subcutaneous tissue disorders: Very Common: Skin rash. Rare: Stevens-Johnson syndrome.
When all bipolar disorder studies (controlled and uncontrolled) conducted with LAMICTAL are considered, skin rashes occurred in 12% of patients on LAMICTAL. Whereas, in controlled clinical trials with bipolar disorder patients, skin rashes occurred in 8% of patients taking LAMICTAL and in 6% of patients taking placebo.
Nervous system disorders: Very Common: Headache. Common: Agitation, somnolence, dizziness.
Musculoskeletal and connective tissue disorders: Common: Arthralgia.
General disorders and administration site conditions: Common: Pain, back pain.
Post-marketing: This section includes adverse reactions identified through post-marketing surveillance for both indications. These adverse reactions should be considered alongside those seen in epilepsy and bipolar disorder clinical trials sections for an overall safety profile of LAMICTAL.
Blood and lymphatic system disorders: Very rare: Haemophagocytic lymphohistiocytosis (see Precautions).
Immune system disorders: Very rare: Hypogammaglobulinaemia.
Skin and subcutaneous tissue disorders: Rare: Alopecia.
Psychiatric disorders: Very rare: Nightmares.
Nervous system disorders: Very common: Somnolence, ataxia, headache, dizziness. Common: Nystagmus, tremor, insomnia. Rare: Aseptic meningitis (see Precautions). Very rare: Agitation, unsteadiness, movement disorders, worsening of Parkinson's disease, extrapyramidal effects, choreoathetosis.
There have been reports that LAMICTAL may worsen parkinsonian symptoms in patients with pre-existing Parkinson's disease, and isolated reports of extrapyramidal effects and choreoathetosis in patients without this underlying condition.
Eye disorders: Very common: Diplopia, blurred vision. Rare: Conjunctivitis.
Gastrointestinal disorders: Very common: Nausea, vomiting. Common: Diarrhoea.
Renal and Urinary disorders: Very Rare: Tubulointerstitial nephritis*.
*may occur in association with uveitis.
Epilepsy only: Nervous system disorders: Very rare: Increase in seizure frequency.

Uridine 5'-diphospho (UDP)-glucuronyl transferases (UGTs) have been identified as the enzymes responsible for metabolism of lamotrigine. Drugs that induce or inhibit glucuronidation may, therefore, affect the apparent clearance of lamotrigine. Strong or moderate inducers of the cytochrome P450 3A4 (CYP3A4) enzyme, which are also known to induce UGTs, may also enhance the metabolism of lamotrigine. There is no evidence that lamotrigine causes clinically significant induction or inhibition of cytochrome P450 enzymes.
Lamotrigine may induce its own metabolism but the effect is modest and unlikely to have significant clinical consequences.
Those drugs that have been demonstrated to have a clinically significant impact on lamotrigine metabolism are outlined in Table 6. Specific dosing guidance for these drugs is provided in Dosage & Administration. In addition, this table lists those drugs which have been shown to have little or no effect on the concentration of lamotrigine. Coadministration of such drugs would generally not be expected to result in any clinical impact. However, consideration should be given to patients whose epilepsy is especially sensitive to fluctuations in concentrations of lamotrigine. (See Table 6.)

Click on icon to see table/diagram/image

Interactions involving AEDs (see Dosage & Administration): Valproate, which inhibits the glucuronidation of lamotrigine, reduces the metabolism of lamotrigine and increases the mean half-life of lamotrigine nearly two-fold.
Certain AEDs (such as phenytoin, carbamazepine, phenobarbitone and primidone) which induce cytochrome P450 enzymes also induce UGTs and, therefore, enhance the metabolism of lamotrigine.
There have been reports of central nervous system events including dizziness, ataxia, diplopia, blurred vision and nausea in patients taking carbamazepine following the introduction of LAMICTAL. These events usually resolve when the dose of carbamazepine is reduced. A similar effect was seen during a study of lamotrigine and oxcarbazepine in healthy adult volunteers, but dose reduction was not investigated.
In a study in healthy adult volunteers using doses of 200 mg lamotrigine and 1200 mg oxcarbazepine, oxcarbazepine did not alter the metabolism of lamotrigine and lamotrigine did not alter the metabolism of oxcarbazepine.
In a study of healthy volunteers, co-administration of felbamate (1200 mg twice daily) with LAMICTAL (100 mg twice daily for 10 days) appeared to have no clinically relevant effects on the pharmacokinetics of lamotrigine.
Based on a retrospective analysis of plasma levels in patients who received LAMICTAL both with and without gabapentin, gabapentin does not appear to change the apparent clearance of lamotrigine.
Potential drug interactions between levetiracetam and lamotrigine were assessed by evaluating serum concentrations of both agents during placebo-controlled clinical trials. These data indicate that lamotrigine does not influence the pharmacokinetics of levetiracetam and that levetiracetam does not influence the pharmacokinetics of lamotrigine.
Steady-state trough plasma concentrations of lamotrigine were not affected by concomitant pregabalin (200 mg 3 times daily) administration. There are no pharmacokinetic interactions between lamotrigine and pregabalin.
Topiramate resulted in no change in plasma concentrations of lamotrigine. Administration of LAMICTAL resulted in a 15% increase in topiramate concentrations.
In a study of patients with epilepsy, co-administration of zonisamide (200 to 400 mg/day) with LAMICTAL (150 to 500 mg/day) for 35 days had no significant effect on the pharmacokinetics of lamotrigine.
Plasma concentrations of lamotrigine were not affected by concomitant lacosamide (200, 400, or 600 mg/day) in placebo-controlled clinical trials in patients with partial onset seizures.
In a pooled analysis of data from three placebo-controlled clinical trials investigating adjunctive perampanel in patients with partial-onset and primary generalised tonic-clonic seizures, the highest perampanel dose evaluated (12 mg/day) increased lamotrigine clearance by less than 10%. An effect of this magnitude is not considered to be clinically relevant.
Although changes in the plasma concentrations of other anti-epileptic drugs have been reported, controlled studies have shown no evidence that lamotrigine affects the plasma concentrations of concomitant anti-epileptic drugs. Evidence from in vitro studies indicates that lamotrigine does not displace other anti-epileptic drugs from protein binding sites.
Interactions involving other psychoactive agents (see Dosage & Administration): The pharmacokinetics of lithium after 2 g of anhydrous lithium gluconate given twice daily for six days to 20 healthy subjects were not altered by co-administration of 100 mg/day LAMICTAL.
Multiple oral doses of bupropion had no statistically significant effects on the single dose pharmacokinetics of LAMICTAL in 12 subjects and had only a slight increase in the AUC of lamotrigine glucuronide.
In a study in healthy adult volunteers, 15 mg olanzapine reduced the AUC and C_max of lamotrigine by an average of 24% and 20%, respectively. An effect of this magnitude is not generally expected to be clinically relevant. Lamotrigine at 200 mg did not affect the pharmacokinetics of olanzapine.
Multiple oral doses of LAMICTAL 400 mg daily had no clinically significant effect on the single dose pharmacokinetics of 2 mg risperidone in 14 healthy adult volunteers. Following the co-administration of risperidone 2 mg with lamotrigine, 12 out of the 14 volunteers reported somnolence compared to 1 out of 20 when risperidone was given alone, and none when LAMICTAL was administered alone.
In a study of 18 adult patients with bipolar I disorder, receiving an established regimen of lamotrigine (>/=100 mg/day), doses of aripiprazole were increased from 10 mg/day to a target of 30 mg/day over a 7 day period and continued once daily for a further 7 days. An average reduction of approximately 10% in C_max and AUC of lamotrigine was observed.
In vitro inhibition experiments indicated that the formation of lamotrigine's primary metabolite, the 2-N-glucuronide, was minimally affected by co-incubation with amitriptyline, bupropion, clonazepam, fluoxetine, haloperidol, or lorazepam. Bufuralol metabolism data from human liver microsome suggested that lamotrigine does not reduce the clearance of drugs eliminated predominantly by CYP2D6. Results of in vitro experiments also suggest that clearance of lamotrigine is unlikely to be affected by clozapine, phenelzine, risperidone, sertraline or trazodone.
Interactions involving hormonal contraceptives: Effect of hormonal contraceptives on lamotrigine pharmacokinetics: In a study of 16 female volunteers, 30 micrograms ethinylestradiol/150 micrograms levonorgestrel in a combined oral contraceptive pill caused an approximately two-fold increase in lamotrigine oral clearance, resulting in an average 52% and 39% reduction in lamotrigine AUC and C_max, respectively. Serum lamotrigine concentrations gradually increased during the course of the week of inactive medication (e.g. "pill-free" week), with pre-dose concentrations at the end of the week of inactive medication being, on average, approximately two-fold higher than during co-therapy - see General Dosing Recommendations For Lamictal In Special Patient Populations under Dosage & Administration (for dosing instructions for women taking hormonal contraceptives) and Hormonal Contraceptives under Precautions.
Effect of lamotrigine on hormonal contraceptive pharmacokinetics: In a study of 16 female volunteers, a steady-state dose of 300 mg lamotrigine had no effect on the pharmacokinetics of the ethinylestradiol component of a combined oral contraceptive pill. A modest increase in oral clearance of the levonorgestrel component was observed, resulting in an average 19% and 12% reduction in levonorgestrel AUC and C_max, respectively. Measurement of serum FSH, LH and estradiol during the study indicated some loss of suppression of ovarian hormonal activity in some women, although measurement of serum progesterone indicated that there was no hormonal evidence of ovulation in any of the 16 subjects. The impact of the modest increase in levonorgestrel clearance, and the changes in serum FSH and LH, on ovarian ovulatory activity is unknown (see Precautions). The effects of doses of lamotrigine other than 300 mg/day have not been studied and studies with other female hormonal preparations have not been conducted.
Interactions involving other medications: In a study in 10 male volunteers, rifampicin increased lamotrigine clearance and decreased lamotrigine half-life due to induction of the hepatic enzymes responsible for glucuronidation. In patients receiving concomitant therapy with rifampicin, the treatment regimen recommended for lamotrigine and concurrent glucuronidation inducers should be used (see Dosage & Administration).
In a study in healthy volunteers, lopinavir/ritonavir approximately halved the plasma concentrations of lamotrigine, probably by induction of glucuronidation. In patients receiving concomitant therapy with lopinavir/ritonavir, the treatment regimen recommended for lamotrigine and concurrent glucuronidation inducers should be used (see Dosage & Administration).
In a study in healthy adult volunteers, atazanavir/ritonavir (300 mg/100 mg) reduced the plasma AUC and C_max of lamotrigine (single 100 mg dose) by an average of 32% and 6%, respectively (see General Dosing Recommendations For Lamictal In Special Patient Populations under Dosage & Administration).
In a study in healthy adult volunteers, paracetamol 1 g (four times daily) reduced the plasma AUC and Cmin of lamotrigine by an average of 20% and 25%, respectively.
Data from in vitro assessment of the effect of lamotrigine at OCT 2 demonstrate that lamotrigine, but not the N(2)-glucuronide metabolite, is an inhibitor of OCT 2 at potentially clinically relevant concentrations. These data demonstrate that lamotrigine is an inhibitor of OCT 2, with an IC₅₀ values of 53.8 μM (see Precautions).
Interactions involving laboratory tests: LAMICTAL has been reported to interfere with the assay used in some rapid urine drug screens, which can result in false positive readings, particularly for phencyclidine (PCP). A more specific alternative chemical method should be used to confirm a positive result.

Incompatibilities: None reported.
Use and Handling: None.

LAMICTAL Tablets (non-dispersible): LAMICTAL 50 mg: Store below 30°C. Keep dry.
LAMICTAL 100 mg: Store below 30°C. Keep dry.
LAMICTAL Dispersible Tablets: LAMICTAL 5 mg: Store below 30°C.
LAMICTAL 25 mg: Store below 25°C.

Anticonvulsants

N03AX09 - lamotrigine ; Belongs to the class of other antiepileptics.

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