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Peak Development for ...

Medication Administration

Vol. 16 Issue 11
November 2015

Psychotherapeutic Agents: Lamotrigine


Peak Development Resources
P.O. Box 13267
Richmond, VA 23225
Phone: (804) 233-3707
Fax: (804) 233-3705
Email: editor@peakdev.com

Peak Development for Medication


Administration and Competency
Assessment Tool for Medication
Administration are components of
a site license for the Peak
Development Resources
Competency Assessment System
for Medication Administration
and may be reproduced for this
individual facility only. Sharing
of these components with any
other freestanding facility within
or outside the licensees corporate
entity is expressly prohibited.

The information contained in


Peak Development for Medication
Administration is intended only as
a guide for the practice of
licensed nursing personnel who
administer medications. Every
effort has been made to verify the
accuracy of the information
herein. Because of rapid changes
in the field of drug therapy, the
reader is advised to consult the
package insert, facility pharmacist
or patients physician for relevant
information. This is particularly
important for new or seldom used
drugs. Use of professional
judgment is required in all patient
care situations. It is the readers
responsibility to understand and
adhere to policies and procedures
set forth by the employing
institution. The editor and
publisher of this newsletter
disclaim any liability resulting
from use or misuse of
information contained herein.
Copyright 2015

After completion the learner should be able to:


1. Identify appropriate indications for use of
lamotrigine.
2. Relate general characteristics of lamotrigine
to specific patient situations.
3. Apply nursing process considerations for
lamotrigine to specific patient situations.
4. Correctly calculate dosage for lamotrigine.
Lamotrigine
Lamotrigine was first approved by the FDA
in 1994, under the brand name Lamictal, to
treat certain types of seizures. In 2003,
approval was granted for use in treatment of
bipolar 1 disorder. In this type of manicdepressive disorder, mood typically alternates
from depressive episodes to mania, a severely
elevated or irritable mood that interferes with
the individuals ability to function normally. In
contrast, bipolar 2 disorder typically causes
mood changes from depressive episodes to
hypomania, a change of mood that is similar to
mania, but is not as severe.
All forms of lamotrigine are administered
orally. Immediate-release lamotrigine is
available as tablets, orally disintegrating tablets,
and chewable/dispersible tablets. An extendedrelease tablet, Lamictal XR, was approved in
2009.
Indications
Immediate-release lamotrigine is indicated
for patients 2 years of age and older, as add-on
therapy for treatment of partial seizures,
generalized tonic-clonic seizures, and
generalized seizures associated with LennoxGastaut syndrome. Patients age 16 and older
with partial seizures and who are taking a
single anti-epileptic drug (AED) may be
converted to lamotrigine as monotherapy. It is
also approved for add-on treatment of bipolar 1
disorder, to delay the occurrence of mood

changes in adult patients who are taking


another medication for acute symptoms of
bipolar 1 disorder.
Lamotrigine XR is indicated for use in
patients age 13 and older, as add-on treatment
of partial and tonic-clonic seizures, and for
conversion to monotherapy for partial seizures
when the patient is taking only one AED. It is
not FDA-approved for use in bipolar disorder.
Pharmacodynamics
The mechanism of action of lamotrigine is
not clearly known, but it may affect sodium
channels in neurons, to decrease stimulation.
Pharmacokinetics
Absorption: Rapidly and completely absorbed,
with high bioavailability; not affected by food
Distribution: Protein binding is not high, so it
is less likely to interact with other AEDs that are
highly protein bound, such as phenytoin;
crosses the placenta and is present in breast
milk
Metabolism: Broken down to inactive
metabolites in the liver
Elimination: Primarily via the kidneys
Major Interactions
Oral contraceptive with estrogen: Reduces
lamotrigine serum levels by 50%; increased
dosage may be required
Valproate: Lamotrigine levels can more
than double; decreased dosage may be needed
Phenytoin, phenobarbital, carbamazepine,
rifampin: May decrease lamotrigine levels by
40%; increased dosage may be required
Adverse Effects/Toxicity
Common adverse effects include nausea,
insomnia, drowsiness, fatigue, rash and rhinitis.
Lamotrigine carries a boxed warning regarding
the risk of serious and fatal skin rashes,
including Stevens Johnson syndrome and toxic
epidermal necrolysis. Risk increases with

concurrent use of valproate, taking more drug than


recommended, and rapid increase in dosage. The drug should
be stopped at the first sign of rash, unless the rash clearly has
another cause. Other serious adverse reactions include
aseptic meningitis, multi-organ hypersensitivity reaction, and
blood dyscrasias, such as anemia, neutropenia and
thrombocytopenia. Suicidal thoughts or behavior may also
occur.
Precautions/Contraindications
The drug dosage should be tapered for at least two weeks
prior to discontinuation, when possible. Withdrawal seizures
have occurred in patients with and without epilepsy. Patients
with significant renal or liver impairment may require reduced
dosage.
Nursing Process
Assessment
Determine baseline status: For treatment of seizures, a
complete assessment should be performed prior to therapy,
focusing on type and frequency of seizures, triggers,
symptoms, presence of aura, and baseline neurologic function.
For patients with bipolar disorder, a thorough assessment is
needed of their current psychological state, signs and
symptoms, and patterns of behavior. Careful screening for risk
of suicidal behavior is also important.
Identify risk factors: A thorough and current medication
history to determine potential drug interactions is needed. Lab
work to assess liver, renal and hematologic function should be
performed prior to start of therapy and periodically thereafter.
Patients who have discontinued lamotrigine in the past due to
skin rash, allergy or severe adverse effects should not take the
drug again.
Age-specific considerations: FDA pregnancy category C.
Nursing infants may ingest significant amounts of drug, and
should be monitored carefully for sleepiness, poor suck and
apnea. Serum drug levels should be drawn on the infant if
signs are noted. Lamotrigine should be used during pregnancy
and breastfeeding only if the benefits outweigh the risks.
Pediatric patients taking lamotrigine are more likely than adults
to experience serious skin rashes. Elderly patients should be
started on doses at the low end of the range, due to the renal
and hepatic impairment common in this group.
Planning and Analysis
The goal of care is to eliminate or minimize the
occurrence of seizures, or to stabilize mood in patients with
bipolar 1 disorder.
Intervention
Medication administration: Lamotrigine is usually started

at lower doses and gradually increased to the maintenance


dose, to reduce the risk of serious skin rash. It is taken in one
to two daily maintenance doses. Lamotrigine and lamotrigine
XR tablets should be swallowed whole. Orally disintegrating
tablets should be placed on the tongue and moved around in
the mouth until dissolved and swallowedno water is
necessary. Chewable/dispersible tablets can be swallowed
whole, or chewed and swallowed with water. They can also be
dissolved in just enough water to cover the tablet, and
swallowed when fully dissolved.
The drug names Lamictal and lamotrigine have been
confused with other drugs, such as Lamisil and lamivudine.
Inspect the drug label and tablet to ensure the correct drug has
been dispensed.
Observe for therapeutic effects: Monitor for control of
seizure activity in patients with epilepsy, and maintenance of
mood stability in patients with bipolar disorder.
Observe for adverse effects: Monitor for skin rash, suicidal
tendencies, and signs of infection, bleeding or anemia. Check
CBC for possible blood dyscrasias.
Patient/Family teaching: Teaching should focus on factors
that promote safe and effective use of lamotrigine.
Take exactly as prescribeddo not skip or double doses.
Do not crush or chew regular or extended-release tablets.
Inspect each refill to ensure the correct drug has been
dispensed.
Do not stop taking the medication without talking with the
prescriber, as abrupt discontinuation may cause seizures.
When traveling, always carry extra medication in an easily
accessible location.
Talk with the prescriber before starting or stopping any
other medications, while taking lamotrigine.
For patients with a seizure disorder, obtain and wear a
medical ID bracelet advising of the condition.
Maintain a seizure chart, noting dates, times, duration,
characteristics and any triggering factors.
Avoid operating cars and dangerous machinery until drug
effects are known and seizure control is achieved. States
may specify a seizure-free period to obtain a drivers
license.
Contact the prescriber promptly if skin rash, bruising,
bleeding, signs of infection or suicidal thoughts occur.
Evaluation
With proper assessment, teaching and monitoring, the
nurse can promote safe and effective use of lamotrigine to
help prevent seizures and stabilize mood.

Peak Development for Medication Administration


Psychotherapeutic Agents: Lamotrigine

Page 2

Peak Development for ...


Medication Administration
Competency Assessment Tool

Vol. 16 Issue 11
November 2015

Psychotherapeutic Agents: Lamotrigine


NAME:

DATE:

UNIT:

Directions: Place the letter of the one best answer in the space provided.
_____1. Bipolar disorder is a psychiatric condition that most typically causes:
A. progressive, unrelenting depression
B. cycles of obsession and compulsion
C. manic episodes alternating with hypomanic episodes
D. alternating cycles of mania and depression
_____2. Immediate-release lamotrigine is approved for treatment of all of the following EXCEPT:
A. partial seizures
B. bipolar 1 disorder
C. schizophrenia
D. generalized tonic-clonic seizures
_____3. Lamotrigine is administered by which of the following routes:
A. oral only
B. oral, subcutaneous, and IV
C. oral and IV
D. oral and subcutaneous
_____4. High serum levels of lamotrigine are most likely to occur when the drug is administered
concurrently with:
A. phenytoin
B. oral contraceptives containing estrogen
C. phenobarbital
D. valproate
_____5. Adverse effects of lamotrigine include:
A. aseptic meningitis
B. suicidal thoughts/behavior
C. thrombocytopenia
D. all of the above

_____6. Lamotrigine carries a boxed warning regarding the risk of:


A. suicide and liver damage
B. serious skin rashes
C. bleeding and infection
D. blood clots
_____7. Before lamotrigine is discontinued, the dosage should be gradually reduced for at least two
weeks, if possible.
A. True
B. False
_____8. Grace is a young mother who has just been prescribed lamotrigine. She is breastfeeding
her 2-month old daughter. Grace should be instructed to:
A. stop breastfeeding immediately
B. wean her baby to formula over the next 3 weeks, before maintenance drug levels occur
C. watch for and report excessive sleepiness, poor suck or breathing problems in the baby
D. continue breastfeeding without concern, since this drug does not enter breast milk
_____9. A patient who is taking lamotrigine should be instructed to:
A. take the medication on an empty stomach
B. avoid prolonged exposure to heat
C. notify the prescriber if skin rash occurs
D. follow a low-sodium diet
_____10. The recommended pediatric dosage of lamotrigine is 4.57.5 mg per Kg of body weight
daily. An order is written for lamotrigine 200 mg total daily dose for a child weighing 77 lbs.
This amount falls within the recommended dosage.
A. True
B. False

Competency Assessment Tool


Psychotherapeutic Agents: Lamotrigine

Page 2

Month: November 2015


Issue:
Psychotherapeutic Agents:
Lamotrigine

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Medication Administration

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Psychotherapeutic Agents: Lamotrigine


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