Lamotrigine Torrent 25mg Tablets
SUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Lamotrigine Torrent 25 mg tablets
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
Each tablet contains 25 mg lamotrigine.
For excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Tablet. Light yellow coloured, round, flat tablets with a breakline on one side.
4 CLINICAL PARTICULARS
4.1 Therapeutic indications
Adults and adolescents
- partial epilepsy with or without generalisation
- primary generalised epilepsy
Children aged 2 to 12 years:
- Add-on therapy for refractory partial epilepsy.
Adults, adolescents and children over 2 years of age:
- Add-on therapy for Lennox-Gastaut-Syndrome when other available anti-epileptic drug combinations fail.
This medicinal product is to be started only by a neurologist or paediatric neurologist with experience in the treatment of epilepsy or to be used in departments of neurology and similar departments.
4.2 Posology and method of administration
Lamotrigine tablets should be swallowed whole, and should not be chewed or crushed.
If the calculated dose of lamotrigine (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 Lamotrigine tablets in patients who have discontinued Lamotrigine tablets for any reason, since the risk of serious rash is associated with high initial doses and exceeding the recommended dose escalation for lamotrigine (see section 4.4). 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 lamotrigine exceeds five halflives (see section 5.2), Lamotrigine tablets should generally be escalated to the maintenance dose according to the appropriate schedule.
It is recommended that Lamotrigine tablets not be restarted in patients who have discontinued due to rash associated with prior treatment with lamotrigine 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 1) and for children and adolescents aged 2 to 12 years (Table 2) are given below. Because of a risk of rash the initial dose and subsequent dose escalation should not be exceeded (see section 4.4).
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 section 4.5).
Table 1: Adults and adolescents aged recommended treatment regimen in epilepsy
13
years
and above
|
Treatment regimen |
Weeks 1 + 2 |
Weeks 3 + 4 |
Usual maintenance dose |
|
Monotherapy: |
25 mg/day (once a day) |
50 mg/day (once a day) |
100 - 200 mg/day (once a day or two divided doses) To achieve maintenance, doses may be increased by maximum of 50 - 100 mg every one to two weeks until optimal response is achieved 500 mg/day has been required by some patients to achieve desired response |
|
Adjunctive therapy WITH valproate (inhibitor of lamotrigine glucuronidation - see section 4.5): | |||
|
This dosage regimen should be used with valproate regardless of any concomitant medicinal products |
12.5 mg/day (given as 25 mg on alternate days) |
25 mg/day (once a day) |
100 - 200 mg/day (once a day or two divided doses) To achieve maintenance, doses may be increased by maximum of 25 - 50 mg every one to two weeks until optimal response is achieved |
|
Adjunctive therapy WITHOUT valproate ant section 4.5): |
WITH inducers of lamotrigine glucuronidation (see | ||
|
This dosage regimen should be used without valproate but with: phenytoin carbamazepine phenobarbitone primidone rifampicin lopinavir/ritonavi r |
50 mg/day (once a day) |
100 mg/day (two divided doses) |
200 - 400 mg/day (two divided doses) To achieve maintenance, doses may be increased by maximum of 100 mg every one to two weeks until optimal response is achieved 700 mg/day has been required by some patients to achieve desired response |
|
Adjunctive therapy WITHOUT valproate ant (see section 4.5): |
WITHOUT inducers of lamotrigine glucuronidation | ||
|
This dosage regimen should be used with other medicinal products that do not significantly inhibit or induce lamotrigine glucuronidation |
25 mg/day (once a day) |
50 mg/day (once a day) |
100 - 200 mg/day (once a day or two divided doses) To achieve maintenance, doses may be increased by maximum of 50 - 100 mg every one to two weeks until optimal |
|
In patients taking medicinal products where the pharmacokinetic interaction with lamotrigine is currently not known (see section 4.5), the treatment regimen as recommended for lamotrigine with concurrent valproate should be used. | |||
Table 2: Children and adolescents aged 2 to 12 years - recommended treatment regimen in epilepsy (total daily dose in mg/kg body weight/day)
|
Treatment regimen |
Weeks 1 + 2 |
Weeks 3 + 4 |
Usual maintenance dose |
|
Monotherapy of typical absence seizures: |
0.3 mg/kg/day (once a day or two divided doses) |
0.6 mg/kg/day (once a day or two divided doses) |
1 - 10 mg/kg/day, although some patients have required higher doses (up to 15 mg/kg/day) to achieve desired response (once a day or two divided doses) To achieve maintenance, doses may be increased by maximum of 0.6 mg/kg/day every one to two weeks until optimal response is achieved |
|
Adjunctive therapy WITH valproate (inhibitor of lamotrigine glucuronidation - see section 4.5): | |||
|
This dosage regimen should be used with valproate regardless of any other concomitant medicinal products |
0.15 mg/kg/day* (once a day) |
0.3 mg/kg/day (once a day) |
1 - 5 mg/kg/day (once a day or two divided doses) To achieve maintenance, doses may be increased by maximum of 0.3 mg/kg every one to two weeks until optimal response is achieved, with a maximum maintenance dose of 200 mg/day |
|
Adjunctive therapy WITHOUT valproate ant section 4.5): |
WITH inducers of lamotrigine glucuronidation (see | ||
|
This dosage regimen should be used without valproate but with: phenytoin carbamazepine phenobarbitone primidone rifampicin lopinavir/ritonavi r |
0.6 mg/kg/day (two divided doses) |
1.2 mg/kg/day (two divided doses) |
5 - 15 mg/kg/day (once a day or two divided doses) To achieve maintenance, doses may be increased by maximum of 1.2 mg/kg every one to two weeks until optimal response is achieved, with a maximum maintenance dose of 400 mg/day |
|
Adjunctive therapy WITHOUT valproate ant (see section 4.5): |
WITHOUT inducers of lamotrigine glucuronidation | ||
|
This dosage regimen should be used with other medicinal products that do not significantly inhibit or induce lamotrigine glucuronidation |
0.3 mg/kg/day (once a day or two divided doses) |
0.6 mg/kg/day (once a day or two divided doses) |
1 - 10 mg/kg/day (once a day or two divided doses) To achieve maintenance, doses may be increased by maximum of 0.6 mg/kg every one to two weeks until optimal response is achieved, with a maximum of maintenance dose of 200 mg/day |
|
In patients taking medicinal products where the pharmacokinetic interaction with lamotrigine is currently not known (see section 4.5), the treatment regimen as recommended for lamotrigine with concurrent valproate should be used. | |||
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 Lamotrigine tablets 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 section 4.4). There are no data in children below 1 month of age. Thus Lamotrigine tablets are not recommended for use in children below 2 years of age. If, based on clinical need, a decision to treat is nevertheless taken, see sections 4.4, 5.1 and 5.2.
Bipolar disorder
The recommended dose escalation and maintenance doses for adults of 18 years of age and above are given in the tables below. The transition regimen involves escalating the dose of lamotrigine to a maintenance stabilisation dose over six weeks (Table 3) after which other psychotropic medicinal products and/or AEDs can be withdrawn, if clinically indicated (Table 4). The dose adjustments following addition of other psychotropic medicinal products and/or AEDs are also provided below (Table 5). Because of the risk of rash the initial dose and subsequent dose escalation should not be exceeded (see section 4.4).
Table 3: Adults aged 18 years and above - recommended dose escalation to the maintenance total daily stabilisation dose in treatment of bipolar disorder
|
Treatment Regimen |
Weeks 1 + 2 |
Weeks 3 + 4 |
Week 5 |
Target Stabilisation Dose | |
|
(Week 6)* |
Monotherapy with lamotrigine OR adjunctive therapy WITHOUT valproate and WITHOUT inducers of lamotrigine glucuronidation (see section 4.5):
|
This dosage regimen should be used with other medicinal products that do not significantly inhibit or induce lamotrigine glucuronidation |
25 mg/day (once a day) |
50 mg/day (once a day or two divided doses) |
100 mg/day (once a day or two divided doses) |
200 mg/day - usual target dose for optimal response (once a day or two divided doses) Doses in the range 100 - 400 mg/day used in clinical trials |
|
Adjunctive therapy WITH valproate (inhibitor of lamotrigine glucuronidation - see section 4.5): | ||||
|
This dosage regimen should be used with valproate regardless of any concomitant medicinal products |
12.5 mg/day (given as 25 mg on alternate days) |
25 mg/day (once a day) |
50 mg/day (once a day or two divided doses) |
100 mg/day - usual target dose for optimal response (once a day or two divided doses) Maximum dose of 200 mg/day can be used depending on clinical response |
|
Adjunctive therapy WITHOUT valproate and WITH inducers of lamotrigine glucuronidation (see section 4.5): | ||||
|
This dosage regimen should be used without valproate but with: phenytoin carbamazepine phenobarbitone primidone rifampicin lopinavir/ritonavir |
50 mg/day (once a day) |
100 mg/day (two divided doses) |
200 mg/day (two divided doses) |
300 mg/day in week 6, if necessary increasing to usual target dose of 400 mg/day in week 7, to achieve optimal response (two divided doses) |
|
In patients taking medicinal proc not known (see section 4.5), the should be used. |
ucts where the pharmacokinetic interaction with dose escalation as recommended for lamotrigine w |
amotrigine is currently ith concurrent valproate, | ||
* The Target stabilisation dose will alter depending on clinical response
Table 4: Adults aged 18 years and above - maintenance stabilisation total daily dose following withdrawal of concomitant medicinal products in treatment of bipolar disorder
Once the target daily maintenance stabilisation dose has been achieved, other medicinal products may be withdrawn as shown below.
|
Treatment Regimen |
Current lamotrigine stabilisation dose (prior to withdrawal) |
Week 1 (beginning with withdrawal) |
Week 2 |
Week 3 onwards * |
|
Withdrawal of valproate (inhibitor ol original dose of lamotrigine: |
' lamotrigine glucuronidation - see section 4.5), depending on | |||
|
When valproate is withdrawn, double the stabilisation dose, not exceeding an increase of more than 100 mg/week |
100 mg/day |
200 mg/day |
Maintain this dose (200 mg/day) (two divided doses) | |
|
200 mg/day |
300 mg/day |
400 mg/day |
Maintain this dose (400 mg/day) | |
|
Withdrawal of inducers of lamotrigine glucuronidation (see section 4.5), depending on original dose of lamotrigine: | ||||
|
This dosage regimen should be used when the following are withdrawn: phenytoin carbamazepine phenobarbitone primidone rifampicin lopinavir/ritonavir |
400 mg/day |
400 mg/day |
300 mg/day |
200 mg/day |
|
300 mg/day |
300 mg/day |
225 mg/day |
150 mg/day | |
|
200 mg/day |
200 mg/day |
150 mg/day |
100 mg/day | |
|
Withdrawal of medicinal products that do NOT significantly inhibit or induce lamotrigine glucuronidation (see section 4.5): | ||||
|
This dosage regimen should be used when other medicinal products that do not significantly inhibit or induce lamotrigine glucuronidation are withdrawn |
Maintain target dose achieved in dose escalation (200 mg/day; two divided doses) (dose range 100 - 400 mg/day) | |||
|
In patients taking medicinal products where the pharmacokinetic interaction with lamotrigine is currently not known (see section 4.5), the treatment regimen as recommended for lamotrigine with concurrent valproate, should be used. | ||||
*Dose may be increased to 400 mg/day as needed
Table 5: Adults aged 18 years and above - adjustment of lamotrigine daily dosing following the addition of other medicinal products in treatment of bipolar disorder
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:
|
Treatment Regimen |
Current lamotrigine stabilisation dose (prior to addition) |
Week 1 (beginning with addition) |
Week 2 |
Week 3 onwards |
|
Addition of valproate (inhibitor of lamotrigine glucuronidation - see section 4.5), depending on original dose of lamotrigine: | ||||
|
This dosage regimen should be used when valproate is added regardless of any concomitant medicinal products |
200 mg/day |
100 mg/day |
Maintain this dose (100 mg/day) | |
|
300 mg/day |
150 mg/day |
Maintain this dose (150 mg/day) | ||
|
400 mg/day |
200 mg/day |
Maintain this dose (200 mg/day) | ||
|
Addition of inducers of lamotrigine glucuronidation in patients NOT taking valproate (see section 4.5), depending on original dose of lamotrigine: | ||||
|
This dosage regimen should be used when the following are added without valproate: phenytoin carbamazepine phenobarbitone primidone rifampicin lopinavir/ritonavir |
200 mg/day |
200 mg/day |
300 mg/day |
400 mg/day |
|
150 mg/day |
150 mg/day |
225 mg/day |
300 mg/day | |
|
100 mg/day |
100 mg/day |
150 mg/day |
200 mg/day | |
|
Addition of medicinal products that do NOT significantly inhibit or int glucuronidation (see section 4.5): |
uce lamotrigine | |||
|
This dosage regimen should be used when other medicinal products that do not significantly inhibit or induce lamotrigine glucuronidation are added |
Maintain target dose achieved in dose escalation (200 mg/day; dose range 100-400 mg/day) | |||
|
In patients taking medicinal products where the pharmacokinetic interaction with lamotrigine is currently not known (see section 4.5), the treatment regimen as recommended for lamotrigine with concurrent valproate, should be used. | ||||
Discontinuation of Lamotrigine tablets 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 lamotrigine versus placebo. Therefore, patients may terminate Lamotrigine tablets without a step-wise reduction of dose.
Children and adolescents below 18 years
Lamotrigine tablets are not recommended for use in children below 18 years of age due to a lack of data on safety and efficacy (see section 4.4).
General dosing recommendations for Lamotrigine tablets in special patient populations
Women taking hormonal contraceptives
The use of an ethinyloestradiol/levonorgestrel (30 pg/150 pg) 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 sections 4.4 and 4.5).
Starting hormonal contraceptives in patients already taking maintenance doses of lamotrigine and NOT taking inducers of lamotrigine glucuronidation The maintenance dose of lamotrigine will in most cases need to be increased by as much as two-fold (see sections 4.4 and 4.5). It is recommended that from the time that the hormonal contraceptive is started, the lamotrigine dose is increased by 50 to 100mg/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 sections 4.4 and 4.5).
Stopping hormonal contraceptives in patients already taking maintenance doses of lamotrigine and NOT taking inducers of lamotrigine glucuronidation The maintenance dose of lamotrigine will in most cases need to be decreased by as much as 50% (see sections 4.4 and 4.5). It is recommended to gradually decrease the daily dose of lamotrigine by 50- 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 the first week after stopping the pill.
Starting lamotrigine 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 lamotrigine 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 lamotrigine should be necessary when lamotrigine 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 lamotrigine dose adjustment is needed (see section 4.5).
Use with lopinavir/ritonavir
No adjustments to the recommended dose escalation of lamotrigine should be necessary when lamotrigine 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 lamotrigine dose adjustment is needed (see section 4.5).
Elderly (above 65 years)
No dosage adjustment from the recommended schedule is required. The pharmacokinetics of lamotrigine in this age group do not differ significantly from a non-elderly adult population (see section 5.2).
Renal impairment
Caution should be exercised when administering Lamotrigine tablets to patients with renal failure. For patients with end-stage renal failure, initial doses of lamotrigine should be based on patients' concomitant medicinal products; reduced maintenance doses may be effective for patients with significant renal functional impairment (see sections 4.4 and 5.2).
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 section 5.2).
4.3 Contraindications
Hypersensitivity to lamotrigine or to any of the excipients.
4.4 Special warnings and precautions for use Skin rash
There have been reports of adverse skin reactions, which have generally occurred within the first eight weeks after initiation of lamotrigine treatment. The majority of rashes are mild and self-limiting, however serious rashes requiring hospitalisation and discontinuation of lamotrigine have also been reported. These have included potentially life-threatening rashes such as Stevens-Johnson syndrome and toxic epidermal necrolysis (see section 4.8).
In adults enrolled in studies utilizing the current lamotrigine 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 Stevens-Johnson syndrome (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 epileptic 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 reaction to lamotrigine treatment 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 lamotrigine and exceeding the recommended dose escalation of lamotrigine therapy (see section 4.2)
- concomitant use of valproate (see section 4.2)
Caution is also required when treating patients with a history of allergy or rash to other AEDs as the frequency of non-serious rash after treatment with lamotrigine 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 Lamotrigine tablets withdrawn immediately unless the rash is clearly not related to lamotrigine treatment. It is recommended that Lamotrigine tablets not be restarted in patients who have discontinued due to rash associated with prior treatment with lamotrigine unless the potential benefit clearly outweighs the risk. If the patient has developed SJS or TEN with the use of lamotrigine, treatment with lamotrigine must not be restarted in this patient at any time.
Rash has also been reported as part of a hypersensitivity syndrome associated with a variable pattern of systemic symptoms including fever, lymphadenopathy, facial oedema and abnormalities of the blood and liver (see section 4.8). The syndrome shows a wide spectrum of clinical severity and may, rarely, lead to disseminated intravascular coagulation and multiorgan failure. It is important to note that early manifestations of hypersensitivity (for example 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 Lamotrigine tablets 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.
Clinical worsening and suicide risk
Suicidal ideation and behaviour have been reported in patients treated with anti- epileptic drugs in several indications. A meta-analysis of randomised placebo controlled trials of anti-epileptic drugs 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 tablets. Therefore patients should be monitored for signs of suicidal ideation and behaviours and appropriate treatment should be considered. Patients (and caregivers of patients) should be advised to seek medical advice should signs of suicidal ideation or behaviour emerge.
In patients with bipolar disorder, worsening of depressive symptoms and/or the emergence of suicidality may occur whether or not they are taking medications for bipolar disorder, including Lamotrigine tablets. Therefore patients receiving Lamotrigine tablets 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.
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 lamotrigine efficacy
The use of an ethinyloestradiol/levonorgestrel (30 pg/150 pg) combination increases the clearance of lamotrigine by approximately two-fold resulting in decreased lamotrigine levels (see section 4.5). A decrease in lamotrigine levels has been associated with loss of seizure control. Following titration, higher maintenance doses of lamotrigine (by as much as two-fold) will be needed in most cases to attain a maximal therapeutic response. When stopping hormonal contraceptives, the clearance of lamotrigine may be halved. Increases in lamotrigine concentrations may be associated with dose-related adverse events. Patients should be monitored with respect to this.
In women not already taking an inducer of lamotrigine glucuronidation and taking a hormonal contraceptive that includes one week of inactive treatment (for example "pill-free week"), gradual transient increases in lamotrigine levels will occur during the week of inactive treatment (see section 4.2). Variations in lamotrigine levels of this order may be associated with adverse effects. 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).
The interaction between other oral contraceptive or HRT treatments and lamotrigine have not been studied, though they may similarly affect lamotrigine pharmacokinetic parameters.
Effects of lamotrigine on hormonal contraceptive efficacy
An interaction study in 16 healthy volunteers has shown that when lamotrigine and a hormonal contraceptive (ethinyloestradiol/levonorgestrel combination) are administered in combination, there is a modest increase in levonorgestrel clearance and changes in serum FSH and LH (see section 4.5). 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 lamotrigine cannot be excluded. Therefore patients should be instructed to promptly report changes in their menstrual pattern, i.e. breakthrough bleeding.
Dihydrofolate reductase
Lamotrigine has a slight inhibitory effect on dihydrofolic acid reductase, hence there is a possibility of interference with folate metabolism during long-term therapy (see section 4.6). However, during prolonged human dosing, lamotrigine 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
Lamotrigine tablets should not be administered to patients currently being treated with any other preparation containing lamotrigine without consulting a doctor.
Excipient of Lamotrigine tablets
Lamotrigine tablets contain lactose monohydrate. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
Development in children
There are no data on the effect of lamotrigine on growth, sexual maturation and cognitive, emotional and behavioural developments in children.
Precautions relating to epilepsy
As with other AEDs, abrupt withdrawal of Lamotrigine tablets may provoke rebound seizures. Unless safety concerns (for example rash) require an abrupt withdrawal, the dose of Lamotrigine tablets 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, multiorgan dysfunction and disseminated intravascular coagulation, sometimes with fatal outcome. Similar cases have occurred in association with the use of lamotrigine.
A clinically significant worsening of seizure frequency instead of an improvement may be observed. In patients with more than one seizure type, the observed benefit of control for one seizure type should be weighed against any observed worsening in another seizure type.
Myoclonic seizures may be worsened by lamotrigine.
There is a suggestion in the data that responses in combination with enzyme inducers is less than in combination with non-enzyme inducing antiepileptic agents. The reason is unclear.
In children taking lamotrigine for the treament of typical absence seizures, efficacy may not be maintained in all patients.
Precautions relating to bipolar disorder
Children and adolescents below 18 years
Treatment with antidepressants is associated with an increased risk of suicidal thinking and behavior in children and adolescents with major depressive disorder and other psychiatric disorders.
4.5 Interaction with other medicinal products and other forms of interaction
Interaction studies have only been performed in adults.
UDP-glucuronyl transferases have been identified as the enzymes responsible for metabolism of lamotrigine. There is no evidence that lamotrigine causes clinically significant induction or inhibition of hepatic oxidative drug-metabolising enzymes, and interactions between lamotrigine and medicinal products metabolised by cytochrome P450 enzymes are unlikely to occur. Lamotrigine may induce its own metabolism but the effect is modest and unlikely to have significant clinical consequences.
Table 6: Effects of other medicinal products on glucuronidation of lamotrigine
|
Medicinal products that significantly inhibit glucuronidation of lamotrigine |
Medicinal products that significantly induce glucuronidation of lamotrigine |
Medicinal products that do not significantly inhibit or induce |
|
Valproate |
Phenytoin |
Oxcarbazepine |
|
Carbamazepine |
Felbamate | |
|
Phenobarbitone |
Gabapentin | |
|
Primidone |
Levetiracetam | |
|
Rifampicin |
Pregabalin | |
|
Lopinavir/ritonavir |
Topiramate | |
|
Ethinyloestradiol/ levonorgestrel combination** |
Zonisamide | |
|
Atazanavir/ritonavir* |
Lithium | |
|
Buproprion | ||
|
Olanzapine |
*For dosing guidance (see section 4.2)
** Other oral contraceptive and HRT treatments have not been studied, though they may similarly affect lamotrigine pharmacokinetic parameters (see sections 4.2 and 4.4).
Interactions involving antiepileptic drugs
Valproate, which inhibits the glucuronidation of lamotrigine, reduces the metabolism of lamotrigine and increases the mean half-life of lamotrigine nearly two-fold. In patients receiving concomitant therapy with valproate, the appropriate treatment regimen should be used (see section 4.2).
Certain AEDs (such as phenytoin, carbamazepine, phenobarbitone and primidone) which induce hepatic drug-metabolising enzymes induce the glucuronidation of lamotrigine and enhance the metabolism of lamotrigine. In patients receiving concomitant therapy with phenytoin, carbamazepine, pheonbarbitone or primidone, the appropriate treatment regimen should be used (see section 4.2).
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 lamotrigine. 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.
There are reports in the literature of decreased lamotrigine levels when lamotrigine was given in combination with oxcarbazepine.
However, in a prospective 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. Therefore in patients receiving concomitant therapy with oxcarbazepine, the treatment regimen for lamotrigine adjunctive therapy without valproate and without inducers of lamotrigine glucuronidation should be used (see section 4.2).
In a study of healthy volunteers, coadministration of felbamate (1200 mg twice
daily) with lamotrigine (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 lamotrigine both with and without gabapentin, gabapentin does not appear to change the apparent clearance of lamotrigine.
Potential 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 lamotrigine resulted in a 15% increase in topiramate concentrations.
In a study of patients with epilepsy, coadministration of zonisamide (200 to 400 mg/day) with lamotrigine (150 to 500 mg/day) for 35 days had no significant effect on the pharmacokinetics of lamotrigine.
Although changes in the plasma concentrations of other AEDs have been reported, controlled studies have shown no evidence that lamotrigine affects the plasma concentrations of concomitant AEDs. Evidence from in vitro studies indicates that lamotrigine does not displace other AEDs from protein binding sites.
Interactions involving other psychoactive agents
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 coadministration of 100 mg/day lamotrigine.
Multiple oral doses of bupropion had no statistically significant effects on the single dose pharmacokinetics of lamotrigine 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 Cmax 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 lamotrigine 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 lamotrigine was administered alone.
In a study of 18 adult patients with bipolar I disorder, receiving an established regimen of lamotrigine (100-400 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 Cmax and AUC of lamotrigine was observed. An effect of this magnitude is not expected to be of clinical consequence.
In vitro experiments indicated that the formation of lamotrigine’s primary metabolite, the 2-N-glucuronide, was minimally inhibited by co-incubation with amitriptyline, bupropion, clonazepam, haloperidol or lorazepam. These experiments also suggested that metabolism of lamotrigine was unlikely to be inhibited by clozapine, fluoxetine, phenelzine, risperidone, sertraline or trazodone. In addition, a study of bufuralol metabolism using human liver microsome preparations suggested that lamotrigine would not reduce the clearance of medicinal products metabolised predominantly by CYP2D6.
Interactions involving hormonal contraceptives
Effect of hormonal contraceptives on lamotrigine pharmacokinetics In a study of 16 female volunteers, dosing with 30 pg ethinyloestradiol/ 150 pg levonorgestrel in a combined oral contraceptive pill caused an approximately twofold increase in lamotrigine oral clearance, resulting in an average 52% and 39% reduction in lamotrigine AUC and Cmax, respectively. Serum lamotrigine concentrations increased during the course of the week of inactive treatment (including the “pill-free” week), with pre-dose concentrations at the end of the week of inactive treatment being, on average, approximately two-fold higher than during co-therapy (see section 4.4). No adjustments to the recommended dose escalation guidelines for lamotrigine should be necessary solely based on the use of hormonal contraceptives, but the maintenance dose of lamotrigine will need to be increased or decreased in most cases when starting or stopping hormonal contraceptives (see section 4.2).
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 ethinyloestradiol 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 Cmax, respectively.
Measurement of serum FSH, LH and oestradiol 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 section 4.4). 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 medicinal products
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 appropriate treatment regimen should be used (see section 4.2).
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
appropriate treatment regimen should be used (see section 4.2).
In a study in healthy adult volunteers, atazanavir/ritonavir (300 mg/100 mg) administered for 9 days reduced the plasma AUC and Cmax of lamotrigine (single 100 mg dose) by an average of 32% and 6%, respectively. In patients receiving concomitant therapy with atazanavir/ritonavir, the appropriate treatment regimen should be used (see section 4.2).
Data from in vitro assessment 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 a more potent in vitro inhibitor of OCT 2 than cimetidine, with IC50 values of 53.8 pM and 186 pM, respectively. Co-administration of lamotrigine with renally excreted medicinal products which are substrates of OCT2 (e.g. metformin, gabapentin and varenicline) may result in increased plasma levels of these drugs.
The clinical significance of this has not been clearly defined, however care should be taken in patients co-administered with these medicinal products.
4.6 Pregnancy and lactation
Risk related to antiepileptic drugs in general
Specialist advice should be given to women who are of childbearing potential. The need for treatment with AEDs should be reviewed when a woman is planning to become pregnant. In women being treated for epilepsy, sudden discontinuation of AED therapy should be avoided as this may lead to breakthrough seizures that could have serious consequences for the woman and the unborn child.
The risk of congenital malformations is increased by a factor of 2 to 3 in the offspring of mothers treated with AEDs compared with the expected incidence in the general population of approximately 3%. The most frequently reported defects are cleft lip, cardiovascular malformations and neural tube defects. Therapy with multiple AEDs is associated with a higher risk of congenital malformations than monotherapy and therefore monotherapy should be used whenever possible.
Risk related to lamotrigine
Pregnancy
Postmarketing data from several prospective pregnancy registries have documented outcomes in over 2000 women exposed to lamotrigine 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 are still too limited to exclude a moderate increase in the risk of oral clefts. Animal studies have shown developmental toxicity (see section 5.3).
If therapy with Lamotrigine tablets is considered necessary during pregnancy, the lowest possible therapeutic dose is recommended.
Lamotrigine has a slight inhibitory effect on dihydrofolic acid reductase and could therefore theoretically lead to an increased risk of embryofoetal damage by reducing folic acid levels (see section 4.4). Intake of folic acid when planning pregnancy and during early pregnancy may be considered.
Physiological changes during pregnancy may affect lamotrigine levels and/or therapeutic effect. There have been reports of decreased lamotrigine plasma levels during pregnancy with a potential risk of loss of seizure control. After birth lamotrigine levels may increase rapidly with a risk of dose-related adverse events. Therefore lamotrigine serum concentrations should be monitored before, during and after pregnancy, as well as shortly after birth. If necessary, the dose should be adapted to maintain the lamotrigine serum concentration at the same level as before pregnancy, or adapted according to clinical response. In addition, dose-related undesirable effects should be monitored after birth.
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 breast-fed infants, serum concentrations of lamotrigine may reach levels at which pharmacological effects occur. Among a limited group of exposed infants, no adverse effects were observed.
The potential benefits of breast-feeding should be weighed against the potential risk of adverse effects occurring in the infant. Should a woman decide to breast-feed while on therapy with lamotrigine, the infant should be monitored for adverse effects.
Fertility
Animal experiments did not reveal impairment of fertility by lamotrigine (see section 5.3).
4.7 Effects on ability to drive and use machines
When treating with lamotrigine, the ability to react may be decreased. This should be taken into account when sharpened attention is required, e.g. when driving vehicles or using machines.
4.8 Undesirable effects
The undesirable effects have been divided into epilepsy and bipolar specific sections based on the data currently available. However, both sections should be consulted when considering the overall safety profile of lamotrigine.
Adverse reactions identified from monotherapy clinical trials (identified by a dagger 1), from bipolar disorder clinical trials (identified by a section mark §), from bipolar
disorder clinical trials (identified by a section mark 5) and during other clinical experience are listed in the table below by their incidence in clinical trials.
The following convention has been utilised for the classification of undesirable effects:- Very common (>1/10), common (>1/100, <1/10),
uncommon (>1/1000, <1/100), rare (>1/10,000, <1/1000), very rare (<1/10,000), not known (cannot be estimated from the available data).
Epilepsy
|
System Organ Class |
Adverse Event |
Frequency |
|
Blood and lymphatic system disorders |
Haematological abnormalities1 including neutropenia, leucopenia, anaemia, thrombocytopenia, pancytopenia, aplastic anaemia, agranulocytosis |
Very rare |
|
Lymphadenopathy1 |
Not known | |
|
Immune System Disorders |
Hypersensitivity syndrome2 (including such symptoms as, fever, lymphadenopathy, facial oedema, abnormalities of the blood and liver, disseminated intravascular coagulation, multi organ failure). |
Very Rare |
|
Psychiatric Disorders |
Aggression, irritability |
Common |
|
Confusion, hallucinations, tics |
Very rare | |
|
Nervous System Disorders |
Headache5 Somnolence15, dizziness15, tremor1', insomnia1 , agitation5 |
Very Common Common |
|
Ataxia1 |
Uncommon | |
|
Nystagmus1 |
Rare | |
|
Agitation, unsteadiness, movement disorders, worsening of Parkinson's disease 3, extrapyramidal effects, choreoathetosis1, increase in seizure frequency |
Very Rare | |
|
Aseptic meningitis (see section 4.4) |
Not known | |
|
Eye disorders |
Diplopia1, blurred vision1 |
Uncommon |
|
Conjunctivitis |
Rare |
|
Gastrointestinal disorders |
Nausea1', vomiting1, diarrhoea1, dry mouth1 |
Common |
|
Hepatobiliary disorders |
Hepatic failure, hepatic dysfunction4, increased liver function tests |
Very rare |
|
Skin and subcutaneous tissue disorders |
Skin rash55 Stevens-Johnson Syndrome1 Toxic epidermal necrolysis |
Very common Rare Very rare |
|
Musculoskeletal and connective tissue disorders |
Arthralgia1 Lupus-like reactions |
Common Very rare |
|
General disorders and administration site conditions |
Common |
Description of selected adverse reactions
'Haematological abnormalities and lymphadenopathy may or may not be associated with the hypersensitivity syndrome (see Immune system disorders2).
2Rash has also been reported as part of a hypersensitivity syndrome associated with a variable pattern of systemic symptoms including fever, lymphadenopathy, facial oedema and abnormalities of the blood and liver. The syndrome shows a wide spectrum of clinical severity and may, rarely, lead to disseminated intravascular coagulation and multiorgan failure. It is important to note that early manifestations of hypersensitivity (for example 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 Lamotrigine tablets discontinued if an alternative aetiology cannot be established.
3These effects have been reported during other clinical experience.
There have been reports that lamotrigine 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.
4Hepatic dysfunction usually occurs in association with hypersensitivity reactions but isolated cases have been reported without overt signs of hypersensitivity.
withdrawal of lamotrigine treatment in 2% of patients. The rash, usually maculopapular in appearance, generally appears within eight weeks of starting treatment and resolves on withdrawal of Lamotrigine tablets (see section 4.4).
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 withdrawal of lamotrigine treatment, some patients experience irreversible scarring and there have been rare cases of associated death (see section 4.4).
The overall risk of rash, appears to be strongly associated with:
- high initial doses of lamotrigine and exceeding the recommended dose escalation of lamotrigine therapy (see section 4.2)
- concomitant use of valproate (see section 4.2)
Rash has also been reported as part of a hypersensitivity syndrome associated with a variable pattern of systemic symptoms (see Immune system disorders2).
There have been reports of decreased bone mineral density , osteopenia, osteoporosis and fractures in patients on long-term therapy with lamotrigine. The mechanism by which lamotrigine affects bone metabolism has not been identified.
4.9 Overdose
Symptoms
Acute ingestion of doses in excess of 10-20 times the maximum therapeutic dose has been reported. Overdose has resulted in symptoms including nystagmus, ataxia, impaired consciousness and coma. ECG changes (small broadening of the QRS-complex and extension of the PR-interval) may occur.
Treatment
In the event of overdose, the patient should be admitted to hospital and given appropriate supportive therapy. Gastric lavage and treatment with activated charcoal for suspected intoxication should be performed if indicated. There is no experience with haemodialysis as treatment for overdose. In 6 patients with renal failure who had been dialysed for 4 hours, 20% of the amount of lamotrigine in the body was removed.
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Other Antiepileptics
ATC code: N03A X09 Mechanism of action
The results of pharmacological studies suggest that lamotrigine is a use- and voltage-dependent blocker of voltage gated sodium channels. It inhibits sustained repetitive firing of neurones and inhibits release of glutamate (the neurotransmitter which plays a key role in the generation of epileptic seizures). These effects are likely to contribute to the anticonvulsant properties of lamotrigine.
In contrast, the mechanisms by which lamotrigine exerts its therapeutic action in bipolar disorder have not been established, although interaction with voltage gated sodium channels is likely to be important.
Pharmacodynamic effects
In tests designed to evaluate the central nervous system effects of medicinal products, 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 co-ordination 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 co-ordination 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 efficacy and safety in children aged 1 to 24 months
The efficacy and safety of adjunctive therapy in partial seizures in patients aged 1 to 24 months has been evaluated in a small double-blind placebo-controlled withdrawal study. Treatment was initiated in 177 subjects, with a dose titration schedule similar to that of children aged 2 to 12 years. Lamotrigine 2 mg tablets are the lowest strength available, therefore the standard dosing schedule was adapted in some cases during the titration phase (for example, by administering a 2 mg tablet on alternate days when the calculated dose was less than 2 mg). Serum levels were measured at the end of week 2 of titration and the subsequent dose either reduced or not increased if the concentration exceeded 0.41 pg/mL, the expected concentration in adults at this time point. Dose reductions of up to 90% were required in some patients at the end of week 2. Thirty-eight responders (> 40% decrease in seizure frequency) were randomised to placebo or continuation of lamotrigine. The proportion of subjects with treatment failure was 84% (16/19 subjects) in the placebo arm and 58% (11/19 subjects) in the lamotrigine arm. The difference was not statistically significant: 26.3%, CI95% -2.6% <> 50.2%, p=0.07.
A total of 256 subjects between 1 to 24 months of age have been exposed to lamotrigine in the dose range 1 to 15 mg/kg/day for up to 72 weeks. The safety profile of lamotrigine in children aged 1 month to 2 years was similar to that in older children except that clinically significant worsening of seizures (>=50%) was reported more often in children under 2 years of age (26%) as compared to older children (14%).
Clinical efficacy and safety in Lennox-Gastaut syndrome
There are no data for monotherapy in seizures associated with Lennox-Gastaut syndrome.
Clinical efficacy in the prevention of mood episodes in patients with bipolar disorder
The efficacy of lamotrigine in the prevention of mood episodes in patients with bipolar I disorder has been evaluated in two studies.
Study SCAB2003 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 lamotrigine monotherapy or adjunctive therapy, patients were randomly assigned into one of five treatment groups: lamotrigine (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). The primary endpoint was "Time to Intervention for a Mood Episode (TIME)", where the interventions were additional pharmacotherapy or electroconvulsive therapy (ECT). Study SCAB2006 had a similar design as study SCAB2003, but differed from study SCAB2003 in evaluating a flexible dose of lamotrigine (100 to 400 mg/day) and including patients with bipolar I disorder who had recently or were currently experiencing a manic episode. The results are shown in Table 7.
Table 7: Summary of results from studies investigating the efficacy of lamotrigine in the prevention of mood episodes in patients with bipolar I disorder
|
‘Proportion’ of patients being event free at week 76 | ||||||
|
Study SCAB2003 Bipolar |
Study SCAB2006 Bipolar I | |||||
|
Inclusion |
Major depressive episode |
Major manic episode | ||||
|
Lamotrigine |
Lithium |
Placebo |
Lamotrigine |
Lithium |
Placebo | |
|
Intervention free |
0.22 |
0.21 |
0.12 |
0.17 |
0.24 |
0.04 |
|
p-value Log rank test |
0.004 |
0.006 |
0.023 |
0.006 | ||
|
Depression free |
0.51 |
0.46 |
0.41 |
0.82 |
0.71 |
0.40 |
|
p-value Log rank test |
0.047 |
0.209 |
- |
0.015 |
0.167 |
- |
|
Free of mania |
0.70 |
0.86 |
0.67 |
0.53 |
0.64 |
0.37 |
|
p-value Log rank test |
0.339 |
0.026 |
0.280 |
0.006 | ||
In supportive analyses of time to first depressive episode and time to first manic/hypomanic or mixed episode, the lamotrigine-treated patients had significantly longer times to first depressive episode than placebo patients, and the treatment difference with respect to time to manic/hypomanic or mixed episodes was not statistically significant.
The efficacy of lamotrigine in combination with mood stabilisers has not been adequately studied.
Study of the effect of lamotrigine on cardiac conduction
A study in healthy adult volunteers evaluated the effect of repeat doses of lamotrigine (up to 400 mg/day) on cardiac conduction, as assessed by 12-lead ECG. There was no clinically significant effect of lamotrigine on QT interval compared to placebo.
5.2 Pharmacokinetic properties
Absorption
Lamotrigine is rapidly and completely absorbed from the gut with no significant first pass metabolism. Peak plasma concentration occur approximately 2-3 hours after oral administration. High interindividual variability in peak plasma concentration at steady state prevails. 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.
Distribution
55% of lamotrigine is bound to plasma proteins. It is very unlikely that displacement from plasma protein would result in toxicity. The volume of distribution is approximately 0.9-1.2 L/kg.
Metabolism
Lamotrigine induces its own metabolism to a modest extent depending on the dose. This leads to a 25 % decrease in half-life at steady state when 150 mg is administered twice daily. However, there is no evidence that lamotrigine affects the pharmacokinetics of other antiepileptic drugs and data suggest that interactions between lamotrigine and active substances metabolised by cytochrome P450 enzymes are unlikely. UDP-glucuronyltransferases are responsible for the metabolism of lamotrigine. The main metabolite found in the urine is 2-N glucuronide which corresponds to 65 % of the dose.
Elimination
The clearance and half-life are independent of the dosage. The mean elimination halflife in healthy adults is 24 to 35 hours. Mean steady-state clearance in healthy volunteers is 39±14 mL/min. Clearance occurs predominantly by metabolism, followed by elimination of glucuronated metabolites in the urine. Less than 10% is eliminated unchanged in the urine, while approximately 2% is excreted in the faeces.
In a study in subjects with Gilbert’s syndrome (glucuronyltransferase deficiency), the mean apparent clearance was reduced by 32% compared with the control group, but the values are within the normal range for the general population.
The half-life of lamotrigine is considerably affected by concomitant treatment. Mean half-life is reduced to approximately 14 hours when given with enzyme-inducing active substances such as carbamazepine or phenytoin and is increased to a mean of approximately 70 hours when co-administered with valproate alone (see section 4.2).
Special patients groups
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 active substances such as carbamazepine and phenytoin and increasing to mean values of 45-50 hours when co-administered with valproate alone (see section 4.2).
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.
Impaired renal Junction
There is no experience of treatment with lamotrigine of patients with renal failure. Pharmacokinetic studies using single doses in subjects with renal failure indicate that the pharmacokinetics of lamotrigine are little affected, but that the plasma concentrations of the major glucuronide metabolite increased almost 8-fold due to reduced renal clearance.
Impaired hepatic Junction
A single dose pharmacokinetic study was performed in 24 patients with various degrees of hepatic impairment and 12 healthy subjects as controls. The median apparent clearance of lamotrigine was 0.31, 0.24 and 0.10 mL/min in patients with grade A, B and C (Child Pugh classification) hepatic impairment, respectively, compared to 0.34 mL/min in the healthy controls. Half-life: 36, 60, or 110 hours versus 32 hours in controls. Reduced doses should generally be used in patients with grade B and C hepatic impairment (see section 4.2).
5.3 Preclinical safety data
In reproductive and developmental toxicity studies in rodents and rabbits, no teratogenic effects but reduced foetal weight and retarded skeletal ossification were observed, at exposure levels below or similar to the expected clinical exposure. Since higher exposure levels could not be tested in animals due to maternal toxicity, the teratogenic potential of lamotrigine has not been characterised above clinical exposure.
In rats, enhanced foetal as well as postnatal mortality was observed when lamotrigine was administered later during gestation (day 15-20). These effects were observed at the expected clinical exposure.
Animal experiments did not reveal impairment of fertility by lamotrigine. Lamotrigine reduced foetal folic acid levels in rats. Folic acid deficiency is assumed to be associated with an enhanced risk of congenital malformations in animals as well as in humans.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Lactose monohydrate Microcrystalline cellulose (E460)
Povidone K 30 (E1201)
Iron oxide yellow (E172)
Sodium starch glycollate type A Magnesium stearate (E470b)
Talc (E553b)
Silica colloidal anhydrous (E551)
6.2 Incompatibilities
Not applicable.
6.3 Shelf life
3 years
6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.
6.5 Nature and contents of container
10, 28, 30, 50, 56, 90, 100 tablets in Aluminium/PVC blisters.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal
No special requirements.
7 MARKETING AUTHORISATION HOLDER
TORRENT PHARMA (UK) Ltd Unit 4, Charlwood Court County Oak Way Crawley RHII 7XA United Kingdom
8 MARKETING AUTHORISATION NUMBER(S)
PL 36687/0002
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE
AUTHORISATION
June 2005
09/04/2014
In clinical trials in adults, skin rashes occurred in up to 8-12% of patients taking lamotrigine and in 5-6% of patients taking placebo. The skin rashes led to the