Phenyltriazine
Lamotrigine belongs to the phenyltriazine drug class and is chemically
unrelated to other anticonvulsants. Lamotrigine is FDA approved for
adjunctive therapy in adults with partial seizures and in children older
than age 2 with generalizedseizures or Lennox-Gastaut syndrome.
Pharmacokinetics
Lamotrigine is well absorbed by the body at a rapid rate. It’s metabolized
by the liver and excreted by the kidneys. Clearance increases in the
presence of other enzyme-inducing anticonvulsant drugs. The drug isn’t
significantly bound to plasma proteins.
Pharmacodynamics
The precise mechanism of action of lamotrigine is unknown, but it is
thought to involve a use-dependent blocking effect on sodium channels,
resulting in inhibition of the release of excitatory neurotransmitters,
glutamate, and aspartate.
Pharmacotherapeutics
Lamotrigine is approved for adjunctive therapy in adults and children older
than age 2 with generalized seizures or Lennox-Gastaut syndrome. It
may also be used for conversion to monotherapy in adults. Lamotrigine
appears effective for many types of generalized seizures, but can worsen
myoclonic seizures. Lamotrigine may also lead to improvement in the
patient’s mood.
Drug interactions
• Carbamazepine, phenytoin, phenobarbital, primidone, and
acetaminophen may result in decreased lamotrigine effects.
• Valproic acid may decrease the clearance of lamotrigine and the
steady-state level of lamotrigine.
• Lamotrigine may produce additive effects when combined with folate
inhibitors.
Adverse reactions
Adverse reactions to lamotrigine commonly include:
• dizziness
• ataxia
• somnolence
• headache
• diplopia
• nausea
• vomiting
• rash.
Several types of rash may occur with lamotrigine use, including Stevens-
Johnson syndrome. This generalized, erythematous, morbilliform rash
usually appears in the first 3 to 4 weeks of therapy and is usually mild to
moderate but may be severe. The drug now carries a “black box” warning
regarding the rash, and the manufacturer recommends discontinuing the
drug at the first sign of a rash. The risk of rash may be increased by
starting at high doses, by rapidly increasing doses, or by using the drug
with valproate.
Nursing process
Assessment
• Obtain a history of the patient’s seizure disorder before therapy.
• Evaluate the patient for reduction in seizure frequency and duration
after therapy begins. Check the adjunct anticonvulsant’s level
periodically.
• Monitor the patient’s serum levels and response to the prescribed
drug as indicated.
• Monitor the patient for adverse reactions.
• Assess the patient’s compliance with therapy at each follow-up visit.
Key nursing diagnoses
• Risk for injury related to adverse reactions
• Impaired physical mobility related to sedation
• Noncompliance related to long-term therapy
Planning outcome goals
• Risk to the patient will be minimized.
• The patient will be able to perform ADLs.
• The patient will exhibit behaviors that comply with long-term therapy.
Implementation
• Administer oral forms of the drug with food to reduce GI irritation.
• Expect the dosage to be lowered if the drug is added to a multidrug
regimen that includes valproic acid.
• Expect that a lowered maintenance dosage will be used in a patient
with severe renal impairment.
• Don’t stop the drug abruptly. Abrupt withdrawal increases the risk of
seizures. Instead, drug withdrawal should be tapered over at least
2 weeks.
• A rash may be life-threatening. Stop the drug and notify the
prescriber at the first sign of a rash.
• Administer safety precautions if the patient has adverse CNS
reactions.
Evaluation
• Patient sustains no injury from adverse reactions.
• Patient maintains physical mobility.
• Patient complies with therapy and has no seizures
