Clinical points to be considered if lamotrigine is chosen to augment clozapine

When treating patients with schizophrenia, what clinical points should be considered if lamotrigine is chosen to augment clozapine?

1. Make sure that blood clozapine levels are in the therapeutic range and the patient is taking the maximum tolerable doses of clozapine over at least 18-24 weeks.

2. Inform the patient and the caregiver about possible dermatological side effects, including Stevens-Johnson syndrome, and how to monitor the skin.

3. The initial dosage of lamotrigine should be as low as possible (12.5-25 mg by mouth, at bedtime) and increased VERY slowly, on average 25 mg/week to clinical response. You may consider increasing to a maximum of 300 mg/day.

4. There has been 1 case of lamotrigine-associated agranulocytosis reported, but one should be aware of such theoretical possibility.

5. Try to keep patients on only the clozapine plus lamotrigine combination and avoid any concomitant medications (including nonpsychotropic medications).

6. Upon achieving a clinically satisfactory response, the patient can be maintained on this combination indefinitely.

Source: J Psychiatry Neurosci. 2001 March; 26(2): 168.