The Case of Jeremy Stewart
Jeremy Stewart is a 44-year-old, white, married father of three who sees you for a psychiatric evaluation. Jeremy is a college professor at a local college, where he teaches art. He also has a small art studio close to campus where he paints. You diagnose Jeremy with bipolar I disorder. As you think about possible medications to offer Jeremy, you decide to start him on lamotrigine (Lamictal) for his symptoms. Jeremy questions you, asking why you are using a medication for seizures to manage his mood.
Articulate why lamotrigine (Lamictal) is an effective medication for bipolar I management
Lamotrigine sold as Lamictal is considered an effective medication helping to reduce some symptoms that significantly affect epileptic and bipolar patients’ quality of life. In patients diagnosed with bipolar I disorder, the discussed medication is used to manage the severe psychotic symptoms and prevent the recurrence of the disease (Terao, Ishida, Kimura, Yarita, & Hara, 2017). There is evidence that in both bipolar I and bipolar II patients, lamotrigine significantly prolongs the time before the relapse of abnormal mood episodes, thus stabilizing people’s mental condition (Terao et al., 2017). Also, due to its effectiveness, the medication is recommended for the prevention of depressive episodes in people with a bipolar disorder of the first type (Terao et al., 2017).
Explain how lamotrigine is dosed for a patient starting the medication and explain the rationale for why this is done
For adults and children, the medication is available in four types of tablets. Also, nine dosage variations are ranging from 2 to 300mg. In the absence of renal or hepatic impairments, bipolar patients are given lamotrigine 25 mg per orally every day for two weeks and 50mg during the next two weeks (“Lamotrigine (Rx),” n.d.). Starting from the fifth week of treatment, the dose is doubled again. Thus, in adult patients diagnosed with bipolar disorder, healthcare providers are recommended to gradually increase the dose since it helps to track and evaluate patients’ response to pharmacological treatment and prevent complications.
Explain the metabolism, excretion, and mechanism of action for lamotrigine
The metabolism of the discussed medication can be affected by numerous factors. In general, lamotrigine belongs to the number of hepatically metabolized drugs, and the metabolic process is catalyzed by the isoenzymes of UDP-glucuronosyltransferase (Petrenaite et al., 2018). Concerning the route of elimination, lamotrigine is excreted really with the total clearance rate ranging from 0.4 to 1.1 mL/min/kg (“Lamotrigine (Rx),” n.d.).
As for the mechanism of action, lamotrigine is considered an antiepileptic drug that impacts the release of EAA glutamate by inhibiting the activity of sodium channels that are voltage-sensitive (“Lamotrigine (Rx),” n.d.). As a result, the drug helps to stabilize the neuronal membrane (“Lamotrigine (Rx),” n.d.). Thus, it is among the medications that impact patients’ condition by blocking sodium channels.
Discuss the most important side effects associated with lamotrigine and note how you should educate the patient about these side effects
The use of lamotrigine is associated with a variety of side effects. The most frequent and important ones that occur in more than ten percent of patients include lightheadedness, the presence of overlapping shadows, different types of headaches, and abnormalities in muscular coordination (“Lamotrigine (Rx),” n.d.). Additionally, it is important that the drug can have negative effects on sleep-wake patterns, causing both somnolence and insomnia (Lamotrigine (Rx),” n.d.).
To educate the patient, I would provide him with the full list of side effects of lamotrigine and explain how they can manifest themselves. Also, I would ask him to pay attention to his mental state and immediately inform me about any warning signs probably related to the medication. Importantly, given the drug’s potential effects on coordination and general condition, I would also provide education concerning treatment and driving.
After Jeremy has been on the medication for four weeks, he calls you stating he has had flu-like symptoms for two days and he has several small blisters on the left side of his chest and his left arm. What should your next step be in this case?
My next step in the situation would be to reduce the dosage and then invite Jeremy to the clinic to assess his condition. The symptoms that he reports present the side effects of lamotrigine with unknown frequency (Lamotrigine (Rx),” n.d.). At the same time, however, an assessment is needed to exclude the presence of infectious diseases causing the same symptoms. Also, I would interview the patient about possible dosage mistakes, the use of other medications or alcohol, and similar issues.
Identify what type of monitoring should be done when prescribing lamotrigine for a patient
Before prescribing lamotrigine for a bipolar patient, it is important to analyze various risk factors. Among them are the history of hematological issues, renal and hepatic impairments, pregnancies in women, and the experience of undesirable reactions to drugs or their specific components (Brickel et al., 2017). More than that, close psychiatric monitoring is required in bipolar patients treated with lamotrigine to identify and control any side effects (Lamotrigine (Rx),” n.d.).
Brickel, N., Shaikh, H., Kirkham, A., Davies, G., Chalker, M., & Yoshida, P. (2017). Collaboration in pharmacovigilance: Lamotrigine and fatal severe cutaneous adverse reactions – A review of spontaneous reports. Therapeutics and Clinical Risk Management, 13, 897-903.
. (n.d.). Web.
Petrenaite, V., Öhman, I., Ekström, L., Sæbye, D., Hansen, T. F., Tomson, T., & Sabers, A. (2018). UGT polymorphisms and lamotrigine clearance during pregnancy. Epilepsy Research, 140, 199-208.
Terao, T., Ishida, A., Kimura, T., Yarita, M., & Hara, T. (2017). Preventive effects of lamotrigine in bipolar II versus bipolar I disorder. The Journal of Clinical Psychiatry, 78(8), e1000-e1005.