Sunday, July 24, 2016

A fatal case of Initial 200 mg/day lamotrigine

Just recently, a sad incident was reported in medical practice.

Yahoo News: A lethal case of overdosing by 16 times in 2014 (in Japanese)

A 43-year-old woman was suffering from epilepsy due the recurrence of a brain tumor. She was planned to take an operation. Also, she had to take some anticonvulsant drugs to prevent seizure. The doctor prescribed lamotrigine, a common antiepileptic drug. But the dose was issued, according to the media.

Lamotrigine is an excellent drug not only for antiepileptic effect but also as a mood stabilizer. However, it has a serious risk of a rush. Different from other drugs, lamotrigine sometimes causes toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome (SJS, a milder form of TEN). This adverse reaction can be fatal. Therefore, medical practitioners should be extremely cautious of this onset and make maximum efforts of prevention.

Wikipedia: Lamotrigine

Wikipedia: Stevens-Johnson syndrome

For minimizing the risk of allergic reactions, the initial dose of lamotrigine is recommended to be 25 mg/day for adults. In the case taking valproate as another anticonvulsant, the regimen in which 25 mg of lamotrigine is taken every other day for initial two weeks is recommended.

However, the doctor in charge prescribed her 200mg/day of lamotrigine. The amount is regular daily dose considered to be effective. Thus, the doctor violated the guideline for quick efficacy of the medication.

As a result, the patient was attacked by TEN, to be fatal three weeks after taking lamotrigine.

The media reported that the patient had wished to attend an event shortly, so the doctor gave her a lot of drugs for successful suppression of seizure. The doctor claims that the patient accepted the risk of adverse effects in advance of taking lamotrigine. But the lawyer said she would not have taken the drug if she had been explained precisely about the fatal risk.

It is not certain an informed consent was done about the initial loading of lamotrigine. If so, in my opinion, the prescription of the doctor is inappropriate. There is rich evidence suggesting that taking a high dose of lamotrigine initially is hazardous. The doctor should have declined her request even if she really wanted to take lamotrigine with initial high dose.

On the other hand, the guideline is not entirely correct. There are numerous exceptions. It was possible that she would have been safe and had enjoyed the event without afraid of seizure. She might not be able to recognize the risk of fatality in spite of the explanation. And it could be difficult for the doctor to make her abandon attend the event. She was unlucky, actually.

Nonetheless, I would never give a patient lamotrigine in such a manner, regardless of the situation. And I believe the doctor is responsible for her death, if the media reports are exact. But it is not derived from the fact that the physician did not adhere to the guidelines. My judgment is originated from my personal sense that initial high dose of lamotrigine is quite risky. Many medical decisions rely on such feelings of the practitioner, in real.

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