In this scenario I take a look at lamotrigine and tramadol amongst other things and why a diagnosis for every medication really matters.

A 71 year old male has been having increasing osteoarthritis pain.  He reports pain in his hands, back, and knees.  Acetaminophen and NSAIDs have not seemed to have helped this patient and the provider writes for tramadol 50 mg BID.

Past medical history includes

• CKD
• Insomnia
• GERD
• Hypertension
• Hyperlipidemia
• Osteoarthritis

Current medications include:

• Amitriptyline 10 mg at bedtime
• Tums 500 mg BID prn
• Famotidine 20 mg daily
• Aspirin 81 mg daily
• Lamotrigine 250 mg BID
• Norvasc 10 mg daily
• Tramadol 50 mg BID

1. The first thing that I notice in this scenario is the relatively decent sized dose of lamotrigine.  Along with that lamotrigine dose, I notice that the patient doesn’t have a diagnosis that would make sense for using this medication.  It would concern me that it is being used for seizures and I would be potentially concerned with the tramadol that can lower seizure threshold.  It could definitely be for mood/behavioral disorder, but it is something that needs to be figured out.  There is also the potential for a CNS depressant drug interaction between these two.
2. The amitriptyline is a little peculiar in a 71 year old patient.  I would suspect being given at bedtime that it is being used for insomnia.  If that’s the case, I’d be looking for alternative options including non-drug interventions if at all possible.
3. With any patient with CKD, I’m always on the lookout for medications that would need to be dose adjusted.  Famotidine comes to mind, but at a relatively modest to low dose it probably wouldn’t be a major concern.  Lamotrigine doesn’t have standard dose adjustments, but given the dose is on the upper end, I would definitely monitor this closely.
4. Hyperlipidemia without a medication is also an interesting finding that should be reviewed.

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