What are the treatment options for seizures, including medication choices and starting doses?

From the Guidelines

Treatment for seizures primarily involves antiepileptic drugs (AEDs), with selection based on seizure type, patient characteristics, and side effect profiles, and according to the most recent guidelines, fosphenytoin, levetiracetam, or valproate may be used as second-line agents with similar efficacy 1. When considering medication choices, the following options are available:

• Levetiracetam, starting at 500mg twice daily, increasing to 1000-1500mg twice daily
• Valproate, starting at 500mg daily, increasing to 500-750mg twice daily
• Fosphenytoin, with dosing dependent on the specific clinical scenario It's essential to note that medication adherence is crucial, and patients should avoid seizure triggers like sleep deprivation, alcohol, and certain medications. Regular monitoring of drug levels and liver function is necessary for some AEDs. If seizures persist despite adequate trials of two appropriate AEDs, referral to a neurologist for consideration of alternative treatments, including surgery, neurostimulation, or dietary therapy, is recommended. In cases of refractory seizures, second-line agents like fosphenytoin, levetiracetam, or valproate can be used, as recommended by the most recent clinical policy 1. The choice of medication should be based on the specific type of seizure, patient characteristics, and side effect profiles. For example, levetiracetam and valproate can be used for both focal and generalized seizures, while fosphenytoin is often used as a second-line agent for refractory seizures 1. It's also important to consider the potential side effects of each medication, such as dizziness, fatigue, and cognitive effects, and to regularly monitor patients for these adverse effects. In addition to medication, other treatment options like surgery, neurostimulation, or dietary therapy may be considered for patients with refractory seizures. Overall, the goal of treatment is to achieve seizure freedom while minimizing side effects and improving quality of life. According to the most recent guidelines, the treatment of seizures should be individualized and based on the specific needs of each patient, taking into account the type of seizure, patient characteristics, and side effect profiles 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Levetiracetam is indicated as adjunctive treatment of partial onset seizures in adults and children 4 years of age and older with epilepsy. Treatment should be initiated with a daily dose of 1000 mg/day, given as twice-daily dosing (500 mg BID) Pediatric Patients Ages 4 To <16 Years Treatment should be initiated with a daily dose of 20 mg/kg in 2 divided doses (10 mg/kg BID).

DOSAGE AND ADMINISTRATION Epilepsy In the controlled add-on trials, no correlation has been demonstrated between trough plasma concentrations of topiramate and clinical efficacy. The recommended dose for topiramate monotherapy in adults and children 10 years of age and older is 400 mg/day in two divided doses The dose should be achieved by titrating according to the following schedule: Morning Dose Evening Dose Week 1 25 mg 25 mg

The different meds for seizures and their starting doses are:

• Levetiracetam (PO):
  • Adults: 1000 mg/day, given as twice-daily dosing (500 mg BID) 2
  • Pediatric Patients Ages 4 To <16 Years: 20 mg/kg in 2 divided doses (10 mg/kg BID) 2
• Topiramate (PO):
  • Adults: 25 mg twice daily, titrating up to 400 mg/day in two divided doses 3
  • Pediatric Patients (Ages 2 - 16 Years): 25 mg (or less, based on a range of 1 to 3 mg/kg/day) nightly for the first week, titrating up to 5 to 9 mg/kg/day in two divided doses 3

From the Research

Treatment Options for Seizures

The treatment options for seizures include various medication choices, with the selection of a particular medication depending on the type of seizure and individual patient characteristics 4, 5.

Medication Choices

Some of the commonly used medications for seizures include:

• Valproate: often used as a first-line treatment for generalized epilepsies 6
• Lamotrigine: effective for partial seizures and generalized seizures, including absence seizures 4, 6
• Carbamazepine: used for partial seizures and generalized seizures 4
• Oxcarbazepine: used for partial seizures and generalized seizures 4
• Topiramate: used for partial seizures and generalized seizures 4, 6
• Levetiracetam: effective for generalized tonic-clonic, tonic, and clonic seizures 6, 7
• Phenytoin: used for partial seizures and generalized seizures, although it may be inferior to valproate for some seizure types 6
• Ethosuximide: used for absence seizures, with efficacy comparable to valproate 6

Starting Doses

The starting doses for these medications vary, but some general guidelines include:

• Valproate: initial dose of 10-15 mg/kg/day, with gradual increase to a maintenance dose of 20-25 mg/kg/day 8
• Lamotrigine: initial dose of 25 mg/day, with gradual increase to a maintenance dose of 100-200 mg/day 8
• Carbamazepine: initial dose of 100-200 mg/day, with gradual increase to a maintenance dose of 400-1200 mg/day 8
• Oxcarbazepine: initial dose of 300 mg/day, with gradual increase to a maintenance dose of 600-2400 mg/day 8
• Topiramate: initial dose of 25-50 mg/day, with gradual increase to a maintenance dose of 100-400 mg/day 8
• Levetiracetam: initial dose of 250-500 mg/day, with gradual increase to a maintenance dose of 1000-3000 mg/day 8, 7
• Phenytoin: initial dose of 100-200 mg/day, with gradual increase to a maintenance dose of 300-400 mg/day 8
• Ethosuximide: initial dose of 250 mg/day, with gradual increase to a maintenance dose of 500-1500 mg/day 8

Individualized Treatment

The choice of medication and starting dose should be individualized based on the patient's specific needs and characteristics, including the type of seizure, age, and comorbid conditions 4, 5, 7.