What medication adjustment is recommended for an 8-year-old male patient with Autism Spectrum Disorder (ASD) and abnormal EEG results, currently taking Aptiom (eslicarbazepine) 300mg BID?

Medication Adjustment for 8-Year-Old with ASD and Abnormal EEG Findings

Based on the frequent epileptiform activity during slow wave sleep (22% spike wave index), I recommend increasing Aptiom (eslicarbazepine) to 400mg BID while monitoring for side effects.

Current Clinical Situation

The patient is:

• 8-year-old male with ASD
• Weight: 31.75kg
• Current medication: Aptiom (eslicarbazepine) 300mg BID
• Recent EEG findings:
  • Occasional right and left sided independent focal epileptiform spikes during awake state
  • Extremely frequent right and left sided independent focal epileptiform spike wave index of 22% during slow wave sleep

Rationale for Medication Adjustment

The patient's current EEG findings indicate significant epileptiform activity, particularly during sleep. A spike wave index of 22% during slow wave sleep is concerning and suggests inadequate seizure control with the current dosage of Aptiom.

According to the FDA label for eslicarbazepine acetate, the recommended dosage for pediatric patients is based on body weight 1. For this 31.75kg child, the current dose (600mg/day) is likely insufficient to control the frequent epileptiform discharges seen on EEG.

Specific Recommendation

1. Increase Aptiom (eslicarbazepine) from 300mg BID to 400mg BID (800mg/day total)

   • This represents a 33% increase in daily dose
   • Maintains the twice-daily dosing schedule for stability
   • Aligns with FDA-approved dosing guidelines for pediatric patients

2. Implement a follow-up EEG in 4-6 weeks to assess the impact of the dose adjustment on epileptiform activity, particularly the spike wave index during sleep

3. Monitor for side effects, including:

   • Dizziness, somnolence, and fatigue (most common in pediatric patients)
   • Diplopia or blurred vision
   • Nausea or vomiting
   • Ataxia or coordination problems
   • Hyponatremia (check sodium levels if symptoms develop)

Supporting Evidence

The FDA label for eslicarbazepine acetate (Aptiom) indicates it is approved for the treatment of partial-onset seizures in patients 4 years of age and older 1. For pediatric patients, dosage adjustments should be based on clinical response and tolerability.

Eslicarbazepine acetate has several advantages in this clinical scenario:

• Once or twice daily dosing improves medication adherence 2
• It has a favorable safety profile in pediatric epilepsy 3
• It enhances slow inactivation of voltage-gated sodium channels, which helps reduce the activity of rapidly firing neurons 2

Important Considerations

1. Do not abruptly discontinue eslicarbazepine acetate as this could increase seizure frequency or precipitate status epilepticus 1

2. Monitor for drug interactions if the patient is on other medications. Eslicarbazepine has fewer drug interactions than carbamazepine but still affects CYP2C19 2

3. Consider seizure diary implementation to track clinical seizures alongside EEG improvement

4. If inadequate response to this dose adjustment, further options include:

   • Additional dose increases up to the maximum tolerated dose
   • Addition of a second antiepileptic medication with a complementary mechanism of action

Common Pitfalls to Avoid

1. Inadequate dose adjustment: Small incremental changes may not sufficiently impact the high spike wave index

2. Failure to follow up with repeat EEG: Clinical seizure control alone may not reflect improvement in the epileptiform activity during sleep

3. Overlooking side effects: Children may not articulate side effects clearly; monitor for behavioral changes, academic performance, and sleep quality

4. Ignoring the impact on comorbid ASD: Monitor for any changes in ASD symptoms or behaviors with medication adjustment

This medication adjustment aims to better control the patient's epileptiform activity while maintaining a favorable side effect profile, ultimately improving seizure control, cognitive function, and quality of life.