Lacosamide Dosing for Status Epilepticus
For status epilepticus, lacosamide (Vimpat) should be administered intravenously at a loading dose of 400 mg over 15 minutes, followed by maintenance dosing of 200 mg twice daily. 1
Dosing Recommendations
Initial Loading Dose
- 400 mg IV loading dose is recommended over a 200 mg loading dose for status epilepticus
Maintenance Dosing
- Begin maintenance dosing 12 hours after loading dose
- Typical maintenance: 200 mg twice daily (equivalent to half the loading dose given twice daily) 2
Pediatric Considerations
- For children with status epilepticus, 10 mg/kg has been shown to be safe and effective 3
- Efficacy rate of 78% with 44% becoming seizure-free in pediatric status epilepticus 3
Clinical Evidence and Efficacy
- Lacosamide has demonstrated effectiveness as an add-on treatment in refractory status epilepticus with seizure termination within 24 hours in multiple studies 4
- Higher loading doses (>9 mg/kg) are associated with achieving serum levels within the therapeutic reference interval (10-20 mg/L) 5
- When used as adjunctive therapy for status epilepticus, lacosamide has shown a 36% response rate as monotherapy and contributed to seizure termination in an additional 32% of patients when combined with other anticonvulsants 1
Safety Considerations
Adverse Effects
- Most common adverse effects occur within 4 hours of infusion and include:
- Dizziness
- Somnolence
- Nausea 2
- Less common: headache, back pain, injection site pain 6
- Withdrawal seizures may occur with abrupt discontinuation 6
Monitoring
- Continuous cardiac monitoring during and after administration
- Blood pressure monitoring
- Pulse oximetry
- Monitor for respiratory depression
Precautions
- The 400 mg loading dose is generally better tolerated than higher doses, with fewer treatment-emergent adverse events compared to doses above this level 2
- 200 mg loading doses may be inadequate for status epilepticus management 1
Place in Therapy
- Lacosamide is considered an adjunctive therapy for partial seizures 6, 7
- For status epilepticus, it should be considered after benzodiazepines have failed
- According to guidelines, fosphenytoin, levetiracetam, or valproate are also options for status epilepticus refractory to benzodiazepines 7
Clinical Pearls
- Near steady-state concentrations can be achieved with a single IV loading dose 2
- Weight-based dosing (>9 mg/kg) correlates better with achieving therapeutic levels than fixed dosing 5
- The rapid administration over 15 minutes allows for quick initiation of therapy in emergency situations 2
- Consider lacosamide particularly when other agents are contraindicated or have failed