What is the next step in medication management for a 13-year-old female with epilepsy and recent breakthrough seizures, currently taking levetiracetam (Keppra) and clobazam (Onfi)?

Management of Breakthrough Seizures in a 13-Year-Old with Epilepsy

The most appropriate next step in medication management for this 13-year-old female with recent breakthrough seizures is to increase clobazam (Onfi) to 15 mg BID as already planned, while maintaining the current levetiracetam (Keppra) dose of 1500 mg BID.

Current Medication Regimen and Recent Changes

• Patient is currently on:
  • Levetiracetam (Keppra) 1500 mg BID (recently increased from previous dose)
  • Clobazam (Onfi) 10 mg BID with additional 5 mg BID during menstrual cycle

Rationale for Medication Adjustment

Clobazam Dose Increase

• The planned increase to clobazam 15 mg BID is appropriate based on:
  • FDA labeling for clobazam indicates that effectiveness increases with increasing dose within the recommended range 1
  • Patient has shown good response to cyclical clobazam adjustment during menstrual cycle
  • Current weight-based dosing guidelines support this increase 1
  • The patient has been tolerating clobazam well without reported adverse effects

Maintaining Current Levetiracetam Dose

• Levetiracetam was recently increased to 1500 mg BID just one week ago
  • This dose should be maintained to allow adequate time to reach steady state and evaluate efficacy
  • Levetiracetam is recognized as an effective option for refractory seizures 2, 3

Monitoring Plan

• Schedule follow-up within 1-2 weeks to assess response to the increased clobazam dose
• Implement seizure diary to track:
  • Seizure frequency, duration, and characteristics
  • Any warning signs (patient's vocalization before seizures)
  • Medication adherence
  • Adverse effects

Additional Diagnostic Evaluation

• Proceed with the planned 23-hour inpatient video EEG to:
  • Assess for subclinical seizures
  • Clarify seizure type and frequency
  • Guide further medication adjustments if needed

Considerations for Clobazam Use

• Benefits:

  • Effective for various seizure types, particularly in refractory epilepsy 4
  • Can be especially helpful for seizures associated with menstrual cycles 5
  • Has shown efficacy in children with refractory epilepsy 6

• Potential concerns:

  • Monitor for tolerance development, though this is less common with intermittent dosing 5
  • Watch for side effects including sedation, behavioral changes, and ataxia 4
  • Implement gradual tapering if discontinuation is needed to prevent withdrawal reactions 1

Alternative Options if Current Plan Fails

If the patient continues to have breakthrough seizures despite the increased clobazam dose:

1. Consider further increasing clobazam (up to maximum of 40 mg daily for >30kg patients) 1
2. Consider adding valproate as an alternative agent (has shown 88% efficacy in refractory status epilepticus) 2, 3
3. Evaluate for surgical options if medications fail to control seizures

Cautions and Monitoring

• Monitor for adverse effects of clobazam including sedation, irritability, and ataxia
• Avoid abrupt discontinuation of either medication to prevent withdrawal seizures
• Ensure adequate education about rescue medication protocols for prolonged seizures
• Continue to evaluate the relationship between seizures and menstrual cycle

The patient's recent seizure pattern and response to medication adjustments suggest that optimizing the clobazam dose while maintaining the recently increased levetiracetam dose represents the most evidence-based approach to managing her breakthrough seizures.