Adult Dosing of Lacosamide
The recommended adult dosing of lacosamide is 200-400 mg/day administered in two divided doses, with a maximum approved dose of 400 mg/day. 1, 2
Initial Dosing and Titration
- Oral lacosamide therapy typically starts at 50 mg twice daily (100 mg/day) and can be increased at weekly intervals by 100 mg/day (50 mg twice daily) to reach the target maintenance dose 2
- For more rapid titration, studies have shown that lacosamide can be safely titrated to reach 400 mg/day within one week without increased adverse events compared to conventional weekly titration 3
- Intravenous loading dose options for rapid initiation:
- 200 mg or 300 mg IV administered over 15 minutes are well-tolerated in lacosamide-naïve patients 4
- Following IV loading, oral maintenance dosing can begin 12 hours later at half the loading dose given twice daily 4
- 400 mg IV loading dose is less well-tolerated due to higher frequency of dose-related adverse events 4
Maintenance Dosing
- Maintenance dose range: 200-400 mg/day divided into two equal doses 1, 2
- Bioequivalence exists among the three lacosamide formulations (oral tablets, oral solution, and IV solution), allowing direct conversion between formulations without titration 1
Special Considerations
- Dose-dependent adverse effects are common, particularly at doses above 400 mg/day 5
- Most common adverse effects include:
- Adverse effects are more common during titration than during maintenance phase 5
- Concomitant use with sodium channel blockers significantly increases the risk of adverse events 3
Pharmacokinetic Profile
- Lacosamide has several favorable pharmacokinetic characteristics: 1
- Rapid absorption and high oral bioavailability not affected by food
- Linear and dose-proportional pharmacokinetics
- Low inter- and intraindividual variability
- Low plasma protein binding
- Renal elimination
- Low potential for clinically relevant drug-drug interactions
Common Pitfalls and Caveats
- Discontinuation of lacosamide or dose reductions due to adverse events occurred in 46% of patients in one study, with 74% of these experiencing adverse events after reaching 400 mg/day, demonstrating apparent dose-dependency 3
- When administering with other antiepileptic drugs, be aware that discontinuations due to adverse events may vary based on concomitant medications: 5
- With carbamazepine: 15.3% (vs 3.9% for placebo)
- With lamotrigine: 19.2% (vs 4.3% for placebo)
- With levetiracetam: 10.1% (vs 3.9% for placebo)
- Most adverse effects are mild to moderate in intensity, with severe adverse events predominantly observed at higher doses (600 mg/day) 5