Lacosamide Dosage and Treatment Protocol for Adults with Partial-Onset Seizures
For adults with partial-onset seizures, lacosamide (Vimpat) should be administered at an initial dose of 50 mg twice daily (100 mg/day), titrated weekly by 100 mg/day increments to a recommended maintenance dose of 200-400 mg/day given in two divided doses. 1
Dosing Protocol
Initial Dosing and Titration
- Start with 50 mg twice daily (100 mg/day) 2
- Increase by 50 mg twice daily (100 mg/day) at weekly intervals 3
- Target maintenance dose: 200-400 mg/day in two divided doses 1
Administration Options
- Available in both oral (tablets, syrup) and intravenous formulations 2
- Oral and IV formulations have similar bioavailability, allowing for interchangeable use when necessary 2
- IV administration should be over 30-60 minutes when oral administration is temporarily not feasible 3
Efficacy Data
- Clinical trials demonstrate significant seizure reduction compared to placebo:
Safety and Tolerability
- Most common adverse effects (occurring in ≥5% of patients and at least twice the rate of placebo): 5
- Dizziness (30.6% vs. 8.2% for placebo)
- Nausea (11.4% vs. 4.4% for placebo)
- Diplopia (10.5% vs. 1.9% for placebo)
- Adverse effects are generally dose-related and more common during titration than maintenance 5
- Most adverse events are mild to moderate in intensity 5, 3
- Severe adverse events are predominantly observed with doses of 600 mg/day 5
Special Considerations
Drug Interactions
- No clinically significant interactions with cytochrome P450 system 6
- Can be safely combined with most commonly used antiepileptic drugs 5
- Discontinuation rates due to adverse events when combined with common AEDs: 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)
Pregnancy Considerations
- For pregnant women with well-controlled epilepsy on lacosamide, continuation of therapy is recommended as seizure control is critical for reducing maternal and fetal morbidity and mortality 7
- Abrupt discontinuation during pregnancy should be avoided as it may precipitate breakthrough seizures 7
Important Clinical Pearls and Pitfalls
- Withdrawal seizures can occur with abrupt discontinuation; taper gradually when discontinuing 1
- Lacosamide is indicated specifically for partial-onset seizures; not studied for other seizure types 1
- The 600 mg/day dose is associated with significantly more adverse effects without proportional increase in efficacy 5
- Monitor patients closely during titration phase when adverse effects are most likely to occur 5
- Consider slower titration in patients experiencing significant adverse effects 3