How to safely discontinue lacosamide (antiepileptic medication)?

How to Safely Discontinue Lacosamide

Taper lacosamide gradually by reducing the dose by 100 mg/day (50 mg twice daily) at weekly intervals until complete discontinuation, while monitoring closely for breakthrough seizures. 1

Tapering Protocol

The recommended withdrawal strategy involves systematic dose reductions at regular intervals:

• Reduce lacosamide by 100 mg/day (50 mg twice daily) decrements at 1-2 week intervals 1
• Monitor for increased seizure frequency after each dose reduction before proceeding to the next step 1
• If withdrawal symptoms or breakthrough seizures occur, return to the previous well-tolerated dose and slow the taper further 1
• Do not discontinue abruptly, as this increases risk of withdrawal seizures despite lacosamide's pharmacokinetic profile 1

Clinical Context for Discontinuation

Consider discontinuation only in specific clinical scenarios:

• Patients who have been seizure-free for 6 months after resolution of underlying lesions (such as single enhancing lesions from neurocysticercosis) without risk factors for recurrent seizures 2
• Risk factors that argue against discontinuation include: residual cystic lesions or calcifications on neuroimaging, breakthrough seizures, or more than 2 seizures during disease course 2
• In patients without risk factors and no seizures for 24 consecutive months, tapering may be considered 2

Monitoring During Discontinuation

Implement a structured monitoring plan throughout the taper:

• Document baseline seizure frequency and type before initiating the taper 1
• Assess for breakthrough seizures after each dose adjustment 1
• If seizure frequency increases significantly, pause or slow the taper 1
• Extended monitoring periods (weeks to months) may be required to identify delayed seizure recurrence after the final dose 2

Critical Safety Considerations

Avoid common pitfalls that compromise patient safety:

• Never discontinue lacosamide abruptly except in cases of serious medical toxicity 2
• Gradual tapering is essential even though some medications theoretically may not require it 2
• Discontinuation in inpatient or short-stay settings is problematic, as symptom recurrence may occur after discharge without adequate monitoring 2
• Obtain complete medication history and previous response patterns before implementing discontinuation, particularly when assuming care from another provider 2

Special Populations

Pregnant patients with well-controlled seizures should not discontinue lacosamide:

• Continue lacosamide throughout pregnancy when seizures are well-controlled, as risks of seizure recurrence outweigh potential medication risks 3
• Abrupt discontinuation can precipitate breakthrough seizures, which carry higher maternal and fetal risks than continuing medication 3
• Maintain current dosage rather than attempting to taper if seizures remain controlled 3

When Transitioning to Another Antiepileptic

If switching from lacosamide to another antiepileptic drug:

• Begin the new medication when lacosamide has been reduced to approximately 50% of the original dose, allowing overlap to maintain seizure control 1
• Continue the 100 mg/day reduction schedule at weekly intervals for the remaining lacosamide dose 1
• This cross-titration strategy minimizes risk of breakthrough seizures during the transition period 1