Prescription Templates for Seizure Management
Status Epilepticus Management
For any patient actively seizing, immediately administer IV lorazepam 4 mg at 2 mg/min as first-line treatment, which demonstrates 65% efficacy in terminating status epilepticus. 1
First-Line Treatment (Active Seizures)
- Lorazepam 4 mg IV at 2 mg/min - preferred benzodiazepine due to longer duration of action 1
- Check fingerstick glucose immediately and correct hypoglycemia while administering treatment 1
- If IV access unavailable, use rectal diazepam as alternative 2
Second-Line Treatment (Seizures Continuing After Benzodiazepines)
After adequate benzodiazepine dosing, administer one of the following agents based on patient-specific factors: 3, 1
Option 1: Valproate (Preferred for Safety Profile)
- Dose: 20-30 mg/kg IV over 5-20 minutes 1
- Efficacy: 88% seizure control 1
- Hypotension risk: 0% 1
- Maintenance: 1-2 mg/kg/hour continuous infusion 2
- Prescription Template:
Valproate 20-30 mg/kg IV (max 3000 mg) Infuse over 5-20 minutes Follow with maintenance infusion 1-2 mg/kg/hour Monitor: Liver function, platelets, ammonia
Option 2: Fosphenytoin (Most Widely Available)
- Dose: 20 mg PE/kg IV at maximum rate of 150 PE/min 1
- Efficacy: 84% seizure control 1
- Hypotension risk: 12% 1
- Requires continuous ECG and blood pressure monitoring 1
- Prescription Template:
Fosphenytoin 20 mg PE/kg IV (max 1500 mg PE) Infuse at maximum rate 150 PE/min Continuous cardiac monitoring required Monitor: Blood pressure, ECG, phenytoin level
Option 3: Levetiracetam (Minimal Cardiovascular Effects)
- Dose: 30 mg/kg IV over 5 minutes 1
- Efficacy: 68-73% seizure control 1
- Minimal drug interactions, no serum level monitoring required 2
- Prescription Template:
Levetiracetam 30 mg/kg IV (max 3000 mg) Infuse over 5 minutes Monitor: Behavioral changes, somnolence
Option 4: Phenobarbital
- Dose: 20 mg/kg IV over 10 minutes 1
- Efficacy: 58.2% seizure control 1
- Higher risk of respiratory depression 1
- Prescription Template:
Phenobarbital 20 mg/kg IV (max 1500 mg) Infuse over 10 minutes Monitor: Respiratory status, blood pressure Prepare for possible intubation
Third-Line Treatment (Refractory Status Epilepticus)
Refractory status epilepticus is defined as seizures continuing despite benzodiazepines and one second-line agent; initiate continuous EEG monitoring at this stage. 1
Option 1: Midazolam Infusion (First Choice for Refractory SE)
- Loading dose: 0.15-0.20 mg/kg IV 1
- Continuous infusion: 1 mg/kg/min 1
- Titrate up by 1 mg/kg/min every 15 minutes to maximum 5 mg/kg/min 1
- Efficacy: 80% overall success rate 1
- Hypotension risk: 30% 1
- Prescription Template:
Midazolam 0.15-0.20 mg/kg IV bolus Follow with continuous infusion 1 mg/kg/min Titrate by 1 mg/kg/min every 15 minutes Maximum rate: 5 mg/kg/min Monitor: Continuous EEG, blood pressure, respiratory status Load phenytoin/valproate/levetiracetam during infusion
Option 2: Propofol (For Intubated Patients)
- Loading dose: 2 mg/kg bolus 1
- Continuous infusion: 3-7 mg/kg/hour 1
- Efficacy: 73% seizure control 1
- Hypotension risk: 42% 1
- Requires mechanical ventilation but shorter ventilation time (4 days vs 14 days with pentobarbital) 1
- Prescription Template:
Propofol 2 mg/kg IV bolus Follow with continuous infusion 3-7 mg/kg/hour Titrate to EEG burst suppression Monitor: Continuous blood pressure, EEG, triglycerides Mechanical ventilation required
Option 3: Pentobarbital (Highest Efficacy, Most Hypotension)
- Loading dose: 13 mg/kg 1
- Continuous infusion: 2-3 mg/kg/hour 1
- Efficacy: 92% seizure control 1
- Hypotension risk: 77% 1
- Prescription Template:
Pentobarbital 13 mg/kg IV bolus Follow with continuous infusion 2-3 mg/kg/hour Titrate to EEG burst suppression Monitor: Continuous blood pressure, EEG Prepare for vasopressor support Mechanical ventilation required
Generalized Tonic-Clonic Seizures (Chronic Management)
For chronic management of generalized tonic-clonic seizures, sodium valproate is the first-line treatment, with lamotrigine and levetiracetam as suitable alternatives, particularly for those of childbearing potential. 4, 5
First-Line Monotherapy Options
Option 1: Valproate (Treatment of Choice)
- Starting dose: 15 mg/kg/day in divided doses 6
- Increase by 5-10 mg/kg/week to achieve optimal response 6
- Target dose: Usually below 60 mg/kg/day 6
- Therapeutic level: 50-100 μg/mL 6
- Prescription Template:
Valproic Acid 250 mg PO TID (for 60 kg patient = 12.5 mg/kg/day) Increase by 250 mg every week as tolerated Target dose: 1000-1500 mg daily in divided doses Monitor: Liver function, CBC, ammonia, valproate level Contraindicated in pregnancy
Option 2: Lamotrigine (Alternative, Especially for Women of Childbearing Age)
- Starting dose: 25 mg daily for 2 weeks (when not on enzyme inducers) 4, 5
- Slow titration required to minimize rash risk 4, 5
- Prescription Template:
Lamotrigine 25 mg PO daily x 2 weeks Then 50 mg daily x 2 weeks Then 100 mg daily x 1 week Target maintenance: 200-400 mg daily in 1-2 divided doses Monitor: Rash (discontinue if develops), liver function Slower titration if on valproate
Option 3: Levetiracetam (Alternative with Minimal Drug Interactions)
- Starting dose: 500 mg twice daily 4, 5
- Increase by 500 mg every 2 weeks 4, 5
- Prescription Template:
Levetiracetam 500 mg PO BID Increase to 1000 mg BID after 2 weeks Target maintenance: 1000-1500 mg BID Monitor: Behavioral changes, mood disturbances No serum level monitoring required
Option 4: Topiramate (Second-Line)
- Starting dose: 25-50 mg daily 7
- Increase by 25-50 mg weekly 7
- Prescription Template:
Topiramate 25 mg PO daily x 1 week Then 50 mg daily x 1 week Then 100 mg daily x 1 week Target maintenance: 200-400 mg daily in 2 divided doses Monitor: Cognitive effects, weight loss, kidney stones
Complex Partial Seizures (Focal Seizures with Impaired Awareness)
For complex partial seizures, carbamazepine and oxcarbazepine are treatments of choice, with lamotrigine and levetiracetam also as first-line options. 7, 4, 5
First-Line Monotherapy Options
Option 1: Oxcarbazepine (Treatment of Choice)
- Starting dose: 300 mg twice daily 7
- Increase by 300 mg every 3 days 7
- Prescription Template:
Oxcarbazepine 300 mg PO BID Increase to 600 mg BID after 3 days Then 900 mg BID after 3 more days Target maintenance: 900-1200 mg BID Monitor: Sodium (hyponatremia risk), rash
Option 2: Carbamazepine (Treatment of Choice)
- Starting dose: 200 mg twice daily 7, 8
- Increase by 200 mg every week 8
- Therapeutic level: 4-12 μg/mL 8
- Prescription Template:
Carbamazepine 200 mg PO BID Increase to 400 mg BID after 1 week Then 600 mg BID after 1 more week Target maintenance: 800-1200 mg daily in 2-3 divided doses Monitor: CBC, liver function, carbamazepine level, sodium Check for HLA-B*1502 in Asian patients before starting
Option 3: Lamotrigine (First-Line Alternative)
- Starting dose: 25 mg daily for 2 weeks 7, 4, 5
- Prescription Template:
Lamotrigine 25 mg PO daily x 2 weeks Then 50 mg daily x 2 weeks Then 100 mg daily x 1 week Target maintenance: 200-400 mg daily in 1-2 divided doses Monitor: Rash (discontinue if develops)
Option 4: Levetiracetam (First-Line Alternative)
- Starting dose: 500 mg twice daily 7, 4, 5
- Prescription Template:
Levetiracetam 500 mg PO BID Increase to 1000 mg BID after 2 weeks Target maintenance: 1000-1500 mg BID Monitor: Behavioral changes, irritability
Adjunctive Therapy (If Monotherapy Fails)
For partial seizures refractory to monotherapy, add one of the following to the initial agent: 9
Valproate Added to Carbamazepine/Oxcarbazepine
- Prescription Template:
Continue current carbamazepine/oxcarbazepine dose Add Valproic Acid 250 mg PO TID Increase by 250 mg weekly Target: 1000-1500 mg daily in divided doses Monitor: Drug levels, liver function, drug interactions
Lamotrigine Added to Carbamazepine/Oxcarbazepine
- Prescription Template:
Continue current carbamazepine/oxcarbazepine dose Add Lamotrigine 25 mg PO daily x 2 weeks Then 50 mg daily x 2 weeks Target: 200-400 mg daily Monitor: Rash, drug interactions
Alternative Add-On Options
- Gabapentin: 300 mg TID, increase to 900-1800 mg TID 9
- Topiramate: 25 mg daily, increase to 200-400 mg daily in divided doses 9
- Vigabatrin: Consider for refractory cases 9
Simple Partial Seizures (Focal Aware Seizures)
Simple partial seizures follow the same treatment algorithm as complex partial seizures, with carbamazepine, oxcarbazepine, lamotrigine, and levetiracetam as first-line options. 7, 4, 5
First-Line Treatment
- Use identical prescribing templates as Complex Partial Seizures above 7, 4, 5
- Oxcarbazepine 300 mg BID titrated to 900-1200 mg BID 7
- Carbamazepine 200 mg BID titrated to 800-1200 mg daily 7, 8
- Lamotrigine 25 mg daily titrated to 200-400 mg daily 7, 4, 5
- Levetiracetam 500 mg BID titrated to 1000-1500 mg BID 7, 4, 5
Absence Seizures
For childhood absence epilepsy, ethosuximide is the treatment of choice, with valproate and lamotrigine also as first-line options. 7
Childhood Absence Epilepsy
Option 1: Ethosuximide (Treatment of Choice)
- Starting dose: 250 mg daily 7
- Increase gradually to therapeutic effect 7
- Prescription Template:
Ethosuximide 250 mg PO daily Increase to 250 mg BID after 1 week Target maintenance: 500-750 mg daily in 2 divided doses Monitor: CBC, liver function, ethosuximide level Therapeutic level: 40-100 μg/mL
Option 2: Valproate (First-Line Alternative)
- Starting dose: 15 mg/kg/day in divided doses 6, 7
- Prescription Template:
Valproic Acid 250 mg PO BID (for 30 kg child = 16.7 mg/kg/day) Increase by 250 mg weekly as tolerated Target: 500-1000 mg daily in divided doses Monitor: Liver function, CBC, ammonia, valproate level Therapeutic level: 50-100 μg/mL
Option 3: Lamotrigine (First-Line Alternative)
- Starting dose: 25 mg daily for 2 weeks 7
- Prescription Template:
Lamotrigine 25 mg PO daily x 2 weeks Then 50 mg daily x 2 weeks Target maintenance: 100-200 mg daily in 1-2 divided doses Monitor: Rash (discontinue if develops)
Juvenile Absence Epilepsy
For juvenile absence epilepsy, valproate and lamotrigine are treatments of choice. 7
Option 1: Valproate (Treatment of Choice for Males)
- Use same dosing as above 7
- Prescription Template:
Valproic Acid 250 mg PO TID Increase by 250 mg weekly Target: 1000-1500 mg daily in divided doses Monitor: Liver function, CBC, valproate level
Option 2: Lamotrigine (Treatment of Choice for Females)
- Use same dosing as childhood absence 7
- Prescription Template:
Lamotrigine 25 mg PO daily x 2 weeks Then 50 mg daily x 2 weeks Target maintenance: 200-400 mg daily Monitor: Rash
Atypical Absence Seizures
For atypical absence seizures, valproate and lamotrigine are recommended. 9
- Use same prescribing templates as typical absence seizures above 9
- Consider combination therapy if monotherapy fails 9
Juvenile Myoclonic Epilepsy
For juvenile myoclonic epilepsy in adolescent males, valproate and lamotrigine are treatments of choice, with topiramate also first-line; for adolescent females, lamotrigine is treatment of choice. 7
For Adolescent Males
Option 1: Valproate (Treatment of Choice)
- Starting dose: 15 mg/kg/day in divided doses 6, 7
- Prescription Template:
Valproic Acid 250 mg PO TID Increase by 250 mg weekly Target: 1000-2000 mg daily in divided doses Monitor: Liver function, CBC, valproate level Therapeutic level: 50-100 μg/mL
Option 2: Lamotrigine (Treatment of Choice)
- Starting dose: 25 mg daily for 2 weeks 7
- Prescription Template:
Lamotrigine 25 mg PO daily x 2 weeks Then 50 mg daily x 2 weeks Then 100 mg daily x 1 week Target maintenance: 200-400 mg daily Monitor: Rash
Option 3: Topiramate (First-Line)
- Starting dose: 25-50 mg daily 7
- Prescription Template:
Topiramate 25 mg PO daily x 1 week Then 50 mg daily x 1 week Then 100 mg daily x 1 week Target maintenance: 200-400 mg daily in 2 divided doses Monitor: Cognitive effects, weight loss
For Adolescent Females (Childbearing Potential)
Option 1: Lamotrigine (Treatment of Choice)
Option 2: Topiramate (First-Line Alternative)
- Use same dosing as above 7
Option 3: Levetiracetam (First-Line Alternative)
- Starting dose: 500 mg twice daily 4, 5
- Prescription Template:
Levetiracetam 500 mg PO BID Increase to 1000 mg BID after 2 weeks Target maintenance: 1000-1500 mg BID Monitor: Behavioral changes
Special Populations and Considerations
Elderly Patients
Due to decreased unbound clearance and greater sensitivity to somnolence, start with reduced doses in elderly patients and increase more slowly with regular monitoring. 6
- Valproate: Start at 250 mg daily, increase by 125-250 mg weekly 6
- Levetiracetam: Start at 250 mg BID, increase by 250 mg every 2 weeks 6
- Monitor for dehydration, decreased food/fluid intake, and excessive somnolence 6
End-Stage Renal Disease
For patients with ESRD and subtherapeutic valproate levels, increase dose from 500 mg daily to at least 750-1000 mg daily (15-20 mg/kg/day range). 10
Levetiracetam may be superior in ESRD patients due to predictable dosing adjustments for dialysis. 10
- Levetiracetam in ESRD: 500-1000 mg daily with supplemental doses after dialysis 10
Critical Pitfalls to Avoid
Status Epilepticus Management
- Never use neuromuscular blockers alone (e.g., rocuronium) as they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 1
- Do not skip to third-line agents (pentobarbital) until benzodiazepines and a second-line agent have been tried 1
- Simultaneously search for and treat underlying causes: hypoglycemia, hyponatremia, hypoxia, drug toxicity, CNS infection, ischemic stroke, intracerebral hemorrhage, withdrawal syndromes 1
Chronic Seizure Management
- Avoid phenobarbital and phenytoin as first-choice drugs for long-term management due to sedative effects and cognitive/cerebellar dysfunction 9
- Monitor for thrombocytopenia with valproate at levels above 110 μg/mL (females) or 135 μg/mL (males) 6
- Avoid valproate in women of childbearing potential when possible due to teratogenicity 4, 5
- Do not abruptly discontinue antiepileptic drugs due to risk of precipitating status epilepticus 6
- Check HLA-B*1502 in Asian patients before starting carbamazepine due to Stevens-Johnson syndrome risk 8