Levetiracetam (Zolevi) and Lacosamide (Focale) Are Both Effective Anti-Seizure Medications
Both levetiracetam (Zolevi) and lacosamide (Focale) are recognized, evidence-based anti-seizure medications with proven efficacy for focal epilepsy, and either can be used as first-line or adjunctive therapy depending on the clinical scenario. 1, 2, 3
Evidence for Levetiracetam (Zolevi)
Levetiracetam is a well-established anti-seizure medication with robust evidence supporting its use:
Efficacy: Demonstrates 68-73% seizure control rates when used as a second-line agent in status epilepticus, and is effective for both focal and generalized epilepsy 4, 1, 2
Safety profile: Causes minimal cardiovascular instability, no significant hypotension risk (0% compared to 12% with fosphenytoin), and minimal sedation at therapeutic doses 4, 1, 5
Dosing: Standard dose is 30 mg/kg IV (approximately 2000-3000 mg for average adults) for acute seizures, with maintenance dosing of 500-1500 mg twice daily for chronic epilepsy 1, 2
Drug interactions: Does not significantly interact with hepatic metabolizing enzymes, making it preferable when patients are on multiple medications 4, 3
Evidence for Lacosamide (Focale)
Lacosamide is a newer anti-seizure medication with comparable evidence:
Efficacy: Has successfully completed conversion to monotherapy trials for focal epilepsy, demonstrating non-inferiority to older agents 3
First-line use: Recommended as one of several newer anti-seizure medications suitable for first-line therapy in focal epilepsy, alongside levetiracetam, lamotrigine, oxcarbazepine, topiramate, and zonisamide 3
Mechanism: Provides a distinct mechanism of action that can be beneficial in rational combination therapy 3
Direct Comparison and Clinical Decision-Making
The choice between these two medications should be based on specific clinical factors rather than efficacy differences:
For acute seizures/status epilepticus: Levetiracetam has more extensive evidence in guidelines, with specific dosing protocols (30 mg/kg IV) and demonstrated 68-73% efficacy 1, 2
For chronic epilepsy management: Both are appropriate first-line options for focal epilepsy, with the decision based on patient-specific factors 3
For patients with psychiatric history: Avoid levetiracetam due to potential behavioral side effects; lacosamide would be preferable 6
For patients requiring rapid IV loading: Levetiracetam can be given as 30 mg/kg IV over 5 minutes without cardiac monitoring requirements, making it more practical in emergency settings 1, 2
Common Pitfalls to Avoid
Do not assume non-standard medications are inferior: Both levetiracetam and lacosamide are FDA-approved, guideline-recommended agents with robust evidence 1, 2, 3
Do not use enzyme-inducing agents (phenytoin, carbamazepine) as first-line when these newer agents are available: They cause more drug interactions and adverse effects 4, 1
Do not underdose: If using levetiracetam for refractory seizures, ensure adequate dosing at 30 mg/kg (not lower doses like 1000 mg) to achieve the 68-73% efficacy demonstrated in trials 1, 2
Monitor for behavioral changes with levetiracetam: While sedation is minimal, psychiatric side effects can occur and may require switching to lacosamide or other alternatives 5, 6