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Antiepileptic — Sodium Channel Slow Inactivation Enhancer Pregnancy: Avoid — limited data; use effective contraception

Lacosamide

Brand names: Vimpat

Adult dose

Dose: 50 mg twice daily initially; target 100–200 mg twice daily
Route: Oral / IV
Frequency: Twice daily
Max: 400 mg/day
Novel mechanism: selectively enhances slow inactivation of voltage-gated Na+ channels — distinct from carbamazepine/phenytoin (fast inactivation). Licensed as monotherapy or adjunct for focal seizures. IV formulation available for acute use when oral not possible.

Paediatric dose

Dose: 1 mg/day/kg
Route: Oral
Frequency: Twice daily
Max: 12 mg/kg/day (max 400 mg/day)
Children ≥4 years: 1–2 mg/kg BD increasing to 4–6 mg/kg BD (max 200 mg BD). Weight-based dosing.

Dose adjustments

Renal

Max 250 mg/day if eGFR <30 mL/min.

Hepatic

Max 250 mg/day in hepatic impairment.

Paediatric weight-based calculator

Children ≥4 years: 1–2 mg/kg BD increasing to 4–6 mg/kg BD (max 200 mg BD). Weight-based dosing.

Clinical pearls

  • ECG before initiating and after dose increases — PR prolongation risk; avoid in 2nd/3rd degree AV block
  • IV-to-oral switch: 1:1 equivalence — ideal for acute hospital setting when oral route unavailable
  • No significant drug interactions via CYP450 induction — minimal effect on contraceptives or warfarin; advantage over enzyme-inducing AEDs

Contraindications

  • 2nd or 3rd degree AV block
  • Hypersensitivity to lacosamide

Side effects

  • Dizziness and diplopia
  • Nausea
  • Headache
  • PR prolongation (ECG monitoring required)
  • Ataxia
  • Depression

Interactions

  • Drugs prolonging PR interval (additive — beta-blockers, calcium channel blockers, digoxin)
  • CYP2C19 inhibitors (omeprazole — modest increase in lacosamide levels)

Monitoring

  • ECG (PR interval)
  • Seizure diary
  • LFTs and renal function at baseline

Reference: BNFc; BNF 90; NICE NG217; EMA Vimpat SPC; BNFc. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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