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Antiepileptic — AMPA Receptor Antagonist Pregnancy: Avoid — teratogenic in animals; use effective contraception (note OCP interaction at high doses)

Perampanel

Brand names: Fycompa

Adult dose

Dose: 2 mg at bedtime initially; increase by 2 mg every 2 weeks; maintenance 8–12 mg nocte
Route: Oral
Frequency: Once daily at bedtime
Max: 12 mg/day (non-enzyme-inducing AEDs); 8 mg if on enzyme inducers
First and only licensed AMPA (alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid) glutamate receptor antagonist. Licensed for focal seizures and primary generalised tonic-clonic seizures. Once-daily dosing at bedtime (reduces CNS side effects).

Paediatric dose

Route: Oral
Frequency: Once daily at bedtime
Max: 12 mg/day
Children ≥4 years: start 2 mg nocte; same adult titration. Weight-based dosing not required.

Dose adjustments

Renal

Avoid in severe renal impairment.

Hepatic

Max 4 mg/day in mild hepatic impairment; avoid in moderate–severe impairment.

Clinical pearls

  • MHRA warning: psychiatric and behavioural adverse effects — aggression, hostility, anger, homicidal ideation reported. Patients and caregivers must be counselled. Withdraw if severe psychiatric symptoms develop.
  • Once-daily bedtime dosing minimises daytime sedation and dizziness
  • Novel mechanism — not cross-resistant with sodium channel blockers; useful in drug-resistant focal epilepsy

Contraindications

  • Severe hepatic or renal impairment

Side effects

  • Dizziness (very common)
  • Somnolence
  • Irritability and aggression (MHRA warning — psychiatric adverse effects)
  • Ataxia
  • Falls (especially elderly)
  • Weight gain

Interactions

  • Enzyme-inducing AEDs — carbamazepine/phenytoin/oxcarbazepine (reduce perampanel levels by ~50% — higher doses needed)
  • Combined oral contraceptives (may reduce efficacy at doses ≥12 mg — use additional contraception)
  • Alcohol (marked CNS depression — absolute alcohol avoidance advised)

Monitoring

  • Seizure diary
  • Behavioural and psychiatric assessment at each visit
  • Weight

Reference: BNFc; BNF 90; NICE NG217; MHRA Fycompa Safety Update; 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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