Lacosamide: Indication, Dosage, Side Effect, Precaution

Generic Medicine Info Patient Medicine Information

This information is not country-specific. Please refer to the Myanmar prescribing information.

Generic Medicine Info

Indications and Dosage

Intravenous
Partial seizures with or without secondary generalisation

Adult: Monotherapy: Initially, 50 mg bid, increased to 100 mg bid after 1 week. Alternatively, initial doses of 100 mg bid may be given. Increase doses in increments of 50 mg bid at weekly intervals depending on patient response and tolerability. Max: 300 mg bid. Adjunctive therapy: Initially, 50 mg bid, increased to 100 mg bid after 1 week. Maintenance dose may be further increased in increments of 50 mg bid at weekly intervals depending on patient response and tolerability. Max: 200 mg bid. Treatment initiation with a loading dose: Initially, 200 mg as a single dose, followed by 100 mg bid after approx 12 hours, then adjust subsequent doses depending on patient response and tolerability.
Child: ≥2 years Monotherapy: Patient weighing <50 kg: Initially, 1 mg/kg bid, increased to 2 mg/kg bid after 1 week. Maintenance dose may be further increased in increments of 1 mg/kg bid at weekly intervals depending on patient response and tolerability. ≥10 kg to <40 kg: Max: Up to 6 mg/kg bid. ≥40 kg to <50 kg: Max: 5 mg/kg bid. Adjunctive therapy: Initially, 1 mg/kg bid, increased to 2 mg/kg bid after 1 week. Maintenance dose may be further increased in increments of 1 mg/kg bid at weekly intervals depending on patient response and tolerability. ≥10 kg to <20 kg: Max: Up to 6 mg/kg bid. ≥20 kg to <30 kg: Max: 5 mg/kg bid. ≥30 kg to <50 kg: Max: 4 mg/kg bid. ≥50 kg: Same as adult dose. Dosing recommendations may vary among countries (refer to specific product guidelines).

Intravenous
Primary generalised tonic-clonic seizures

Adult: Adjunctive therapy: Initially, 50 mg bid, increased to 100 mg bid after 1 week. Maintenance dose may be further increased in increments of 50 mg bid at weekly intervals depending on patient response and tolerability. Max: 200 mg bid. Treatment initiation with a loading dose: Initially, 200 mg as a single dose, followed by 100 mg bid after approx 12 hours, then adjust subsequent doses according to patient response and tolerability.
Child: ≥4 years weighing <50 kg: Adjunctive therapy: Initially, 1 mg/kg bid, increased to 2 mg/kg bid after 1 week. Maintenance dose may be further increased in increments of 1 mg/kg bid at weekly intervals depending on patient response and tolerability. ≥10 kg to <20 kg: Max: Up to 6 mg/kg bid. ≥20 kg to <30 kg: Max: 5 mg/kg bid. ≥30 kg to <50 kg: Max: 4 mg/kg bid. ≥50 kg: Same as adult dose. Dosing recommendations may vary among countries (refer to specific product guidelines).

Oral
Primary generalised tonic-clonic seizures

Adult: Adjunctive therapy: Initially, 50 mg bid, increased to 100 mg bid after 1 week. Maintenance dose may be further increased in increments of 50 mg bid at weekly intervals depending on patient response and tolerability. Max: 200 mg bid. Treatment initiation with a loading dose: Initially, 200 mg as a single dose, followed by 100 mg bid after approx 12 hours, then adjust subsequent doses according to patient response and tolerability.
Child: ≥4 years weighing <50 kg: Adjunctive therapy: Initially, 1 mg/kg bid, increased to 2 mg/kg bid after 1 week. Maintenance dose may be further increased in increments of 1 mg/kg bid at weekly intervals depending on the patient response and tolerability. ≥10 kg to <20 kg: Max: Up to 6 mg/kg bid. ≥20 kg to <30 kg: Max: 5 mg/kg bid. ≥30 kg to <50 kg: Max: 4 mg/kg bid. ≥50 kg: Same as adult dose. Dosing recommendations may vary among individual products and between countries (refer to specific product guidelines).

Oral
Partial seizures with or without secondary generalisation

Adult: Monotherapy: Initially, 50 mg bid, increased to 100 mg bid after 1 week. Alternatively, initial doses of 100 mg bid may be given. Increase doses in increments of 50 mg bid at weekly intervals depending on the patient response and tolerability. Max: 300 mg bid. Adjunctive therapy: Initially, 50 mg bid, increased to 100 mg bid after 1 week. Maintenance dose may be further increased in increments of 50 mg bid at weekly intervals depending on the patient response and tolerability. Max: 200 mg bid. Treatment initiation with a loading dose: Initially, 200 mg as a single dose, followed by 100 mg bid after approx 12 hours, then adjust subsequent doses depending on patient response and tolerability. Dosing recommendations may vary among countries (refer to specific product guidelines).
Child: ≥2 years Monotherapy: Patient weighing <50 kg: Initially, 1 mg/kg bid, increased to 2 mg/kg bid after 1 week. Maintenance dose may be further increased in increments of 1 mg/kg bid at weekly intervals depending on the patient response and tolerability. ≥10 kg to <40 kg: Max: Up to 6 mg/kg bid. ≥40 kg to <50 kg: Max: 5 mg/kg bid. Adjunctive therapy: Initially, 1 mg/kg bid, increased to 2 mg/kg bid after 1 week. Maintenance dose may be further increased in increments of 1 mg/kg bid at weekly intervals depending on the patient response and tolerability. ≥10 kg to <20 kg: Max: Up to 6 mg/kg bid. ≥20 kg to <30 kg: Max: 5 mg/kg bid. ≥30 kg to <50 kg: Max: 4 mg/kg bid. ≥50 kg: Same as adult dose. Dosing recommendations may vary among countries (refer to specific product guidelines).

Special Patient Group

Lacosamide is metabolised to its major metabolite O-desmethyl (inactive) mainly by the CYP2C19, CYP2C9, and CYP3A4 isoenzymes.

The European Medicines Agency (EMA) and US Food and Drug Administration (FDA) approved drug labels for lacosamide cite that results from studies showed that there are no clinically relevant differences in the pharmacokinetics of lacosamide between CYP2C19 poor metabolisers (n=4) and extensive metabolisers (n=8), but plasma concentrations and the amount of the O-desmethyl metabolite excreted into urine were about 70% reduced in poor metabolisers.

There is no evidence supporting clinical CYP2C19 pharmacogenetic testing prior to initiating lacosamide treatment, and testing has not yet been addressed by currently available professional society practice guidelines.

Renal Impairment

Patient with ESRD: Treatment with loading dose: Initially, 100 mg, followed by 50 mg bid for the 1st week. Max: 250 mg daily. Titrate dose with caution. Patient undergoing haemodialysis: Supplement dose of up to 50% of the divided daily dose directly after the end of each session.

CrCl (mL/min)	Dosage
≤30	Treatment with loading dose: Initially, 100 mg, followed by 50 mg bid for the 1st week. Max: 250 mg daily. Titrate dose with caution.
>30	May consider loading dose of 200 mg, further dose titration (>200 mg daily) should be performed with caution.

Hepatic Impairment

Mild to moderate: May consider loading dose of 200 mg, further dose titration (>200 mg daily) should be performed with caution. Max: 300 mg daily. Severe: Not recommended.

Administration

FC tab & oral soln: May be taken with or without food. FC tab: Swallow whole w/ liqd, do not divide. Oral soln: May be administered via nasogastric or gastrostomy tube.

Reconstitution

IV infusion: May be administered without further dilution or may be mixed with compatible diluents (e.g. 0.9% NaCl inj, Lactated Ringer's solution, 5% dextrose in water).

Contraindications

2nd- or 3rd-degree AV block.

Special Precautions

Patient with underlying proarrhythmic conditions such as known cardiac conduction problems (e.g. sick sinus syndrome without pacemaker), severe cardiac disease (e.g. MI, myocardial ischaemia, heart failure, structural heart disease), cardiac Na channelopathies (e.g. Brugada Syndrome). Avoid abrupt withdrawal. Concomitant use with drugs that affect cardiac conduction and prolong PR interval; strong CYP3A4 or CYP2C9 inhibitors. Renal and hepatic impairment. Children and elderly. Pregnancy and lactation.

Adverse Reactions

Significant: PR interval prolongation (dose-related), suicidal ideation and behaviour, syncope, dizziness (may increase the risk of accidental injury or falls), ataxia, new-onset or exacerbation of myoclonic seizures.
Ear and labyrinth disorders: Vertigo, tinnitus.
Eye disorders: Diplopia, blurred vision.
Gastrointestinal disorders: Nausea, vomiting, constipation, flatulence, dyspepsia, dry mouth, diarrhoea.
General disorders and administration site conditions: Gait disturbance, asthenia, fatigue, irritability, feeling drunk, inj site reactions (e.g. pain, discomfort, irritation).
Musculoskeletal and connective tissue disorders: Muscle spasms.
Nervous system disorders: Headache, balance disorder, memory impairment, cognitive disorder, somnolence, tremor, nystagmus, hypoaesthesia, dysarthria, paraesthesia.
Psychiatric disorders: Depression, confusion, insomnia.
Skin and subcutaneous tissue disorders: Pruritus, rash.
Potentially Fatal: Cardiac arrhythmias including bradycardia, atrioventricular (AV) block, and tachyarrhythmias (e.g. atrial fibrillation, atrial flutter, ventricular tachycardia); drug reaction with eosinophilia and systemic symptoms (DRESS).

Pregnancy Category (US FDA)

IV/Parenteral/PO: Z (Insufficient data to conclude its safety and risk during pregnancy. Use only when benefits outweigh risks.)

Patient Counseling Information

This drug may cause dizziness or blurred vision, if affected, do not drive or operate machinery.

Monitoring Parameters

Perform ECG tracing before treatment initiation and at steady-state (in patients with conduction problems, severe cardiac disease and Na channelopathies). Monitor mental alertness, suicidal ideation and behaviour. Assess for signs and symptoms of conduction problems and DRESS.

Overdosage

Symptoms: Dizziness, nausea, vomiting, seizures (e.g. generalised tonic-clonic seizures, status epilepticus), cardiac conduction disorders, shock and coma. Management: Symptomatic and supportive treatment. May consider haemodialysis if necessary.

Drug Interactions

Increased systemic exposure with strong CYP2C9 (e.g. fluconazole) and CYP3A4 inhibitors (e.g. itraconazole, ketoconazole, ritonavir, clarithromycin). Increased risk of PR interval prolongation with carbamazepine, lamotrigine, pregabalin, and antiarrhythmics. May reduce systemic exposure with rifampicin, carbamazepine, phenytoin, and phenobarbital.

Food Interaction

May reduce systemic exposure with St. John's wort. May increase effects of alcohol.

Action

Description: Lacosamide, a functionalised amino acid, selectively enhances the slow inactivation of voltage-gated Na channels, resulting in the stabilisation of hyperexcitable neuronal membranes and inhibition of repetitive neuronal firing. It binds to collapsin response mediator protein-2 (CMRP-2), a phosphoprotein involved in neuronal differentiation, polarisation, gene expression, and control of axonal outgrowth.
Pharmacokinetics:
Absorption: Rapidly and completely absorbed (oral). Bioavailability: Approx 100% (oral). Time to peak plasma concentration: 1-4 hours (oral).
Distribution: Volume of distribution: Approx 0.6 L/kg. Plasma protein binding: <15%.
Metabolism: Metabolised in the liver by the CYP3A4, CYP2C9, and CYP2C19 isoenzymes to form its inactive metabolite, O-desmethyl-lacosamide.
Excretion: Mainly via urine (95%; approx 40% as unchanged drug, <30% as O-desmethyl-lacosamide, approx 20% as uncharacterised metabolites); faeces (<0.5%). Elimination half-life: Approx 13 hours.

Chemical Structure

Storage

Tab, oral solution, IV: Store between 15-30°C. Oral solution, IV: Do not freeze.

MIMS Class

Anticonvulsants

ATC Classification

N03AX18 - lacosamide ; Belongs to the class of other antiepileptics.

References

Annotation of EMA Label for Lacosamide and CYP2C19. Pharmacogenomics Knowledgebase (PharmGKB). https://www.pharmgkb.org. Accessed 01/08/2022.

Annotation of FDA Label for Lacosamide and CYP2C19. Pharmacogenomics Knowledgebase (PharmGKB). https://www.pharmgkb.org. Accessed 01/08/2022.

Anon. CYP2C19 - Lacosamide (Pharmacogenomics). Lexicomp Online. Hudson, Ohio. Wolters Kluwer Clinical Drug Information, Inc. https://online.lexi.com. Accessed 01/08/2022.

Anon. Lacosamide. AHFS Clinical Drug Information [online]. Bethesda, MD. American Society of Health-System Pharmacists, Inc. https://www.ahfscdi.com. Accessed 01/08/2022.

Anon. Lacosamide. Lexicomp Online. Hudson, Ohio. Wolters Kluwer Clinical Drug Information, Inc. https://online.lexi.com. Accessed 01/08/2022.

Buckingham R (ed). Lacosamide. Martindale: The Complete Drug Reference [online]. London. Pharmaceutical Press. https://www.medicinescomplete.com. Accessed 01/08/2022.

Joint Formulary Committee. Lacosamide. British National Formulary [online]. London. BMJ Group and Pharmaceutical Press. https://www.medicinescomplete.com. Accessed 01/08/2022.

Seqirus (NZ) Ltd. Vimpat Film-coated Tablets and Oral Solution data sheet 19 July 2022. Medsafe. http://www.medsafe.govt.nz. Accessed 01/08/2022.

Seqirus (NZ) Ltd. Vimpat Injection data sheet 19 July 2022. Medsafe. http://www.medsafe.govt.nz. Accessed 01/08/2022.

Vimpat 10 mg/mL Solution for Infusion (UCB Pharma Limited). MHRA. https://products.mhra.gov.uk. Accessed 01/08/2022.

Vimpat 10 mg/mL Syrup (UCB Pharma Limited). MHRA. https://products.mhra.gov.uk. Accessed 01/08/2022.

Vimpat 50 mg, 100 mg, 150 mg, 200 mg Film-coated Tablets (UCB Pharma Limited). MHRA. https://products.mhra.gov.uk. Accessed 01/08/2022.

Vimpat Film-coated Tablets, Injection, Oral Solution (UCB, Inc.). DailyMed. Source: U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed. Accessed 01/08/2022.

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