Difference between revisions of "Anticonvulsant levels and reloading"

(/* LoadingSeizures ACEP Policy committee . Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures. Ann Emerg Med. 2014;63(4):437–447.e15. doi:10.1016/j.annemergmed.2014...)
(/* LoadingSeizures ACEP Policy committee . Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures. Ann Emerg Med. 2014;63(4):437–447.e15. doi:10.1016/j.annemergmed.2014...)
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|'''Loading Dose and Route of Administration'''
 
|'''Loading Dose and Route of Administration'''
 
|-
 
|-
| Carbamazepine Tegretol||8 mg/kg oral suspension;
+
| [[Carbamazepine]] (Tegretol)||8 mg/kg oral suspension;
 
single oral load;  
 
single oral load;  
 
IV not available  
 
IV not available  
 
|-
 
|-
| Gabapentin (Neurontin) ||900 mg/day oral (300 mg tid) for 3 days;
+
| [[Gabapentin]] (Neurontin) ||900 mg/day oral (300 mg tid) for 3 days;
 
IV not available  
 
IV not available  
 
|-
 
|-
| Lacosamide (Vimpat) ||Oral and IV formulations available and safe;
+
| [[Lacosamide]] (Vimpat) ||Oral and IV formulations available and safe;
 
loading dosages not studied  
 
loading dosages not studied  
 
|-
 
|-
| Lamotrigine (Lamicta)l ||6.5 mg/kg single oral load if on lamotrigine;
+
| [[Lamotrigine]] (Lamictal) ||6.5 mg/kg single oral load if on lamotrigine;
 
for >6 mo without a history of rash or intolerance in the past and only off lamotrigine for <5 days;
 
for >6 mo without a history of rash or intolerance in the past and only off lamotrigine for <5 days;
;IV not available  
+
IV not available  
 
|-
 
|-
| Levetiracetam (Keppra) ||1,500 mg oral load;
+
| [[Levetiracetam]] (Keppra) ||1,500 mg oral load;
 
rapid IV loading safe and well tolerated in doses up to 60 mg/kg  
 
rapid IV loading safe and well tolerated in doses up to 60 mg/kg  
 
|-
 
|-
| Phenytoin (Dilantin) ||20 mg/kg divided in maximum doses of 400 mg every 2 h orally;
+
| [[Phenytoin]] (Dilantin) ||20 mg/kg divided in maximum doses of 400 mg every 2 h orally;
 
or 18 mg/kg IV at maximum rate of 50 mg/min  
 
or 18 mg/kg IV at maximum rate of 50 mg/min  
 
|-
 
|-
| Fosphenytoin (Cerebyx) ||18 PE/kg IV at maximum rate of 150 PE/min;
+
| [[Fosphenytoin]] (Cerebyx) ||18 PE/kg IV at maximum rate of 150 PE/min;
 
IM administration possible  
 
IM administration possible  
 
|-
 
|-
| Valproate (Depacon) ||Up to 30 mg/kg IV at max rate of 10 mg/kg/min IV  
+
| [[Valproate]] (Depacon) ||Up to 30 mg/kg IV at max rate of 10 mg/kg/min IV  
 
|}
 
|}
  

Revision as of 22:34, 20 April 2014

Background

  • IV load can be performed with phenobarbital, phenytoin, valproate, levetiracetam
  • Oral loading can be spread over day or more to avoid GI upset

Dose

Dose (mg) = ideal body weight (kg) X Vd X [desired level - current level (mcg/mL)]

Volume of Distribution

Agent
Volume of Distribution
Phenytoin (dilantin) 0.8
Carbamazepine (tegretol) 0.8
Phenobarbital 0.6
Valproate (depakote) 0.2

Desired Level

  • Pt's optimal level = desired level
    • If optimal level unknown target upper end of therapeutic range:
      • Phenytoin = 20 mcg/mL
      • Valproate = 100 mcg/mL
      • Phenobarbital = 40 mcg/mL

Loading[1]

Drug (With Selected References) Loading Dose and Route of Administration
Carbamazepine (Tegretol) 8 mg/kg oral suspension;

single oral load; IV not available

Gabapentin (Neurontin) 900 mg/day oral (300 mg tid) for 3 days;

IV not available

Lacosamide (Vimpat) Oral and IV formulations available and safe;

loading dosages not studied

Lamotrigine (Lamictal) 6.5 mg/kg single oral load if on lamotrigine;

for >6 mo without a history of rash or intolerance in the past and only off lamotrigine for <5 days; IV not available

Levetiracetam (Keppra) 1,500 mg oral load;

rapid IV loading safe and well tolerated in doses up to 60 mg/kg

Phenytoin (Dilantin) 20 mg/kg divided in maximum doses of 400 mg every 2 h orally;

or 18 mg/kg IV at maximum rate of 50 mg/min

Fosphenytoin (Cerebyx) 18 PE/kg IV at maximum rate of 150 PE/min;

IM administration possible

Valproate (Depacon) Up to 30 mg/kg IV at max rate of 10 mg/kg/min IV

See Also

Source

  1. Seizures ACEP Policy committee . Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures. Ann Emerg Med. 2014;63(4):437–447.e15. doi:10.1016/j.annemergmed.2014.01.018.