Lacosamide | Epilepsy clinician handbook

Lacosamide is used to treat partial seizures in children aged 4-16 years. It is also used in the treatment of primary generalised seizures with idiopathic generalised epilepsy aged 4 years and older.
The PBS indication is for intractable partial seizures not controlled by other anti-convulsants, including first-line medications, in children aged 4-16 years. The PBS indication for primary generalised tonic-clonic seizures in patients with idiopathic generalised epilepsy is as add-on therapy for children aged 4 years and older. In both PBS indications there are treatment criteria that must be met (see PBS link below).
Its mechanism of action is slow inactivation of voltage gated sodium channels.
It does not have significant drug interactions and has a relatively good safety profile.

Therapeutic indications

Australian Product Information Sheets:

Vimpat (lacosamide) tablets and oral solution are indicated as:

monotherapy in the treatment of partial-onset seizures with or without secondary generalisation in patients with epilepsy aged 16 years and older;
add-on therapy in the treatment of partial-onset seizures with or without secondary generalisation in patients with epilepsy aged 4 years and older;
add-on therapy in the treatment of primary generalised tonic-clonic seizures in patients with idiopathic generalised epilepsy aged 4 years and older.

Other notable side effects:

Less commonly: irritability, tics, mood change, depression, palpitations, irregular heartbeat, nausea, vomiting and cognitive difficulties.
Rarely: Hypersensitivity syndrome, facial oedema.
All anti-seizure medications are potentially teratogenic and this is often dose related.
For a complete list of adverse effects, appropriate formularies should be consulted.

Precautions

Hepatic impairment: Lacosamide’s use is not recommended in patients with severe hepatic impairment.
Patients with hepatic impairment who are taking strong inhibitors of CYP3A4 and CYP2C9 may have a significant increase in exposure to Lacosamide.
Dose reduction may be necessary in these patients.

Weaning

When ceasing Lacosamide it is important to withdraw slowly (over a minimum of 1 week) to minimize the potential of increased seizure frequency in patients with seizure disorders.

Cardiac

Lacosamide may cause prolongation of the PR interval, this is dose related, so monitoring of PR interval may be necessary.
Other sodium channel drugs should be avoided e.g. carbamazepine or dilantin.
There must be caution if there is a history of cardiac disease or conduction problems.

Pregnancy

Usage in pregnancy needs to be discussed with a neurologist.
There is limited data on Lacosamide in pregnancy; theoretically it may interfere with CNS development of the foetus.