Table 16.4.
Dose regimens of symptomatic management of seizures in brain tumor-related epilepsy
| Low-grade glioma (and other primary brain tumors or brain metastasis, except glioblastoma multiforme) |
| First-line antiepileptic drug |
| Levetiracetam (LEV) |
| Medication schedule: 2 × 500 mg/day (first week 2 × 250 mg/day) |
| If necessary, up to 2 × 750–1500 mg/day |
| Therapeutic plasma range of LEV: 5–25 mg/L |
| Be alert to irritability or ill temper |
| If seizures continue: add valproic acid (VPA) |
| Dose: 20–25 mg/kg/day, can be initiated instantly |
| For example, 2 × 500 mg/day; if necessary up to 2 × 1000 mg/day |
| Therapeutic plasma range of VPA: 50–100 mg/L |
| Glioblastoma |
| First-line AED (preferably during first-line chemotherapy, including temozolomide): |
| Valproic acid (VPA) |
| Medication schedule |
| Dose: 20–25 mg/kg/day, can be initiated instantly |
| For example, 2 × 500 mg/day; if necessary up to 2 × 1000 mg/day |
| Therapeutic plasma range of VPA: 50–100 mg/L |
| Be alert to thrombopenia, particularly in association with chemotherapy |
| If seizures continue, add LEV 2 × 500 mg/day |
| If necessary, up to 2 × 750–1000 mg/day LEV (therapeutic plasma range 5–25 mg/L) |
| For both low-grade glioma and GBM, if LEV/VPA is insufficient: |
| Add lacosamide, lamotrigine, or zonisamide (in order to replace VPA or LEV) |
| To add lacosamide |
| Start 2 × 50 mg/day for 1 week, subsequently 2 × 100 mg/day |
| If necessary, increase weekly by 2 × 50 mg/day, up to 2 × 200 mg/day |
| If necessary, start at 200 mg/day in a single loading dose, and continue after 12 hours on a maintenance of 2 × 100 mg/day |
| Therapeutic plasma range 10–20 mg/L |
| To add lamotrigine |
| With VPA co-therapy: start 25 mg every other day for 2 weeks, subsequently 1 × 25 mg/day for 2 weeks, whereafter increase weekly by 25–50 mg/day, until 2 × 50–100/day |
| Without VPA co-therapy: start LTG 1 × 25 mg for 2 weeks, subsequently 50 mg/day for 2 weeks, whereafter increase the dose (bi-)weekly by 50–100 mg/day, until 2 × 100 mg/day is achieved; if necessary up to 500 mg/day |
| Therapeutic plasma range 5–15 mg/L |
| To add zonisamide |
| Initiate 2 × 25 mg/day; after 1 week 2 × 50 mg/day, whereafter if necessary, increase the dose weekly by 100 mg/day up to 2 × 150–250 mg/day |
| Therapeutic plasma range 10–40 mg/L |
When satisfactory seizure control is achieved with lacosamide, lamotrigine, or zonisamide in combination with LEV/VPA, consider tapering VPA or LEV after 1 or 2 months. With lamotrigine, it is better to maintain the use of VPA.