The anti-seizure medication escalation guidelines for University Hospitals Birmingham NHS Foundation Trust are as follows:
Brivaracetam
Patients can find out more about brivaracetam (Briviact) on the Electronic Medicines Compendium:
Please escalate as follows:
- 25mg BD (twice daily) for two weeks
- 50mg BD (twice daily) thereafter
If a patient has more seizures but they are infrequent (less than or equal to one every three months), increase in 25mg once daily increments after each seizure:
- 50mg in the morning, 75mg at night
- 75mg BD
- 75mg in the morning, 100mg at night etc. with a maximum dose of 100mg BD
If a patient has more seizures and they are frequent (more than one every three months), increase in 25mg twice daily increments after each seizure (maximum one increase per week):
- 75mg BD
- 100mg BD (this is the maximum dose, although a patient can be taken higher under expert guidance)
Despite brivaracetam being intended for people who have had anxiety with levetiracetam, the main side effect to watch out for is still agitation. If a patient becomes anxious or aggressive, please contact us as soon as possible. It is possible to become very paranoid on brivaracetam, so please do not ‘sit on it’.
Brivaracetam is mostly excreted through the kidneys so doesn’t have many interactions. It should be used with caution in people with severe kidney failure and the maximum dose would be 100mg twice daily.
Pregnancy
We advise female patients on brivaracetam to avoid unplanned pregnancy if possible.
Unfortunately, there are no extant guidelines on contraception or pregnancy for brivaracetam. However, it would be sensible for women who are on brivaracetam to use two effective forms of contraception.
If a patients finds that they are pregnant while taking brivaracetam they should not stop taking it, please contact the epilepsy nurses as soon as possible.
Carbamazepine
Carbamazepine (Tegretol) was developed as an anti-epileptic but it is also used for a variety of other neurological problems, most notably trigeminal neuralgia.
Patients can find out more about carbamazepine on the Electronic Medicines Compendium:
Please escalate as follows:
- 100mg BD (twice daily) for two weeks
- 200mg BD (twice daily) thereafter
No one really knows the best dose of carbamazepine as it is probably different for each person and varies with what other tablets the patient is on. Carbamazepine can induce its own metabolism, so sometimes works well for a short period of time before the attacks (seizures or pain) break through. In that case, the dose should be increased.
The maximum dose of carbamazepine is 1800mg over 24 hours. This can be split up however your patient chooses, but for epilepsy we aim for a twice daily split (it is often given more frequently in trigeminal neuralgia).
The main side effect to watch out for initially is a rash. This is like a nettle rash and usually starts within a couple of days of starting the drug. If a patient gets a rash, reduce the dose to 50% for 24 hours and then stop it. In the event of a rash, please contact the Epilepsy Specialist Nursing Team. Failure to stop the drug with a rash can lead to Stevens-Johnson syndrome.
Carbamazepine also causes drowsiness and balance problems. The latter can be particularly bad in people with conditions like multiple sclerosis which can also affect their balance. Carbamazepine interacts with a lot of medications so before starting anything new you should consult the BNF and let the Neurology Team know what is planned. Adding in new drugs can often make the side-effects from carbamazepine worse.
We recommend you monitor a patient’s sodium levels and vitamin D (both of which can become low with carbamazepine treatment). The carbamazepine levels are not terribly informative in patients who adhere to the medication.
Pregnancy
We advise female patients on carbamazepine to avoid unplanned pregnancy if possible. Epilepsy Action provide clear guidelines on how to manage contraception for patients on carbamazepine.
If a patient taking carbamazepine for epilepsy discovers they are pregnant, it is extremely important that they do not stop taking it. They should be referred to the pregnant epilepsy service at the Birmingham Women’s Hospital.
The first contact for clinical support is the Epilepsy Specialist Nursing Team:
Cenobamate
Patients can find out more about cenobamate (Ontozry) on the Electronic Medicines Compendium:
Please escalate as follows:
- 12.5mg OD (once daily) for two weeks
- 25mg OD (once daily) for two weeks
- 50mg OD (once daily) for two weeks
- 100mg OD (once daily) thereafter
If a patient has more seizures, increase by 50mg OD (once daily) every two weeks until the patient is seizure free or they have reached a dose of 400mg OD (once daily).
Please do not increase the dose of cenobamate faster than the guidelines. Drug reaction with eosinophilia and systemic symptoms (DRESS) has been reported in three cases with a higher starting dose (50-100mg) and faster titration.
If a patient experiences fever, lymphadenopathy with or without rash, then cenobamate should be stopped immediately and the patient referred back to the epilepsy clinic/nurse for advice on further management.
The typical maintenance dose is 200mg OD (once daily) so it would be a good idea to check with the Epilepsy Specialist Nursing Team if the dose is being increased beyond this level.
Pregnancy and breastfeeding
We advise female patients on cenobamate to avoid unplanned pregnancy if possible.
Cenobamate can potentially interact with hormone-based contraceptives (e.g. the pill, patches, implants etc.). For more information, please see the Epilepsy Action website:
At this time, we don’t know if breastfeeding on cenobamate is safe, so we would advise against it and bottle feeding instead.
The first contact for clinical support is the Epilepsy Specialist Nursing Team:
Eslicarbazepine
Eslicarbazepine (Zebinix) was developed as an anti-epileptic but it is also used for a variety of other neurological problems, most notably trigeminal neuralgia.
Patients can find out more about eslicarbazepine on the Electronic Medicines Compendium:
Please escalate as follows:
- 200mg OD (once daily) for two weeks
- 400mg OD (once daily) thereafter
No one really knows the best dose of eslicarbazepine as it is probably different for each person and varies with what other tablets the patient is on. Eslicarbazepine can induce its own metabolism, so sometimes works well for a short period of time before the attacks (seizures or pain) break through. In that case, the dose should be increased.
The maximum dose of eslicarbazepine is 1600mg over 24 hours. This can be split up however your patient chooses, but for epilepsy we aim for a twice daily split (it is often given more frequently in trigeminal neuralgia).
The main side effect to watch out for initially is a rash. This is like a nettle rash and usually starts within a couple of days of starting the drug. If the patient gets a rash, reduce the dose to 50% for 24 hours and then stop it. In the event of a rash, please contact the Epilepsy Specialist Nursing Team. Failure to stop the drug with a rash can lead to Stevens-Johnson syndrome.
Eslicarbazepine can slow conduction in the heart. The patient will need an ECG prior to starting the medication, after every increase in dose and every three months for the first year of treatment. Any sign of an increase in the PR interval (heart block) and the medication should be discontinued.
Eslicarbazepine also causes drowsiness and balance problems.
We recommend you monitor a patient’s sodium levels and vitamin D (both of which can become low with eslicarbazepine treatment). The eslicarbazepine levels are not terribly informative in patients who adhere to the medication.
Pregnancy
We advise female patients on eslicarbazepine to avoid unplanned pregnancy if possible. Epilepsy Action provide clear guidelines on how to manage contraception for patients on eslicarbazepine.
If a patient taking eslicarbazepine for epilepsy discovers they are pregnant, it is extremely important that they do not stop taking it. They should be referred to the pregnant epilepsy service at the Birmingham Women’s Hospital.
The first contact for clinical support is the Epilepsy Specialist Nursing Team:
Lacosamide
Lacosamide (Vimpat) was developed as an anti-epileptic but it is also used for a variety of other neurological problems.
Patients can find out more about lacosamide on the Electronic Medicines Compendium:
Please escalate as follows:
- Start at 50mg BD
If a patient has more seizures but they are infrequent (less than or equal to one every three months), increase in 25mg daily increments after each seizure:
- 50mg in the morning, 100mg at night
- 100mg BD
- 100mg in the morning, 150mg at night etc. with a maximum dose of 200mg BD
If a patient has more seizures and they are frequent (more than one every three months), increase in 100mg daily increments after each seizure (maximum one increase per week):
- 100mg BD
- 150mg BD
- 200mg BD (this is the maximum initial dose, although a patient can be taken higher under expert guidance)
The main side effect that concerns us is prolonged PR interval. Patients should have an ECG every three months while on lacosamide.
Pregnancy
We advise female patients on lacosamide to avoid unplanned pregnancy if possible. Epilepsy Action provide clear guidelines on how to manage contraception for patients on lacosamide.
If a patient taking lacosamide for epilepsy discovers they are pregnant, it is extremely important that they do not stop taking it. They should be referred to the pregnant epilepsy service at the Birmingham Women’s Hospital.
The first contact for clinical support is the Epilepsy Specialist Nursing Team:
Lamotrigine
Lamotrigine (Lamictal) was developed as an anti-epileptic but it is also used for a variety of other neurological problems.
Patients can find out more about lamotrigine on the Electronic Medicines Compendium:
Please escalate as follows:
- 25mg OD for two weeks
- 25mg BD for two weeks
- 50mg BD thereafter (this is the lowest therapeutic dose and if the patient has no further seizures this would be the maintenance dose)
If a patient has more seizures but they are infrequent (less than or equal to one every three months), increase in 25mg daily increments after each seizure:
- 50mg in the morning, 75mg at night
- 75mg BD
- 75mg in the morning, 100mg at night etc. with a maximum dose of 200mg BD
If a patient has more seizures and they are frequent (more than one every three months), increase in 100mg daily increments after each seizure (maximum one increase per week):
- 100mg BD
- 150mg BD
- 200mg BD (this is the maximum dose, although a patient can be taken higher under expert guidance)
The main side effect to watch out for is a rash. This is like a nettle rash and usually starts within a couple of days of starting the drug. If the patient gets a rash, reduce the dose to 50% for 24 hours and then stop it. In the event of a rash, please contact the Epilepsy Specialist Nursing Team. Failure to stop the drug with a rash can lead to Stevens-Johnson syndrome.
The main drug interaction with lamotrigine is with sodium valproate (Epilim/Epilim Chrono). This increases the circulating levels of lamotrigine by 50%. Do not adjust a patients dose, but inform the CNS as soon as possible.
Pregnancy
We advise female patients on lamotrigine to avoid unplanned pregnancy if possible. Epilepsy Action provide clear guidelines on how to manage contraception for patients on lamotrigine.
If a patient taking lamotrigine for epilepsy discovers they are pregnant, it is extremely important that they do not stop taking it. They should be referred to the pregnant epilepsy service at the Birmingham Women’s Hospital.
The blood levels of lamotrigine fall fairly sharply at the start of pregnancy and the medication seems to be less effective, so it is really important that patients are seen early on in pregnancy. If in doubt, please contact the Epilepsy Specialist Nursing Team:
Levetiracetam
Patients can find out more about levetiracetam (Keppra) on the Electronic Medicines Compendium:
Please escalate as follows:
- 250mg BD (twice daily) for two weeks
- 500mg BD (twice daily) thereafter
If a patient has more seizures but they are infrequent (less than or equal to one every three months), increase in 250mg once daily increments after each seizure:
- 500mg in the morning, 750mg at night
- 750mg BD
- 750mg in the morning, 1000mg at night etc. with a maximum dose of 1500mg BD
If a patient has more seizures and they are frequent (more than one every three months), increase in 250mg twice daily increments after each seizure (maximum one increase per week):
- 750mg BD
- 1000mg BD
- 1250mg BD
- 1500mg BD (this is the maximum dose, although a patient can be taken higher under expert guidance)
The main side effect to watch out for agitation. If a patient becomes anxious or aggressive then please contact us as soon as possible. It is possible to become very paranoid on levetiracetam, so please don’t ‘sit on it’.
Levetiracetam is mostly excreted through the kidneys so doesn’t have many interactions. It should be used with caution in people with severe kidney failure and the maximum dose would be 750mg BD.
Pregnancy
We advise female patients on levetiracetam to avoid unplanned pregnancy if possible. Epilepsy Action provide clear guidelines on how to manage contraception for patients on levetiracetam.
If a patient taking levetiracetam for epilepsy discovers they are pregnant, it is extremely important that they do not stop taking it. They should be referred to the pregnant epilepsy service at the Birmingham Women’s Hospital.
The first contact for clinical support is the Epilepsy Specialist Nursing Team:
Oxcarbazepine
Oxcarbazepine (Trileptal) was developed as an anti-epileptic but it is also used for a variety of other neurological problems, most notably trigeminal neuralgia.
Patients can find out more about oxcarbazepine on the Electronic Medicines Compendium:
Please escalate as follows:
- 150mg BD (twice daily) for two weeks
- 300mg BD (twice daily) thereafter
No one really knows the best dose of oxcarbazepine as it is probably different for each person and varies with what other tablets the patient is on. Oxcarbazepine can induce its own metabolism, so sometimes works well for a short period of time before the attacks (seizures or pain) break through. In that case, the dose should be increased.
The maximum dose of oxcarbazepine is 2100mg over 24 hours. This can be split up however your patient chooses, but for epilepsy we aim for a twice daily split (it is often given more frequently in trigeminal neuralgia).
The main side effect to watch out for is a rash. This is like a nettle rash and usually starts within a couple of days of starting the drug. If the patient gets a rash, reduce the dose to 50% for 24 hours and then stop it. In the event of a rash, please contact the Epilepsy Specialist Nursing Team. Failure to stop the drug with a rash can lead to Stevens-Johnson syndrome.
Oxcarbazepine also causes drowsiness and balance problems. The latter can be concerning in people with conditions like multiple sclerosis which can also affect the balance. Oxcarbazepine interacts with a lot of medications so before starting anything new you should consult the BNF and let the Neurology Team know what is planned. Often adding in new drugs can make the side-effects from the oxcarbazepine worse.
We recommend you monitor a patient’s sodium levels and vitamin D (both of which can become low with oxcarbazepine treatment). The oxcarbazepine levels are not terribly informative in patients who adhere to the medication.
Pregnancy
We advise female patients on oxcarbazepine to avoid unplanned pregnancy if possible. Epilepsy Action provide clear guidelines on how to manage contraception for patients on oxcarbazepine.
If a patient taking oxcarbazepine for epilepsy discovers they are pregnant, it is extremely important that they do not stop taking it. They should be referred to the pregnant epilepsy service at the Birmingham Women’s Hospital.
The first contact for clinical support is the Epilepsy Specialist Nursing Team:
Perampanel
Patients can find out more about perampanel (Fycompa) on the Electronic Medicines Compendium:
Please escalate as follows:
- 2mg once a day for three weeks
If a patient’s seizures continue at the same rate, increase the dose of perampanel by 2mg once a day.
The maximum dose is 12mg once a day, although some patients are given a higher dose under specialist supervision.
The main side effect of perampanel is agitation. If this occurs, please contact the Epilepsy Specialist Nursing Team. Like all anti-seizure medication, perampanel can be associated with a serious skin rash. If a patient gets a rash, the medication should be stopped and you should contact the Epilepsy Specialist Nursing Team.
Perampanel interacts with some other anti-seizure medication. Carbamazepine, clobazam and valproate reduce the levels of perampanel, so watch out for side-effects if these are being reduced. Oxcabazepine significantly increases the levels of perampanel, so watch out for recurrence of seizure if this is reduced.
Pregnancy
We advise female patients on perampanel to avoid unplanned pregnancy if possible.
Unfortunately, there are no extant guidelines on contraception or pregnancy for perampanel. However, it would be sensible for women who are on perampanel to use two effective forms of contraception.
If a patients finds that they are pregnant while taking perampanel they should not stop taking it, please contact the epilepsy nurses as soon as possible.
Phenytoin
Patients can find out more about phenytoin (Epanutin) on the Electronic Medicines Compendium:
Please escalate as follows:
- 300mg once a day for one week
- Get blood phenytoin levels – these must be ‘pre-dose trough’ (i.e. done just before the patient has taken their dose)
- If the blood level is less than 10mmol/L, increase the dose by 25mg and recheck levels after a week
- If the blood level is more than 20mmol/L, reduce the dose by 25mg and recheck levels after a week
The stomach does not absorb phenytoin well, so patients on NG or PG feed should pause the feed for two hours after the dose.
Phenytoin can cause a severe rash like most anti-seizure medications. If a patient gets a rash, please contact the epilepsy team as soon as possible.
There are numerous phenytoin side-effects and many are dose-related and interact with other medications
The metabolism of phenytoin can also change with time, even if the patient is not on any new tablets. If a patient has new issues (particularly balance problems) please check their phenytoin levels and adjust as described above.
Pregnancy
We advise female patients on phenytoin to avoid unplanned pregnancy if possible.
Unfortunately, there are no extant guidelines on contraception or pregnancy for phenytoin. However, it would be sensible for women who are on phenytoin to use two effective forms of contraception.
If a patients finds that they are pregnant while taking phenytoin they should not stop taking it, please contact the epilepsy nurses as soon as possible.
Sodium valproate
Sodium valproate (Epilim) was developed as an anti-epileptic but it is also used for a variety of other neurological problems, most notably migraine.
Patients can find out more about sodium valproate on the Electronic Medicines Compendium:
Please escalate as follows:
- 500mg as Epilim Chrono OD (once daily)
Sodium valproate can be increased in 200mg increments.
The maximum dose is 30mg/kg body weight in divided doses (this equates to about 1000mg BD in an average adult man).
The main side effect to watch out for is a tremor that can resemble the tremor of Parkinson’s disease. It is preferred that patients who develop a tremor are moved to a different drug. Sodium valproate also causes high ammonia, particularly when paired with certain antibiotics.
Pregnancy
Sodium valproate is teratogenic that doubles the risk of conditions like spina bifida. It also massively increases a baby’s risk of autistic spectrum disorder (ASD) and learning difficulties (LD). Up to eight in 100 babies exposed to sodium valproate with have conditions like spina bifida and four in ten babies will have ASD or LD.
Unless we have tried all other options, we will not start patients who have the potential to get pregnant on sodium valproate. We prefer patients not to have unplanned pregnancies while on sodium valproate.
Epilepsy Action and GOV.UK provide clear guidelines on contraception and sodium valproate:
If nothing but sodium valproate works for a patient and they want to start a family, it is extremely important that they do not stop taking it. Patients should start a high dose (5mg daily) of folic acid and discuss with the Epilepsy Specialist Nursing Team as soon as possible.
If a patient taking sodium valproate for epilepsy discovers they are pregnant, it is extremely important that they do not stop taking it. They should be referred to the pregnant epilepsy service at the Birmingham Women’s Hospital.
The first contact for clinical support is the Epilepsy Specialist Nursing Team:
Topiramate
Topiramate (Topamax) was developed as an anti-epileptic but is frequently used in the treatment of migraine and occasionally in other pain syndromes. It should be taken everyday to prevent headaches or seizures.
It is important that if a patient needs to stop topiramate it must be done so slowly, ideally reducing by 25-50mg every two weeks but it can be reduced faster in an emergency.
The major contraindications are glaucoma and kidney stones. If the patient develops a red painful eye or abdominal pain they need to receive urgent medical advice.
The main side-effects are:
- Funny taste in the mouth
- Tingling in the hands
- Weight loss
- Occasionally psychiatric problems like anxiety
Patients can find out more about topiramate on the Electronic Medicines Compendium:
The starting dose for patients taking topiramate for epilepsy is 25mg BD and the patient should keep a seizure diary.
If there is no reduction in seizure frequency, topiramate can be increased by 25mg BD every two weeks. If a patient’s seizures are less common, enough time will need to be given to judge whether the medication is working. The maximum dose for epilepsy is 250mg BD, but it can be taken higher under expert advice.
Pregnancy
We advise female patients on topiramate to avoid unplanned pregnancy if possible as there is a theoretical risk of structural abnormalities. Epilepsy Action provide clear guidelines on how to manage contraception for patients on topiramate. Please note that the advice differs depending on if the patient is on less than or more than 200mg of topiramate daily.
If a patient taking topiramate for epilepsy discovers they are pregnant, it is extremely important that they do not stop taking it. They should be referred to the pregnant epilepsy service at the Birmingham Women’s Hospital.
The first contact for clinical support is the Epilepsy Specialist Nursing Team:
Zonisamide
Zonisamide (Zonegran) was developed as an anti-epileptic but is frequently used in the treatment of migraine and occasionally in other pain syndromes. It should be taken everyday to prevent headaches or seizures.
It is important that if a patient needs to stop zonisamide it must be done so slowly, ideally reducing by 25-50mg every two weeks but it can be reduced faster in an emergency.
Zonisamide has many possible side effects and a shared care agreement which takes you through them is discussed with patients.
Zonisamide is similar to topiramate so patients should look out for:
- weight loss
- anxiety/agitation
- cognitive impairment
Zonisamide can precipitate acute closed-angle glaucoma so if a patient develops a painful, red eye they should contact the Birmingham and Midland Eye Centre (BMEC).
Zonisamide can cause a rash (that looks similar to a nettle rash) that usually starts within a couple of days of starting the drug. If a patient gets a rash, reduce the dose to 50% for 24 hours and then stop taking it. Failure to stop the drug with a rash can lead to Stevens-Johnson syndrome. In the event of a rash, please contact the Epilepsy Specialist Nursing Team.
The starting dose for patients taking zonisamide for epilepsy is 100mg OD and the patient should keep a seizure diary.
If there is no reduction in seizure frequency, zonisamide can be increased by 25mg BD every two weeks. If a patient’s seizures are less common, enough time will need to be given to judge whether the medication is working. The maximum dose for epilepsy is 500mg in 24 hours, but it can be taken higher under expert advice.
Pregnancy
We advise female patients on zonisamide to avoid unplanned pregnancy if possible as there is a theoretical risk of structural abnormalities. Epilepsy Action provide clear guidelines on how to manage contraception for patients on zonisamide.
If a patient taking zonisamide for epilepsy discovers they are pregnant, it is extremely important that they do not stop taking it. They should be referred to the pregnant epilepsy service at the Birmingham Women’s Hospital.
The first contact for clinical support is the Epilepsy Specialist Nursing Team:
Last reviewed 15 May 2024