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©2013 UpToDate ® Print Email Treatment of atypical absence, myoclonic, atonic seizures Drugs Total daily adult dosage* Total daily pediatric dosage* Usual dosing interval Starting Maintenance Starting Maintenance Atypical absence, myoclonic, atonic Drugs of choice: Valproate •,Δ 500-1000 mg 1000-3500 mg 10-15 mg/kg 15-60 mg/kg Once/bid/tid ◊ or Lamotrigine § 12.5-50 mg ¥ 100-700 mg ¥ 0.15-0.6 mg/kg ������ 1-15 mg/kg ������ Bid or Levetiracetam ������ 500-1000 mg 1000-3000 mg 10-20 mg/kg 40-60 mg/kg Bid Alternatives: Topiramate** 25-50 mg 200-400 mg 1-3 mg/kg 5-9 mg/kg Bid Zonisamide •• 100 mg 100-600 mg 1-2 mg/kg ΔΔ 6-8 mg/kg ΔΔ Once/bid Clonazepam 1.5 mg 1.5-8 mg 0.01-0.03 mg/kg 0.05-0.2 mg/kg Bid/tid Felbamate** 600-800 mg 2400-4800 mg 15 mg/kg 15-60 mg/kg Bid/qid * Dosage may need to be adjusted for renal or hepatic impairment, or concomitant use of other drugs. • Measurement of serum concentrations may be useful to guide therapy. Usual therapeutic serum concentrations are: carbamazepine 6-12 mcg/mL, phenobarbital 15-35 mcg/mL, phenytoin 10-20 mcg/mL, valproate 50-120 mcg/mL. Some patients achieve complete seizure control at lower concentrations, and occasional patients need higher concentrations. Δ Not FDA-approved unless absence is involved. ◊ Once daily for the extended-release formulation (Depakote ER). § FDA-approved for adjunctive therapy in adults and children ≥2 years old with partial seizures, with Lennox-Gastaut syndrome or with primary generalized seizures, and as monotherapy in adults with partial seizures as a substitute for carbamazepine, phenytoin, phenobarbital or valproate. ¥ Starting dosage is 25 mg every other day and maintenance dosage is 100 to 400 mg daily when given with valproate. ‡ Starting dosage is 0.15 mg/kg daily and maintenance dosage is 1 to 5 mg/kg daily when given with valproate. † FDA-approved as adjunctive therapy for patients 12 years and older with myoclonic seizures. ** FDA-approved as adjunctive therapy for patients with Lennox-Gastaut syndrome. •• Not FDA-approved for this indication. ΔΔ Not FDA-approved for pediatric use. Reproduced with permission from: Drugs for Epilepsy. Treatment guidelines from The Medical Letter 2008; 6(70): 37-46. Copyright ©2008 The Medical Letter.