Authors: Lauren Baugh, Karen Babb
Background:
Lacosamide is an FDA approved medication for the treatment of focal onset seizures and primary generalized tonic-clonic seizures and is also used off-label for status epilepticus.1 The Neurocritical Critical Care Guidelines for the Evaluation and Management of Status Epilepticus propose 200 mg lacosamide given over 15 minutes as an alternative for rapid administration, while acknowledging the risk for possible adverse effects, such as hypotension or QT prolongation.2 Recent studies suggest an increased incidence of cardiovascular, neurological, and infusion site related adverse events with intravenous push as compared to intravenous piggyback administration.4
This study will assess the incidence of adverse events associated with intravenous push compared to intravenous piggyback lacosamide within our institution.
Methodology:
This was a single-center retrospective cohort analysis. Chart review was utilized to compare patients that received lacosamide via intravenous piggyback or push administration. Included in the study were adult patients 18 years old or older that received at least one dose of IV push or IV piggyback lacosamide from May 1, 2024 - October 31, 2024 and December 1, 2024 - May 31, 2025. Exclusion criteria was doses greater than 400 milligrams. The primary outcome was incidence of adverse drug events (hypotension, bradycardia, infusion site reactions, sedation) in patients receiving intravenous push lacosamide compared to those that receive intravenous piggyback lacosamide. Secondary outcomes reviewed time to administration of intravenous push lacosamide compared to that of intravenous piggyback lacosamide.
Results:
A total of 110 patients were included in the study, with 50 in the intravenous piggyback group and 60 in the intravenous push group. Baseline characteristics, such as age, sex, weight, race, home lacosamide use, and pre-existing comorbidities, were comparable between the two cohorts. Of the 110 patients, a total of 747 doses were observed, with 379 doses given intravenous push and 368 given intravenous piggyback. Of the primary outcomes, incidence of bradycardia, hypotension, medication related sedation, and administration site reaction, there were no statistically significant differences. The median time to first dose administration was 50 minutes in the intravenous push group and 62 minutes in the intravenous piggyback group.
Conclusion:
This study highlights the advantages of administering intravenous push lacosamide without increased risk of adverse events. The findings indicate that the incidence of adverse events was not higher than that seen in the intravenous piggyback administration, while providing shorter time to first dose administration. However, limitations of the study should be considered in the interpretation of the results. The primary limitation of this study was the missing documentation of heart rate, blood pressure, and sedation scores with each dose of lacosamide given. Furthermore, findings should be interpreted in light of the fact that patients requiring hospitalization are often critically ill and exposed to a multitude of factors which could independently contribute to adverse outcomes rather than solely lacosamide administration. In the future, the findings should be presented to the pharmacy and therapeutics committee to further support the current implemented practice. The results of this study should also encourage education on the importance of standardized nursing documentation.
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