This protocol addresses a specific and well-defined patient profile: a child with childhood absence epilepsy (CAE) whose seizures consist exclusively of absence seizures, with no history of generalized tonic-clonic seizures — and in whom an initial medication course has not achieved the required clinical targets.
The patient presents with absence seizures as the only seizure type. There is no history of generalized tonic-clonic seizures. Treatment selection in this subgroup is guided by the seizure pattern and by the patient's response to prior therapy.
The previous treatment line used Valproic acid (VPA). This protocol applies when VPA has not achieved its defined clinical targets: freedom from absence seizures — confirmed by both parent report and EEG — and a valproate serum level within the therapeutic range. The failure to meet these goals is the trigger for escalation to this next-step regimen.
The treatment of choice for CAE with absence seizures only is ethosuximide.
Therefore, based on the CAE trial, ETX is the drug of choice as initial monotherapy for CAE, when absence seizures are the only seizure type, but there are specific treatment considerations for each drug, which are discussed below.
Persistent seizures or AE on ETX and VPA monotherapy, or contraindication to VPA: Treat with LTG
While our practice is to use ETX as the first monotherapy, LTG can be considered as second monotherapy if ETX fails and if VPA is a less appealing choice for a specific patient.
For a child on no other medication, LTG is typically initiated at a dosage of 0.6 mg/kg/day for 2 weeks, then 1.2 mg/kg/day for 2 weeks, and then increased by 0.6 mg/kg/day every 1–2 weeks until a goal dosage of 5–12 mg/kg/day is reached.
Serum levels of LTG considered to be in the therapeutic range are between 5 and 15 µg/mL, though dose-dependent side effects may emerge when levels exceed 10–12 µg/mL.
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