ASM Dosing

Daily (maintenance) dosing

Medication

Rescue / status epilepticus

First-line benzodiazepine

Second-line IV loading dose

Clonazepam (Klonopin) bridge

Short, scheduled clonazepam (days to a few weeks) for a period of higher seizure risk, then stopped. It is not single-dose rescue and not long-term maintenance. Bridging is a practice convention, not a labeled indication.

When it's used

Seizure clusters or flurries (clonazepam ODT is the most common first-line choice in US pediatric practice; FDA-approved cluster rescue is rectal or nasal diazepam, or nasal midazolam).
Seizures worsening with an illness: give for several days and stop as the illness resolves.
While a new medicine is titrated to an effective dose (e.g., lamotrigine, clobazam), or during a cross-taper between medicines.
Catamenial seizures (adolescents): evidence is stronger for clobazam; clonazepam is used by analogy.
Short-term cover around surgery: expert opinion only.

How long, and stopping

No guideline sets the length. Up to 2–3 weeks: low dependence risk, so a short taper or stop is usually feasible. About 4–6 weeks: dependence possible, so taper. 3 months or more: taper is mandatory; tolerance develops in up to 30%.
In a child with epilepsy, taper any course longer than a few days. Abrupt stopping can cause withdrawal seizures or status epilepticus (boxed warning). Withdrawal can start 1–2 days after stopping and peak in the second week.
Taper options: the label's rate is 0.125 mg twice daily less every 3 days (pause or go back a step if withdrawal appears). After longer use, about 10% of the original dose every 7 days over 8–12 weeks.

Cautions

Boxed warnings: profound sedation, respiratory depression and death with opioids; abuse and misuse; physical dependence and withdrawal.

Contraindicated with significant liver disease, acute narrow-angle glaucoma, or benzodiazepine hypersensitivity.

Drowsiness (about 50%), ataxia (about 30%), behavior problems (about 25%; paradoxical agitation more likely in children), drooling and increased airway secretions (watch children who struggle with secretions). Additive sedation with other CNS depressants, including phenobarbital. May worsen tonic-clonic seizures in mixed seizure types; with valproate may provoke absence status. Enzyme inducers lower clonazepam levels.

Clobazam alternative: less sedation and tolerance. 30 kg or less: 5 mg/day, 10 mg on day 7, max 20 mg on day 14; over 30 kg: 10, 20, max 40 mg/day. Once daily if 5 mg/day or less, otherwise twice daily. Taper 5–10 mg/day each week. Suspension 2.5 mg/mL.

Sources: FDA Klonopin label (tablets and ODT); Pediatrics in Review 2023; Pediatric Epilepsy Research Consortium survey (Pediatrics); AAP guidance on tapering; FDA Onfi label. Compiled with OpenEvidence.

Infantile spasms

Choosing first-line treatment

Not tuberous sclerosis: hormonal therapy (ACTH or high-dose oral prednisolone) is preferred over vigabatrin. UKISS: spasms stopped by day 14 in 73% with hormonal therapy vs 54% with vigabatrin.

Tuberous sclerosis: vigabatrin first-line.

Combination (ICISS): hormonal therapy plus vigabatrin stopped spasms more often early (days 14–42: 72% vs 57%), with no developmental difference at 18 months. Many centers still treat one drug at a time.

Judging response

All or none: spasms must stop and hypsarrhythmia must resolve on EEG. Fewer spasms is not a response. Reassess at day 14 (most responders stop by day 7) with a sleep–wake or 24-hour video EEG.

Hormonal course: about 2 weeks of treatment plus a 2-week taper.

Height (cm), for ACTH dosing Treatment

Monitoring

Hormonal therapy: blood pressure, infection (the most common serious side effect in ICISS), electrolytes and glucose, irritability, Cushingoid changes, cardiac hypertrophy, and adrenal insufficiency after the course.

Vigabatrin: vision testing per the boxed warning (by 4 weeks, every 3 months, and 3–6 months after stopping; ERG in infants); reversible MRI changes; REMS only.

Sources: AAN/CNS practice parameter (Go 2012, since retired); ICISS (O'Callaghan, Lancet Neurol 2017; 18-month outcomes, Lancet Child Adolesc Health 2018); UKISS; NISC (Pellock 2010; Knupp 2016); Baram 1996; FDA Acthar Gel and Sabril labels.