Intensive Care Medicine: Published: 15 July 2026
Abstract
Purpose
Antiseizure medications (ASMs) are commonly used in the
intensive care unit (ICU) and often exhibit pharmacokinetics that differ
substantially from those in healthy volunteers or in the outpatient setting.
Organ dysfunction, polypharmacy, exogenous devices, and greater severity of
illness all influence ASM pharmacokinetics, dosing decisions, and monitoring
parameters. It is essential for critical care clinicians to familiarize
themselves with the pharmacokinetics, dosing considerations, effects of exogenous
devices, and therapeutic drug monitoring (TDM)—all covered in this narrative
review—to incorporate in their approach to ASMs in the critical care setting.
Methods
We identified relevant literature from MEDLINE from
inception to March 2026 related to ASMs in the ICU. Data on pharmacokinetics,
dosing in the ICU, the effect of renal replacement therapy, extracorporeal
membrane oxygenation (ECMO), and plasmapheresis (PLEX) on ASM exposure, and the
role of TDM in the ICU were collected and summarized.
Results
Considerations for 15 ASMs (brivaracetam, cannabidiol,
carbamazepine, cenobamate, clobazam, lacosamide, lamotrigine, levetiracetam,
oxcarbazepine, perampanel, phenobarbital, phenytoin, topiramate, valproate, and
zonisamide) were included in the review. Dosing considerations for TDM,
including indications and target reference ranges, and specific settings such
as organ dysfunction, illness severity, renal replacement therapy, ECMO, and
PLEX are discussed.
Conclusion
The use of ASMs in the ICU require a distinct approach from
outpatient settings. Severity of illness, organ dysfunction and replacement
devices, and frequent drug–drug interactions warrant tailored agent selection,
dosing, and monitoring.
