Phenytoin Dosage

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Usual Adult Dose for:

Usual Pediatric Dose for:

Additional dosage information:

Usual Adult Dose for Seizures

Oral (except suspension) Loading dose: Only when indicated for inpatients.
1 g orally divided in 3 doses (400 mg, 300 mg, 300 mg) given at 2 hour intervals. Then normal maintenance dosage started 24 hours after loading dose.
Initial dose: 100 mg extended release orally 3 times a day.
Maintenance dose: 100 mg orally 3 to 4 times a day. If seizure control is established with divided doses of three 100 mg capsules daily, once-a-day dosage with 300 mg of extended release phenytoin sodium may be considered. Alternatively, the dosage may need to be increased up to 200 mg orally 3 times a day, if necessary.

Suspension: Patients who have received no previous treatment may be started on 125 mg (one teaspoonful) of the suspension three times daily, and the dose is then adjusted to suit individual requirements. An increase to five teaspoonfuls daily may be made, if necessary.

IV: Do not exceed the infusion rate of 50 mg/min.
Loading dose: 10 to 15 mg/kg IV slowly.
Maintenance dose: 100 mg IV every 6 to 8 hours.

IM: Avoid the IM route due to erratic absorption.

Usual Adult Dose for Arrhythmias

Loading Dose:
1.25 mg/kg IV every 5 minutes. May repeat up to a loading dose of 15 mg/kg, or
250 mg orally 4 times a day for 1 day, then 250 mg twice daily for 2 days

Maintenance Dose:
300 to 400 mg/day orally in divided doses 1 to 4 times a day

Usual Adult Dose for Status Epilepticus

IV:
Loading dose: Manufacturer recommends 10 to 15 mg/kg by slow IV administration (at a rate not exceeding 50 mg/minute). Alternatively, generally accepted guidelines suggest 15 to 20 mg/kg by slow IV administration (at a rate not exceeding 50 mg/minute).
Maintenance rate: 100 mg orally or IV every 6 to 8 hours
Maximum rate: 50 mg/minute

Maintenance dose: IV or Oral: 100 mg every 6 to 8 hours

Usual Adult Dose for Neurosurgery

Neurosurgery (prophylactic): 100 to 200 mg IM at about 4 hour intervals during surgery and the immediate postoperative period. (Note: While the manufacturer recommends IM administration, this route may cause severe local tissue destruction and necrosis. Some clinicians recommend the use of fosphenytoin if IM administration is necessary.) If IM administration is not necessary, accepted protocol has been 100 to 200 mg IV at about 4 hour intervals during surgery and the immediate postoperative period.

Usual Pediatric Dose for Seizures

Status Epilepticus: Loading Dose:
Infants, Children: 15 to 20 mg/kg IV in a single or divided doses

Anticonvulsant: Loading Dose:
All ages: 15 to 20 mg/kg orally (based on phenytoin serum concentrations and recent dosing history). The oral loading dose should be given in 3 divided doses administered every 2 to 4 hours.

Anticonvulsant: Maintenance Dose:
(IV or oral) (Note: May initially divided daily dose into 3 doses/day, then adjust to suit individual requirements.)
Less than or equal to 4 weeks: Initial: 5 mg/kg/day in 2 divided doses
Usual: 5 to 8 mg/kg/day IV in 2 divided doses (may require dosing every 8 hours).
Greater than or equal to 4 weeks: Initial: 5 mg/kg/day in 2 to 3 divided doses
Usual: (may require up to every 8 hour dosing)
6 months to 3 years: 8 to 10 mg/kg/day
4 to 6 years: 7.5 to 9 mg/kg/day
7 to 9 years: 7 to 8 mg/kg/day
10 to 16 years: 6 to 7 mg/kg/day

Usual Pediatric Dose for Arrhythmias

Greater than 1 year:
Loading Dose: 1.25 mg/kg IV every 5 minutes. May repeat up to a loading dose of 15 mg/kg.
Maintenance Dose: 5 to 10 mg/kg/day orally or IV in 2 to 3 divided doses

Renal Dose Adjustments

Patients with renal disease should not receive the oral loading regimen.

Liver Dose Adjustments

Patients with liver disease should not receive the oral loading regimen.

Dose Adjustments

Changes in dosage should not be carried out at intervals shorter than 7 to 10 days. If seizure control is established with 100 mg 3 times a day, 300 mg extended release once a day may be considered.

Precautions

The IV administration rate of phenytoin should not exceed 50 mg per minute and 1 to 3 mg/kg/min in pediatric patients because of the risk of severe hypotension and cardiac arrhythmias. Careful cardiac monitoring is needed during and after administering intravenous phenytoin. Although the risk of cardiovascular toxicity increases with infusion rates above the recommended infusion rate, these events have also been reported at or below the recommended infusion rate. Reduction in rate of administration or discontinuation of dosing may be needed.

Serum levels should be monitored in changing from extended release to prompt release, and from the sodium salt to the free acid suspension and chewable tablets forms.

Hypotension usually occurs when the drug is administered rapidly by the IV route. IV administration should not exceed 50 mg/minute in adults. In neonates, the drug should be administered at a rate not exceeding 1 to 3 mg/kg/minute.

The intramuscular route is not recommended for the treatment of status epilepticus since blood levels of phenytoin in the therapeutic range cannot be readily achieved with doses and methods of administration ordinarily employed.

Acute alcoholic intake may increase phenytoin serum levels while chronic alcoholic use may decrease serum levels.

Dialysis

Data not available

Other Comments

In some cases, serum blood level determinations may be necessary for optimal dosage adjustments. The clinically effective serum level is usually 10 to 20 mcg/mL.

When intramuscular administration is required for a patient previously stabilized orally, compensating dosage adjustments are necessary to maintain therapeutic plasma levels. An intramuscular dose 50% greater than the oral dose is necessary to maintain these levels. When returned to oral administration, the dose should be reduced by 50% of the original oral dose for one week to prevent excessive plasma levels due to sustained release from intramuscular tissue sites.

If the patient requires more than a week of IM phenytoin, alternative routes should be explored, such as gastric intubation. For time periods less than one week, the patient shifted back from IM administration should receive one-half the original oral dose for the same period of time the patient received IM phenytoin. Monitoring plasma levels help prevent a fall into the subtherapeutic range. Serum blood level determinations are especially helpful when possible drug interactions are suspected.

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