When do you use seizure prophylaxis in patients on clozapine?

The topic of the use of anticonvulsants for primary prophylaxis of clozapine-induced seizures continues to be debated. The idea of prescribing anticonvulsants prophylactically for patients taking >600 mg/day of clozapine was suggested by Devinksy et al., PMID 2006003 in 1991. Clozapine-induced seizu...

I follow Stahl's recommendation in his Clozapine Handbook. From the book, the first large data set covering 1,481 clozapine-treated patients showed a seizure rate of 2.8% with a dose-dependent relationship. A subsequent 1994 analysis cited by the same authors of 5,629 patients found only 71 cases of...

Congruent with Dr. @Dr. First Last and as recommended by Caetano, PMID 23996793, I based my decisions more on the clozapine level than on the dose per se. When prescribing an anticonvulsant, I tend to prescribe Lamotrigine (anticonvulsant doses 400-600 mg/day divided into two doses) due to favorable...

As long as it is tolerated with careful monitoring of adverse effects and drug-drug interactions.

As soon as it is clear that clozapine is the actual culprit for the seizures and when the dose is 600 mg a day or more, clozapine plasma level above 500 μg/l.

I would not prescribe any anticonvulsant after the first seizure. I will be mindful of dose-dependent relationships (<300 mg and >600 mg daily).

Following the second clozapine-induced seizure, I would consult with the neurologist, if possible, or add Lamotrigine, while tapering clozapine off.

Get concentration levels, and review the medication list for seizure-inducers, but do not treat after the first seizure. If a second seizure occurs, repeat the above but treat the seizure with lamotrigine and re-evaluate anti-psychotic choices given the patient's history.