From the Guidelines
I would not recommend holding Keppra in patients with hyponatremia or hypovolemia, as the benefits of continued seizure prophylaxis outweigh the risks associated with these conditions. According to the study published in the Annals of Emergency Medicine 1, levetiracetam (Keppra) has a safe and well-tolerated oral loading dose of 1,500 mg, and rapid IV loading is also safe in doses up to 60 mg/kg. The study does not mention any significant adverse effects related to hyponatremia or hypovolemia.
Key points to consider:
- Keppra does not significantly affect sodium levels or volume status, unlike some other antiepileptic medications.
- The primary concern with abruptly stopping Keppra would be breakthrough seizures, which could worsen the patient's overall condition.
- Address the underlying hyponatremia/hypovolemia with appropriate fluid management while continuing seizure prophylaxis.
- Monitor renal function, as Keppra is primarily renally cleared and may need dose adjustment in significant renal impairment that can accompany severe volume depletion.
- If the patient has severe hyponatremia (sodium <120 mEq/L) with neurological symptoms or severe hypovolemia with hemodynamic instability, consult with neurology regarding temporary dose adjustment.
From the Research
Hyponatremia and Hypovolemia
- Hyponatremia is a common electrolyte disorder that can be caused by various factors, including hypovolemia, euvolemia, or hypervolemia 2, 3.
- Hypovolemic hyponatremia is often caused by gastrointestinal fluid loss, thiazide diuretics, or other factors that lead to a decrease in blood volume 4.
- The management of hypovolemic hyponatremia involves correcting the underlying cause and using isotonic fluid to replenish volume while avoiding an overly rapid rise in serum sodium concentration 4.
Antiepileptic Drugs and Hyponatremia
- Certain antiepileptic drugs, such as carbamazepine, oxcarbazepine, and eslicarbazepine acetate, can cause hyponatremia as a side effect 5.
- Levetiracetam, another antiepileptic drug, can also contribute to hyponatremia, particularly when combined with other medications such as pain medications 6.
- In patients with hyponatremia, it is essential to carefully evaluate the potential causes, including the use of antiepileptic drugs, and adjust treatment accordingly.
Keppra (Levetiracetam) and Hyponatremia
- There is evidence to suggest that levetiracetam can contribute to hyponatremia, particularly in patients with underlying conditions such as central diabetes insipidus 6.
- In patients with hyponatremia and hypovolemia, it may be necessary to hold or adjust keppra (levetiracetam) to prevent further complications, as seen in the case report where switching from levetiracetam to lacosamide helped to normalize sodium levels and prevent further seizures 6.