Can a 53-year-old male stroke patient, who has been on Levetiracetam (levetiracetam) 500mg, one tablet twice daily (BID), for 8 months, discontinue the medication and be observed for seizures, given that he is 10 months post-stroke with no new symptoms and exhibits angry behavior?

From the Guidelines

I strongly advise against discontinuing levetiracetam without medical supervision, as it may trigger seizures in a 53-year-old male stroke patient who has been on the medication for 8 months. The patient's wife has reported angry behavior, which is a known side effect of levetiracetam 1. Although the patient is 10 months post-stroke with no new symptoms, the risk of seizures can persist long-term, especially in patients with a history of stroke.

Key Considerations

• The American Heart Association/American Stroke Association guidelines do not recommend prophylactic administration of antiepileptic drugs after stroke, but they do emphasize the importance of treating seizures that do occur 1.
• The decision to discontinue or modify levetiracetam should be made in consultation with the patient's neurologist, taking into account the patient's original seizure risk, the severity of behavioral changes, and overall stroke recovery.
• Gradually tapering the medication over several weeks while monitoring for seizure activity may be a safer approach than abrupt discontinuation.
• Alternative anti-seizure medications with fewer behavioral side effects, such as lamotrigine or valproate, may be considered if the patient's behavioral changes are severe.

Next Steps

• Consult with the patient's neurologist to discuss the patient's behavioral changes and determine the best course of action for modifying or discontinuing levetiracetam.
• Monitor the patient closely for seizure activity and other potential side effects if the medication is tapered or discontinued.
• Consider alternative treatments for the patient's behavioral changes, such as counseling or behavioral therapy, in addition to modifying the anti-seizure medication regimen.

From the FDA Drug Label

Non-psychotic behavioral disorders (reported as aggression and irritability) occurred in 5% of the levetiracetam-treated patients compared to 0% of placebo patients. Antiepileptic drugs, including levetiracetam, should be withdrawn gradually to minimize the potential of increased seizure frequency.

The patient is experiencing angry behavior, which is a reported side effect of levetiracetam.

• The drug label recommends gradual withdrawal of levetiracetam to minimize the potential of increased seizure frequency.
• It is not recommended to discontinue levetiracetam abruptly and observe for seizures, as this may increase the risk of seizure frequency 2.
• A gradual taper of the medication should be considered to assess the patient's seizure control and behavior while minimizing the risk of increased seizure frequency.

From the Research

Patient's Condition

• The patient is a 53-year-old male who has been on levetiracetam 500mg, 1 tab BID for 8 months.
• He is a stroke patient, currently 10 months post-stroke with no new symptoms.
• The patient's wife has reported angry behavior, which may be a side effect of levetiracetam 3.

Levetiracetam and Post-Stroke Seizures

• Levetiracetam has been shown to be effective in treating post-stroke seizures, with 77.1% of patients achieving seizure freedom in one study 3.
• Another study found that levetiracetam was a valid alternative to carbamazepine in post-stroke seizures, with fewer side effects 4.
• Levetiracetam monotherapy has been found to be effective and well-tolerated in elderly patients with late-onset post-stroke seizures 5, 6.

Discontinuing Levetiracetam

• There is no clear evidence to suggest that discontinuing levetiracetam is recommended, especially if the patient has a history of post-stroke seizures.
• However, the patient's angry behavior may be a side effect of levetiracetam, and discontinuing the medication may be considered if the behavior persists 3.
• It is essential to monitor the patient for seizures after discontinuing levetiracetam, as the risk of seizure recurrence is unknown 4, 5, 6.

Observations and Next Steps

• The patient's condition should be closely monitored for any changes in seizure activity or behavior after discontinuing levetiracetam.
• If the patient experiences any seizures or worsening of symptoms, levetiracetam may need to be restarted or alternative treatments considered 3, 4, 5, 6, 7.