What labs and orders should be placed for a 32-year-old female with a history of seizures and migraines, presenting with two recent seizure episodes, taking Keppra (levetiracetam) and Zoloft (sertraline), with no history of migraine-induced seizures?

From the Guidelines

The patient should undergo immediate laboratory tests, including a comprehensive metabolic panel (CMP), complete blood count (CBC), anti-epileptic drug (AED) levels, and toxicology screening, as well as brain imaging and an urgent EEG to determine the cause of the breakthrough seizures and develop an appropriate treatment plan. Given the patient's history of seizures and migraines, and the recent seizure episodes, it is crucial to assess for any underlying conditions that may be contributing to the seizures. The CMP will help identify any electrolyte imbalances, such as sodium, calcium, and glucose levels, which can trigger seizures if imbalanced 1. The CBC will help identify any infections or hematologic abnormalities that may be contributing to the seizures. Measuring AED levels, specifically Keppra (levetiracetam), will determine if therapeutic levels are being maintained, which is essential for preventing further seizures 1. Toxicology screening is also important to rule out substance use that might lower the seizure threshold. Brain imaging, preferably an MRI of the brain, should be performed to evaluate for structural abnormalities, and an urgent EEG would help characterize the seizure activity and determine if there is ongoing subclinical seizure activity. Considering the patient's history of migraines preceding the seizures, a neurological consultation is essential to determine if there is a relationship between the migraines and seizures. The patient should be monitored closely for additional seizures, and if seizures continue, consideration should be given to administering a benzodiazepine such as lorazepam 2mg IV, as indicated by the most recent guidelines for the management of adult patients presenting to the emergency department with seizures 1. Some key points to consider in the management of this patient include:

• Monitoring for additional seizures and being prepared to administer rescue medications as needed
• Evaluating for any underlying conditions that may be contributing to the seizures, such as electrolyte imbalances or infections
• Adjusting the patient's AED regimen as needed to prevent further seizures
• Considering the potential relationship between the patient's migraines and seizures, and developing a treatment plan that takes this into account.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Assessment and Monitoring

The patient's presentation with two seizure episodes within a short period, preceded by a worsening migraine, necessitates a thorough assessment and monitoring plan. Given the patient's history of seizures and migraines, and current medication regimen of Keppra and Zoloft, the following considerations should be taken into account:

• The patient's seizure episodes and response to treatment should be closely monitored, as the current episodes may indicate a need for adjustment in the antiepileptic medication regimen 2, 3, 4, 5.
• The patient's level of consciousness, as well as other vital signs, should be regularly assessed to quickly identify any signs of clinical deterioration 6.
• Laboratory parameters, such as complete blood counts and electrolyte levels, may be useful in assessing the patient's overall health status and potential side effects of medications 2, 3, 4, 5.

Laboratory Orders

Based on the patient's presentation and medication regimen, the following laboratory orders may be considered:

• Complete blood count (CBC) to assess for any potential hematologic side effects of Keppra 2, 3, 4, 5.
• Electrolyte panel to evaluate for any electrolyte imbalances that may be contributing to the patient's seizure episodes.
• Liver function tests (LFTs) to assess for any potential hepatic side effects of medications, although Keppra is not known to be hepatotoxic 2, 3, 4, 5.
• Renal function tests to evaluate the patient's kidney function, as Keppra is primarily eliminated through the kidneys 2, 3, 4, 5.

Medication Monitoring

The patient's medication regimen, including Keppra and Zoloft, should be closely monitored for efficacy and potential side effects:

• Keppra levels may be measured to assess the patient's therapeutic range and potential need for dose adjustment 3.
• The patient should be monitored for any signs of behavioral adverse effects, such as irritability, agitation, or aggression, which have been reported with Keppra use 2, 3, 4, 5.