What are the pregnancy recommendations for a patient on Keppra (levetiracetam)?

From the Guidelines

Women with epilepsy who are well-controlled on Keppra should typically continue it throughout pregnancy, as discontinuing seizure medication poses greater risks to both mother and fetus than the medication itself. When considering pregnancy recommendations for a patient on Keppra (levetiracetam), it is essential to weigh the risks and benefits of continuing or discontinuing the medication. The provided evidence does not directly address pregnancy recommendations for patients on Keppra; however, general medical knowledge and guidelines suggest that levetiracetam is considered one of the safer antiepileptic medications during pregnancy 1.

Key Considerations

• Patients should take folic acid 1-5 mg daily, starting before conception if possible, to reduce the risk of neural tube defects.
• Regular monitoring of levetiracetam blood levels is recommended during pregnancy, as physiological changes may necessitate dose adjustments, particularly in the third trimester when drug clearance often increases.
• The risk of major congenital malformations with levetiracetam monotherapy appears relatively low (approximately 2-3%), similar to the general population.
• After delivery, breastfeeding is generally considered compatible with levetiracetam therapy, as the benefits of breastfeeding typically outweigh potential risks.

Ongoing Care

• Throughout pregnancy, patients should maintain regular follow-up with both their neurologist and obstetrician for coordinated care.
• It is crucial to discuss the potential risks and benefits of continuing or discontinuing Keppra during pregnancy with the patient, taking into account their individual circumstances and medical history.

Summary of Recommendations

• Continue Keppra throughout pregnancy if the patient is well-controlled.
• Monitor levetiracetam blood levels regularly during pregnancy.
• Take folic acid 1-5 mg daily to reduce the risk of neural tube defects.
• Breastfeeding is generally considered compatible with levetiracetam therapy after delivery.

From the FDA Drug Label

Pregnancy Category C In animal studies, levetiracetam produced evidence of developmental toxicity at doses similar to or greater than human therapeutic doses Administration to female rats throughout pregnancy and lactation was associated with increased incidences of minor fetal skeletal abnormalities and retarded offspring growth pre- and/or postnatally at doses ≥350 mg/kg/day Levetiracetam should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Pregnancy Recommendation: Levetiracetam should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus 2.

• Key Points:
  • Pregnancy Category C
  • Developmental toxicity observed in animal studies at doses similar to or greater than human therapeutic doses
  • Potential risk to the fetus exists, and the benefit of using levetiracetam during pregnancy must be carefully weighed against this risk.

From the Research

Pregnancy Recommendations for Patients on Keppra (Levetiracetam)

• The risk of congenital malformations in infants born to women with epilepsy is approximately twice that of the general population 3.
• Data concerning the risk for congenital malformations associated with newer AEDs, including levetiracetam, are still limited 3.
• To minimize risk, it is recommended to use a single AED at the lowest effective dosage, and seizure control must not be neglected in a pregnant woman with epilepsy 3, 4.
• Folic acid supplementation is recommended for women with epilepsy, as it is for other women of childbearing age, although its protective effect against AED-induced teratogenicity is unclear 3, 5, 6.
• If levetiracetam is used during pregnancy, women should receive adequate amounts of folic acid (0.4-5 mg/day) and serum concentrations of levetiracetam should be determined before conception if possible and during each trimester, especially during the middle of the third trimester 7.
• The dose of levetiracetam may need to be increased during the third trimester to provide concentrations consistent with those before conception 7.
• Patients should be informed that there appears to be a small chance of malformations with levetiracetam, but that the data are limited 7.

Key Considerations

• Close cooperation and communication among the obstetrician, neurologist, pediatrician, and patient are essential for optimizing the outcome of pregnancy in women with epilepsy 4.
• Simple interventions such as avoiding sleep deprivation and giving the infant a vitamin K injection at birth can help optimize the outcome 4.
• Women with epilepsy should be treated with the minimum number of folate-lowering drugs possible and receive folic acid supplementation to minimize the risk of adverse pregnancy outcomes 5.