From the Guidelines
Anticonvulsant drugs like Keppra (levetiracetam) are indicated in patients with brain metastasis who have experienced at least one seizure, but should not be used prophylactically in patients who have never had a seizure. The use of anticonvulsant medications in patients with brain metastasis is guided by the principle of minimizing the risk of seizures while avoiding unnecessary medication side effects. According to the most recent guidelines, including those from the Society for Neuro-Ocology (SNO) and the European Association of Neuro-Oncology (EANO) 1, anticonvulsant prophylaxis is not recommended for routine use in patients with brain metastases who did not undergo surgical resection and who are otherwise seizure-free.
Key Considerations
- Seizure Risk: Approximately 10-20% of patients with brain metastases present with seizures at diagnosis, and an additional 10-11% may develop seizures later on 1.
- Medication Choice: Levetiracetam (Keppra) is often preferred over older anticonvulsants like phenytoin or carbamazepine due to its favorable side effect profile and fewer drug interactions, particularly with chemotherapy and steroids 1.
- Dosing and Monitoring: For patients who have had a seizure, Keppra is typically started at 500 mg twice daily and titrated as needed up to 1500 mg twice daily, with adjustments made for renal impairment. Regular monitoring for side effects such as fatigue, mood changes, and coordination problems is important, with dose adjustments made accordingly.
Evidence Summary
The evidence from recent studies, including those published in Neuro-Oncology 1, supports the use of anticonvulsant medications only in patients with brain metastasis who have experienced a seizure, and not for prophylactic use in seizure-free patients. The choice of medication should be guided by the potential for drug interactions and side effects, with levetiracetam being a preferred option due to its favorable profile.
Clinical Implications
In clinical practice, the decision to start anticonvulsant therapy should be based on the individual patient's risk of seizures and the potential benefits and risks of medication. Patients with brain metastasis who have not had a seizure should not be started on anticonvulsant prophylaxis, while those who have experienced a seizure should be considered for treatment with levetiracetam or other suitable agents, with close monitoring for side effects and adjustments as needed.
From the Research
Indications for Anticonvulsant Drugs in Brain Metastasis
- Anticonvulsant drugs, such as levetiracetam, are indicated in patients with brain metastasis who have experienced a seizure 2, 3.
- The highest risk for seizures is in patients with melanoma and lung cancer 2.
- Prophylaxis with anticonvulsant drugs for patients with brain metastases without a history of seizures is not recommended 4, 5, 6.
Choice of Anticonvulsant Drug
- Levetiracetam and valproic acid are considered the most appropriate drugs for patients with brain metastasis and seizures 2.
- Second- and third-generation antiepileptic drugs are the preferred options for initiation, due to a lack of hepatic enzyme induction and reduced likelihood for drug-drug interactions 3.
- Other appropriate initial antiepileptic drug options for monotherapy or as an add-on anticonvulsant include lacosamide, briviracetam, lamotrigine, and perampanel 3.