From the Guidelines
For a patient with a recent seizure and no current antiepileptic medication, I recommend ordering a comprehensive laboratory workup and initiating appropriate antiepileptic therapy with levetiracetam (Keppra) as the first-line treatment, and administering benzodiazepines such as lorazepam (2-4 mg IV) or diazepam (5-10 mg IV) for acute seizure management. Essential labs include:
- Complete blood count
- Comprehensive metabolic panel (including electrolytes, glucose, calcium, magnesium, liver and kidney function)
- Toxicology screen
- Antiepileptic drug levels if there's any possibility of prior use Levetiracetam is typically started at 500 mg twice daily and titrated up to 1000-1500 mg twice daily as needed. If the patient has status epilepticus or clusters of seizures, a loading dose of levetiracetam (20-60 mg/kg IV) may be appropriate, as supported by recent guidelines 1. Additional workup should include an electroencephalogram (EEG) and brain imaging (MRI preferred over CT) to identify potential structural causes. Levetiracetam is preferred due to its favorable side effect profile, minimal drug interactions, and effectiveness across multiple seizure types, as noted in several studies 1. Patients should be counseled about medication adherence, potential side effects (irritability, mood changes, fatigue), and seizure precautions including driving restrictions according to local laws. Benzodiazepines like lorazepam or diazepam are recommended for acute seizure management, with dosages of 2-4 mg IV or 5-10 mg IV, respectively, as suggested by clinical policies 1. The use of zyprexa is not typically recommended for acute seizure management, and its use should be considered on a case-by-case basis. Overall, the management of seizures should prioritize the cessation of seizures, reduction of morbidity and mortality, and improvement of quality of life, as emphasized in recent clinical policies 1.
From the FDA Drug Label
The disposition of levetiracetam was studied in adult subjects with varying degrees of renal function Total body clearance of levetiracetam is reduced in patients with impaired renal function by 40% in the mild group (CLcr = 50-80 mL/min), 50% in the moderate group (CLcr = 30-50 mL/min) and 60% in the severe renal impairment group (CLcr <30 mL/min). Levetiracetam (3000 mg daily) had no effect on the pharmacokinetic disposition of phenytoin in patients with refractory epilepsy. Levetiracetam (1500 mg twice daily) did not alter the pharmacokinetics of valproate in healthy volunteers
The patient should be given Keppra 1500 mg IV as prescribed. To determine the appropriate labs, consider the following:
- Renal function tests: Given that levetiracetam is primarily renally excreted, assessing the patient's renal function through tests such as creatinine clearance (CLcr) is crucial to determine if a dose adjustment is necessary.
- Liver function tests: Although the drug label indicates that no dose adjustment is needed for patients with hepatic impairment, assessing liver function may still be relevant for a comprehensive evaluation.
- Complete blood count (CBC): To assess for any potential infections or other underlying conditions that may have contributed to the seizure.
- Electrolyte panel: To evaluate for any electrolyte imbalances that could have triggered the seizure.
- Blood glucose: To rule out hypoglycemia as a cause of the seizure.
- Toxicology screen: If substance use is suspected as a potential cause of the seizure.
- Imaging studies: Such as a CT scan or MRI of the head to evaluate for any structural abnormalities that may have caused the seizure.
Regarding the use of benzodiazepines or Zyprexa, there is no direct information in the provided drug labels to support their use in this specific scenario. Benzodiazepines may be considered for acute seizure management or status epilepticus, but their use should be based on clinical judgment and specific patient needs. Zyprexa (olanzapine) is an antipsychotic and is not typically used as a first-line treatment for seizures. Its use in this context would depend on the patient's psychiatric history and current mental status. 2 2
From the Research
Labs and Medications for a Patient with a Recent Seizure
The patient, a 41-year-old female with a witnessed seizure and no current antiepileptic medication, requires immediate attention. The following labs and medications should be considered:
- Labs:
- Complete blood count (CBC)
- Basic metabolic panel (BMP)
- Liver function tests (LFTs)
- Electrolyte panel
- Toxicology screen
- Imaging studies (e.g., CT or MRI) to rule out any underlying structural causes of the seizure
- Medications:
- Antiepileptic drugs (AEDs): Keppra (levetiracetam) 1500 mg IV is a suitable option, as it has been shown to be effective in controlling seizures in patients with epilepsy 3, 4.
- Benzodiazepines: May be considered for acute seizure management, but should be used with caution due to potential side effects and interactions with other medications 5.
- Other medications: Zyprexa (olanzapine) is not typically used as a first-line treatment for seizures, but may be considered for patients with concomitant psychiatric conditions.
Considerations for Medication Administration
When administering Keppra (levetiracetam) 1500 mg IV, it is essential to consider the patient's renal function and adjust the dose accordingly, as levetiracetam is primarily eliminated by the kidneys 3, 4. Additionally, the patient should be monitored for potential side effects, such as behavioral adverse effects, which have been associated with levetiracetam use 3, 4.
Combination Therapy
Combination therapy with levetiracetam and other AEDs may be considered for patients with refractory seizures, as it has been shown to provide additional therapeutic benefit 6. However, the decision to use combination therapy should be made on a case-by-case basis, taking into account the patient's individual needs and medical history.