Should a 41-year-old female with recurrent seizures be prescribed Keppra (levetiracetam) without a neurology appointment or seizure disorder diagnosis?

From the Guidelines

A 41-year-old female with recurrent seizures should not be prescribed Keppra (levetiracetam) without first having a neurology evaluation and proper diagnosis. Recurrent seizures require thorough investigation to determine their cause, type, and appropriate treatment approach. A neurologist should perform a comprehensive assessment including medical history, physical examination, electroencephalogram (EEG), and possibly brain imaging such as MRI. While Keppra is an effective antiepileptic medication commonly used for various seizure types, as seen in the management of status epilepticus where levetiracetam can result in cessation of seizures in approximately half of all patients 1, starting any seizure medication without proper diagnosis could mask underlying conditions, delay appropriate treatment, or expose the patient to unnecessary side effects. Seizures can result from various causes including epilepsy, brain tumors, infections, metabolic disorders, or other neurological conditions, each requiring specific management approaches.

The provided evidence from the study published in Annals of Emergency Medicine 1 highlights the importance of proper management of seizures, but it does not support initiating treatment with Keppra without a diagnosis. Another study published in Nature Reviews Clinical Oncology 1 discusses the use of levetiracetam for seizure prophylaxis in patients receiving CAR T cell therapy, but this context is not relevant to the current patient's situation.

The patient should seek urgent neurological evaluation, and in the meantime, learn seizure first aid and safety precautions to prevent injury during episodes. This approach prioritizes the patient's morbidity, mortality, and quality of life by ensuring that any treatment is based on a thorough understanding of the underlying cause of the seizures. Urgent neurological evaluation is crucial to determine the appropriate treatment approach, including whether Keppra or any other antiepileptic medication is necessary, and to identify any potential underlying conditions that require specific management.

From the Research

Seizure Disorder Diagnosis and Treatment

• The patient's recurrent seizures suggest the need for a thorough diagnosis and treatment plan, as stated in the study 2.
• The decision to initiate an antiseizure drug (ASD) should be individualized, but should be strongly considered after 2 unprovoked seizures or after 1 unprovoked seizure that occurred during sleep and/or in the presence of epileptiform activity on an electroencephalogram and/or in the presence of a structural lesion on the brain magnetic resonance imaging 2.

Levetiracetam (Keppra) as a Treatment Option

• Levetiracetam is an established second-generation antiepileptic drug (AED) with a novel structure and unique mechanisms of action, as described in the study 3.
• It is commonly used as adjunctive treatment of partial onset seizures with or without secondary generalization, and as monotherapy treatment of partial onset seizures with or without secondary generalization 3.
• However, the study 4 found that levetiracetam did not meet the criteria for non-inferiority in the primary intention-to-treat analysis of time to 12-month remission for focal epilepsy, and was not recommended as a first-line treatment for newly diagnosed generalised epilepsy.

Considerations for Prescribing Levetiracetam

• The selection of an ASD should consider the seizure and epilepsy types, the epilepsy syndrome, and the adverse effects associated with the drug, as stated in the study 2.
• Levetiracetam may be considered if there is no history of psychiatric disorder, but its use should be individualized and based on the patient's specific condition and medical history 2.
• The study 5 found that levetiracetam may be preferred post supratentorial neurosurgery, but more high-quality randomized trials of prophylactic levetiracetam are warranted.

Conclusion Not Provided as per Request

• The patient's situation should be evaluated on a case-by-case basis, taking into account the severity and frequency of seizures, medical history, and potential interactions with other medications, as suggested by the studies 2, 3, and 4.
• It is essential to consult with a neurologist to determine the best course of treatment, as stated in the studies 2 and 4.