From the Guidelines
Levetiracetam (Keppra) prophylaxis is not recommended for routine use in traumatic brain injury.
Indications for Levetiracetam Prophylaxis
- The use of levetiracetam for primary prevention of post-traumatic seizures can be considered in specific cases with risk factors, such as:
- Chronic subdural hematoma
- Past history of epilepsy
- In such cases, levetiracetam is preferred over phenytoin due to its higher degree of tolerance, as suggested by the study 1.
Rationale
- The incidence of early clinical seizures (within 7 days after the brain injury) is relatively low, at 2.2%, and the incidence of delayed seizures (after 7 days) is 2.1% 1.
- Multiple clinical trials and meta-analyses have shown that antiepileptic drugs, including levetiracetam and phenytoin, do not have a significant effect on preventing early or delayed post-traumatic seizures 1.
- The use of antiepileptic drugs has been associated with increased side effects and potentially worsening neurological outcomes 1.
From the Research
Indications for Levetiracetam Prophylaxis in Traumatic Brain Injury
The indications for Levetiracetam (Keppra) prophylaxis in traumatic brain injury (TBI) are as follows:
- Levetiracetam is used as an alternative to phenytoin for early posttraumatic seizure prophylaxis following TBI 2, 3, 4, 5, 6
- The Brain Trauma Foundation and the American Academy of Neurology (AAN) recommend seizure prophylaxis only during the first seven days after TBI 3
- Levetiracetam has demonstrated comparable efficacy to phenytoin for seizure prophylaxis and is associated with fewer adverse effects and monitoring considerations 3, 5, 6
- The use of levetiracetam for seizure prophylaxis in TBI has been increasing, with some studies showing a trend favoring levetiracetam over phenytoin 4
Dosing Strategies
- Different dosing strategies of levetiracetam have been studied, including ≤ 1000 mg/day, 1500 mg/day, and ≥ 2000 mg/day 2
- The optimal dosing strategy for levetiracetam in TBI has not been elucidated, with some studies showing no statistically significant difference in the cumulative incidence of early posttraumatic seizures between different dosing strategies 2
Comparison with Phenytoin
- Levetiracetam and phenytoin have similar incidences of early seizures after TBI, with no significant difference in efficacy or safety 5, 6
- Phenytoin has been the most extensively studied antiepileptic drug for seizure prophylaxis in TBI, but levetiracetam may be a reasonable alternative due to its favorable pharmacokinetic features and minimal adverse events profile 3, 6