What is the best practice if a patient is at home with an aura to a seizure, should they double the dose of Keppra (levetiracetam) or take Valium (diazepam)?

Management of Seizure Aura at Home

For a patient experiencing an aura to a seizure at home, taking a benzodiazepine such as diazepam (Valium) is the recommended first-line intervention rather than doubling the dose of levetiracetam (Keppra). 1

Rationale for Using Benzodiazepines

Benzodiazepines are the established first-line treatment for acute seizure management for several important reasons:

• Benzodiazepines like diazepam work rapidly to suppress seizure activity through GABA-mediated inhibition
• The American Academy of Neurology recommends benzodiazepines as first-line agents for status epilepticus with a 65% success rate 1
• Diazepam can be administered rectally or orally at home, making it accessible for patients experiencing an aura

Why Not Double Keppra?

Doubling the dose of levetiracetam (Keppra) during an aura is not recommended for several reasons:

• Levetiracetam is considered a second-line agent for ongoing seizures, not a rescue medication 2, 1
• The onset of action for oral levetiracetam is not rapid enough to abort an impending seizure
• There is no evidence supporting the practice of doubling levetiracetam doses as an effective rescue strategy
• While levetiracetam has a favorable safety profile, acute high doses may increase the risk of behavioral side effects 3, 4

Recommended Home Rescue Protocol

1. At first sign of aura:

   • Administer diazepam (Valium) as prescribed for rescue therapy
   • Move to a safe position away from hazards
   • Note the time the aura began

2. After the seizure (if it occurs):

   • Continue taking regularly scheduled antiepileptic medications including levetiracetam
   • Do not make up for or double doses of daily medications
   • Seek medical attention if the seizure lasts more than 5 minutes or if multiple seizures occur without recovery

Important Considerations

• Safety profile: Benzodiazepines may cause respiratory depression, especially in elderly patients or those with respiratory conditions 1
• Medication availability: Ensure rescue medication is always accessible and not expired
• Documentation: Keep a seizure diary noting when rescue medication was used and its effectiveness
• Follow-up: Report all rescue medication use to your neurologist at your next appointment

Common Pitfalls to Avoid

• Delay in administration: Waiting too long after an aura begins before taking rescue medication reduces effectiveness
• Improper dosing: Taking more than the prescribed amount of benzodiazepine can lead to excessive sedation
• Medication confusion: Having a clear, written protocol can prevent mistakes during the stress of an impending seizure
• Overreliance on rescue medication: Frequent need for rescue medication may indicate that the baseline antiepileptic regimen needs adjustment

Patients experiencing frequent auras requiring rescue medication should consult their neurologist to optimize their regular antiepileptic medication regimen, which might include adjustments to their levetiracetam dosing schedule 4, 5.