What to do if a patient experiences a seizure while on Keppra (levetiracetam)?

Management of Seizures in Patients on Levetiracetam (Keppra)

When a patient experiences a seizure while on levetiracetam, the dosage should be increased immediately, with consideration of adding a second antiepileptic medication if seizures persist despite dose optimization.

Initial Assessment and Management

When a patient on levetiracetam experiences a breakthrough seizure, take the following steps:

1. Ensure patient safety during the seizure:

   • Protect from injury
   • Position on side if possible to prevent aspiration
   • Do not place anything in the mouth
   • Time the seizure duration

2. Immediate post-seizure evaluation:

   • Assess vital signs and neurological status
   • Check for precipitating factors:
     • Medication non-adherence
     • Sleep deprivation
     • Alcohol consumption
     • Electrolyte disturbances
     • Fever or infection 1
     • Recent medication changes 1

Medication Management

Dose Optimization

• Increase levetiracetam dose if current dose is suboptimal:

  • Therapeutic range is typically 1000-3000 mg/day in divided doses
  • Can be safely increased up to 4000 mg/day with monitoring 2
  • Doses of 30-50 mg/kg/day have shown efficacy 1, 3

• Dosing considerations:

  • Adjust based on patient's age, weight, and seizure response
  • Monitor for dose-dependent side effects (somnolence, asthenia) 2
  • No dose adjustment needed for acute administration in hepatic impairment 1
  • Caution with frequent dosing in renal impairment 1

Add Second Antiepileptic Drug

If seizures persist despite levetiracetam dose optimization, consider adding:

• Valproate: 20-30 mg/kg IV with 88% success rate 1
• Other options based on seizure type and patient characteristics:
  • Lorazepam: 4 mg IV (65% success rate) for acute management 1
  • Phenytoin/Fosphenytoin: 18-20 mg/kg IV (56% success rate) 1

Special Considerations

For Status Epilepticus

If the patient progresses to status epilepticus:

1. First-line: Lorazepam 4 mg IV or midazolam 0.2 mg/kg IM if IV access unavailable 1
2. Second-line: Levetiracetam 30-50 mg/kg IV (44-73% success rate) 4, 1
3. Third-line: Consider propofol or pentobarbital if refractory 4

For Patients with Brain Tumors

• Consider adding dexamethasone 4-8 mg/day if perilesional edema is present 1
• Levetiracetam doses of 500-2500 mg (30-50 mg/kg/day) have shown efficacy in patients with brain tumors undergoing radiotherapy 3

Diagnostic Evaluation

After seizure control, perform:

• Laboratory tests:

  • Complete blood count
  • Comprehensive metabolic panel (electrolytes, glucose, calcium, magnesium)
  • Levetiracetam serum level if available (therapeutic range: 10-37 μg/mL) 5

• Neuroimaging if:

  • First breakthrough seizure
  • Change in seizure pattern
  • Focal neurological deficits
  • Prolonged post-ictal state

• EEG monitoring to:

  • Evaluate for subclinical seizures
  • Guide therapy adjustments
  • Assess for status epilepticus 1

Follow-up and Monitoring

• Schedule follow-up within 1-2 weeks after a breakthrough seizure
• Have patient maintain a seizure diary noting:
  • Seizure frequency, duration, and characteristics
  • Medication adherence
  • Use of rescue medications 1
• Monitor for adverse effects of increased levetiracetam:
  • Behavioral changes (irritability, aggression)
  • Somnolence
  • Asthenia 6

Common Pitfalls to Avoid

• Don't assume medication non-adherence without verification
• Don't overlook potential drug interactions, though levetiracetam has minimal drug-drug interactions 6
• Don't fail to consider alternative diagnoses for events that may mimic seizures
• Don't delay treatment of status epilepticus; patients with breakthrough seizures have higher risk of developing status epilepticus 1
• Don't miss underlying causes of breakthrough seizures (infection, metabolic disturbances, sleep deprivation) 1

By following this structured approach, clinicians can effectively manage breakthrough seizures in patients on levetiracetam therapy, optimizing outcomes and reducing the risk of complications.