Aside from loading a patient with Keppra (levetiracetam) IV for seizures, what other medications can be given as a one-time dose?

Alternative Medications for Seizure Management Beyond Keppra IV

For patients with seizures who need an alternative to Keppra (levetiracetam) IV loading, valproate (20-30 mg/kg IV) is the most effective one-time dose option with an 88% success rate and fewer adverse effects than phenytoin. 1

First-Line Alternatives to Levetiracetam

Valproate (First Choice)

• Dosing: 20-30 mg/kg IV at a rate of 40 mg/min 2
• Efficacy: 88% success rate in controlling seizures 1
• Advantages:
  • Can be given more quickly than phenytoin
  • Fewer adverse effects than phenytoin/fosphenytoin
  • Comparable efficacy to phenytoin in status epilepticus 3
• Potential adverse effects: Dizziness, thrombocytopenia, liver toxicity, hyperammonemia 2

Phenytoin/Fosphenytoin (Second Choice)

• Dosing: 18-20 mg/kg IV (or PE/kg for fosphenytoin) 2
• Efficacy: 56% success rate 1
• Limitations:
  • Slower administration required (maximum rate of 150 PE/min)
  • Higher risk of adverse effects
• Potential adverse effects: Hypotension, cardiac dysrhythmias, purple glove syndrome, soft tissue injury with extravasation 2, 4

Other Effective One-Time Dose Options

Phenobarbital

• Dosing: 10-20 mg/kg IV; may repeat 5-10 mg/kg at 10 min 2
• Efficacy: 58.2% success rate in the Veterans Affairs cooperative trial 2
• Caution: Higher risk of respiratory depression and hypotension compared to other options 2
• Best use case: Consider when benzodiazepines and other second-line agents have failed

Propofol

• Dosing: 2 mg/kg IV bolus; may repeat in 3-5 min 2
• Maintenance: 5 mg/kg/hour infusion if needed 2
• Limitations:
  • Requires respiratory support
  • Risk of hypotension
  • Best used in already intubated patients 2

Decision Algorithm for Alternative Selection

1. First assess: Is the patient hemodynamically stable?

   • If YES → Consider valproate (20-30 mg/kg IV)
   • If NO → Consider levetiracetam (already ruled out) or phenobarbital with close monitoring

2. If cardiac concerns exist:

   • Avoid phenytoin/fosphenytoin due to cardiac dysrhythmia risk
   • Prefer valproate or levetiracetam

3. If rapid administration is needed:

   • Valproate can be given more quickly than phenytoin
   • Avoid phenytoin if IV access is tenuous (risk of purple glove syndrome)

4. For intubated patients with refractory seizures:

   • Consider propofol (2 mg/kg bolus) if not hypotensive 2

Important Clinical Considerations

• Monitor vital signs closely with all antiepileptic medications, particularly with phenytoin and phenobarbital
• Have airway equipment immediately available, especially when using medications with higher risk of respiratory depression
• Higher doses of antiepileptics may be more effective - studies show that higher doses of levetiracetam (>1000mg total daily dose) resulted in better seizure control 5
• The choice between agents should consider the specific clinical scenario, but valproate offers the best balance of efficacy, safety, and ease of administration for most patients requiring a one-time dose alternative to levetiracetam 1, 3

Common Pitfalls to Avoid

• Underdosing antiepileptic medications (particularly common with levetiracetam) 6
• Failing to monitor for hypotension with phenytoin, phenobarbital, and propofol
• Not considering drug interactions (phenytoin is a strong enzyme inducer) 4
• Delaying treatment while waiting for the "ideal" medication - prompt treatment is essential in status epilepticus

Remember that while these medications can be given as one-time doses, patients with ongoing seizure risk will typically require maintenance therapy following the loading dose.