Risk of Seizure When Changing from Keppra (Levetiracetam) to Briviact (Brivaracetam)
Switching from Keppra (levetiracetam) to Briviact (brivaracetam) carries a low risk of breakthrough seizures when done properly, with an overnight switch at a conversion ratio of 10:1 to 15:1 being feasible and potentially improving tolerability, especially regarding behavioral side effects.
Understanding the Medications
Both medications work through a similar mechanism:
- Levetiracetam (Keppra) and brivaracetam (Briviact) are SV2A ligands
- Brivaracetam has a higher affinity for SV2A receptors than levetiracetam
- Both are used for seizure control in epilepsy patients
Conversion Strategy and Risk Assessment
Recommended Conversion Approach
- An immediate overnight switch from levetiracetam to brivaracetam is feasible at a conversion ratio of 10:1 to 15:1 1
- For example:
- 1000 mg levetiracetam would convert to 100 mg brivaracetam
- 1500 mg levetiracetam would convert to 100-150 mg brivaracetam
Seizure Risk Factors
- The risk of breakthrough seizures appears to be low when switching between these specific medications
- Studies have shown that brivaracetam may be better tolerated than levetiracetam, with 57.1% of patients reporting improved tolerability after switching 2
- Patients with behavioral side effects from levetiracetam may particularly benefit from the switch 1, 2
Efficacy Considerations
Brivaracetam has demonstrated good efficacy in clinical trials:
- Significant median seizure reduction rates of 30.5% to 53.1% for 50 mg/day
- 50% responder rates of 32.7% to 55.8% for 50 mg/day 1
- In a study of patients switched from levetiracetam to brivaracetam:
- 32.6% were 50%-responders
- 21.7% became newly seizure-free 2
Monitoring and Management
During Transition
- Monitor closely for breakthrough seizures in the first few weeks after switching
- Consider checking drug levels if available, especially if there are concerns about efficacy
- Be alert for any new side effects, though brivaracetam is generally well-tolerated
Common Side Effects to Monitor
- Main adverse events with brivaracetam are fatigue, dizziness, and somnolence 1
- These are typically milder than with levetiracetam, especially behavioral side effects
Important Caveats and Pitfalls
Generic vs. Brand Considerations
- There have been reports of breakthrough seizures when switching from brand-name to generic levetiracetam 3, 4
- In one study, patients who experienced breakthrough seizures after switching to generic levetiracetam returned to seizure control when switched back to brand-name Keppra 3
- This highlights the importance of consistency in formulation, regardless of which medication is chosen
Special Populations
- While not directly related to the Keppra-to-Briviact switch, it's worth noting that the American Academy of Neurology recommends levetiracetam over older antiepileptic drugs to reduce side effects (level C recommendation) 5
- This principle likely extends to brivaracetam, which has an even more favorable side effect profile
Conclusion
The transition from Keppra to Briviact carries a relatively low risk of breakthrough seizures when done with appropriate dosing conversion. The potential benefits of improved tolerability may outweigh the risks for many patients, particularly those experiencing behavioral side effects on levetiracetam.