Can I stop Keppra (levetiracetam) in an 82-year-old patient with a history of Urinary Tract Infection (UTI) and metabolic encephalopathy?

Discontinuation of Levetiracetam in Elderly Patient with Metabolic Encephalopathy

Yes, you can discontinue Keppra (levetiracetam) in this 82-year-old patient with metabolic encephalopathy due to UTI, as the drug was likely started empirically and is not indicated for this condition. Metabolic encephalopathy from UTI should resolve with appropriate antibiotic treatment of the underlying infection rather than antiepileptic medication.

Understanding the Clinical Scenario

This 82-year-old patient presents with:

• Altered mental status (found unresponsive)
• History of UTI in the setting of chronic catheterization
• EEG showing metabolic encephalopathy (not seizure activity)
• Started on Keppra (levetiracetam)

Rationale for Discontinuation

1. Metabolic Encephalopathy vs. Seizures

• The EEG shows metabolic encephalopathy, not seizure activity
• Levetiracetam is indicated for seizure disorders, not metabolic encephalopathy 1
• Metabolic encephalopathy in this case is likely secondary to UTI, which requires antibiotic treatment, not antiepileptic drugs

2. Risk of Medication Accumulation

• Levetiracetam is primarily eliminated renally 1
• Elderly patients often have reduced renal function
• There is risk of levetiracetam accumulation in renal impairment, which can paradoxically worsen encephalopathy 2
• Case reports document levetiracetam accumulation causing myoclonic encephalopathy with triphasic waves in patients with renal failure 2

3. Treatment of Underlying Cause

• The appropriate treatment for metabolic encephalopathy is addressing the underlying cause
• In this case, the UTI should be treated with appropriate antibiotics 3
• European Urology guidelines support that confusion in elderly patients can be an atypical presentation of UTI, especially when accompanied by positive urine culture 3

Management Approach

1. Discontinue Levetiracetam:

   • Since the EEG shows metabolic encephalopathy rather than seizure activity
   • No evidence supports continuing antiepileptic drugs in this scenario

2. Treat the Underlying UTI:

   • Select appropriate antibiotics based on culture results and local resistance patterns
   • Consider a 7-14 day course for elderly males with UTI due to potential prostate involvement 3
   • Adjust antibiotic dosing based on renal function

3. Monitor Mental Status:

   • Reassess mental status daily to track improvement with antibiotic therapy
   • Improvement in mental status with antibiotic treatment confirms UTI as the cause of encephalopathy

4. Consider Other Causes of Metabolic Encephalopathy:

   • Electrolyte abnormalities
   • Hyperammonemia (can occur with UTIs involving urea-splitting organisms) 4, 5
   • Medication effects (consider other medications that could contribute to encephalopathy)

Important Considerations

• If the patient has a history of seizures (not mentioned in the case), reassess the need for antiepileptic therapy after resolution of the acute illness
• If seizures occur during hospitalization, reconsider antiepileptic therapy
• Monitor renal function, as both UTI and certain antibiotics can affect kidney function

Potential Pitfalls

• Avoid assuming all altered mental status in elderly patients requires antiepileptic drugs
• Be cautious with medication accumulation in elderly patients with potential renal impairment
• Don't overlook the importance of treating the underlying cause of metabolic encephalopathy
• Recognize that asymptomatic bacteriuria should not be treated with antibiotics in elderly patients 6, but this patient has symptomatic infection (altered mental status)

By discontinuing levetiracetam and focusing on appropriate antibiotic therapy for the UTI, you will address the root cause of the metabolic encephalopathy and avoid potential adverse effects from unnecessary medication.