Can I stop taking Keppra (levetiracetam)?

Stopping Keppra (Levetiracetam): Guidelines for Discontinuation

Abruptly stopping Keppra (levetiracetam) is not recommended as it should be withdrawn gradually to minimize the potential of increased seizure frequency. 1

Decision Framework for Discontinuing Levetiracetam

When Discontinuation May Be Appropriate:

• After 2 years of seizure freedom if EEG is normal
• For patients with few seizures and resolution of lesions on imaging, consider tapering after 6-24 months of seizure freedom 2

Tapering Protocol:

1. Gradual reduction: Decrease dose by 25% every 2 weeks
2. Monitor closely: Watch for breakthrough seizures during tapering
3. Extended tapering: For patients on long-term therapy (>1 year), consider a more extended tapering period of 3-6 months

Factors to Consider Before Stopping

Favorable Factors for Discontinuation:

• Complete seizure control for at least 2 years
• Normal EEG findings
• Single seizure type
• Normal neurological examination
• Resolution of underlying seizure cause (if applicable)

Risk Factors for Seizure Recurrence:

• History of status epilepticus
• Multiple seizure types
• Abnormal EEG
• Structural brain abnormalities
• Family history of epilepsy
• Prior failed attempts at medication withdrawal

Special Considerations

For Patients with Status Epilepticus History:

Levetiracetam is one of the recommended second-line agents for status epilepticus. If you have a history of status epilepticus, discontinuation carries higher risks 3. The 2024 ACEP guidelines indicate that levetiracetam, fosphenytoin, or valproate may be used with similar efficacy in status epilepticus management.

For Patients with Migraine:

If Keppra was prescribed for migraine prevention, current guidelines state there is insufficient evidence to recommend for or against levetiracetam for the prevention of episodic migraine 3. Alternative medications with stronger evidence include candesartan, telmisartan, erenumab, fremanezumab, or galcanezumab.

For Patients with Behavioral Side Effects:

If experiencing behavioral side effects (reported in 5-12% of patients), discontinuation may improve quality of life, but must be balanced against seizure control benefits 1.

Common Pitfalls to Avoid

1. Abrupt discontinuation: This significantly increases seizure risk, including status epilepticus
2. Discontinuing without medical supervision: Always consult your healthcare provider
3. Stopping due to minor side effects: Some side effects may resolve with time or dose adjustment
4. Discontinuing during periods of stress or illness: These can lower seizure threshold
5. Ignoring drug interactions: If on multiple medications, removal of levetiracetam may affect other drug levels

Monitoring During Discontinuation

• Regular follow-up visits during tapering period
• Consider EEG monitoring before and during tapering
• Be alert for emergence of seizure activity
• Have rescue medication available if appropriate
• Document any withdrawal symptoms or seizure activity

Conclusion

The decision to stop Keppra requires careful consideration of seizure history, duration of seizure freedom, EEG findings, and potential risks. While discontinuation may be appropriate after prolonged seizure freedom, it must be done gradually under medical supervision to minimize risks of seizure recurrence.