Do you start Keppra (levetiracetam) after a first seizure?

Management of First Seizure: When to Start Levetiracetam (Keppra)

Antiepileptic medication should not be initiated after a first unprovoked seizure in patients who have returned to their clinical baseline and have no evidence of brain disease or injury. 1

Decision Algorithm for First Seizure Management

For Unprovoked First Seizures

1. No treatment recommended for patients with:

   • First unprovoked seizure without evidence of brain disease/injury 1
   • Return to clinical baseline in the ED 1

2. Consider starting levetiracetam only for patients with:

   • Remote history of brain disease or injury (stroke, trauma, tumor) 1
   • Abnormal structural findings on neuroimaging 1
   • Focal onset of seizures 1

For Provoked First Seizures

• Do not initiate antiepileptic medication 1
• Instead, identify and treat the precipitating medical condition 1

Evidence-Based Rationale

Risk of Seizure Recurrence

• 33-50% of patients with first unprovoked seizure will have recurrence within 5 years 1
• For patients with a single unprovoked seizure, the number needed to treat (NNT) to prevent one seizure recurrence within 2 years is 14 patients 1
• Early treatment may delay time to subsequent seizure but does not alter long-term outcomes 2

Special Considerations for Brain Tumors

• For patients with newly diagnosed brain tumors who have not experienced a seizure:
  • Anticonvulsant prophylaxis is unlikely to be effective in increasing seizure-free survival 1
  • Perioperative anticonvulsant prophylaxis is possibly not effective in reducing seizures during the first 14 days following neurosurgery 1

Medication Selection When Treatment Is Indicated

When treatment is indicated (after second seizure or in high-risk first seizure):

• Levetiracetam (Keppra) is preferred for:

  • Young adults 3
  • Women of childbearing potential (avoid valproate due to teratogenicity) 3
  • Patients with renal or hepatic impairment 3
  • Patients on multiple medications (minimal drug interactions) 3
  • Initial dose: 500-1000 mg twice daily 3

• Alternative options:

  • Lamotrigine (better side effect profile than valproate) 3, 4
  • Valproate (for generalized epilepsy, but avoid in women of childbearing potential) 3, 4

Common Pitfalls to Avoid

1. Overtreatment: Starting medication after a single unprovoked seizure without risk factors for recurrence 1, 2

2. Undertreatment: Failing to start medication in patients with high risk of recurrence (brain injury/disease) 1

3. Inappropriate medication choice: Using valproate in women of childbearing potential or enzyme-inducing AEDs in patients on multiple medications 3

4. Inadequate follow-up: Not establishing a monitoring plan for seizure frequency, medication adherence, and side effects 3

Conclusion for Clinical Practice

The decision to start levetiracetam after a first seizure should be based on risk stratification. For most patients with a first unprovoked seizure who have returned to baseline, observation without medication is appropriate. Treatment should be reserved for those with significant risk factors for recurrence, such as structural brain abnormalities or history of brain injury.