From the Guidelines
For a 61-year-old male with seizure disorders currently taking lamotrigine and eslicarbazepine (Aptiom), who has heart failure with preserved ejection fraction, levetiracetam (Keppra) would be an appropriate alternative medication. This recommendation is based on the need to reduce the risk of serious arrhythmias in a patient with a history of heart failure with preserved ejection fraction (HFpEF) 1. Levetiracetam has a different mechanism of action than sodium channel blockers, binding to synaptic vesicle protein SV2A rather than affecting sodium channels, which reduces the risk of cardiac conduction abnormalities and arrhythmias that can occur with multiple sodium channel blockers.
The management of patients with HFpEF involves controlling symptoms and preventing hospitalization, as no treatment has been shown to convincingly reduce morbidity and mortality in these patients 1. However, in the context of managing seizure disorders in a patient with HFpEF, the choice of antiepileptic medication is crucial to avoid exacerbating cardiac conditions.
Some key points to consider in the management of HFpEF include:
- Controlling resting heart rate using either a beta blocker or nondihydropyridine calcium channel antagonist is recommended for patients with persistent or permanent AF and compensated HF with preserved ejection fraction (HFpEF) 1.
- The use of SGLT2 inhibitors, such as dapagliflozin or empagliflozin, is recommended in patients with Heart Failure with mildly reduced Ejection Fraction (HFmrEF) or HFpEF to reduce the risk of HF hospitalization or cardiovascular death 1.
- The transition from current medications to levetiracetam should be gradual, with levetiracetam being initiated while slowly tapering the sodium channel blockers under close medical supervision to prevent breakthrough seizures.
Levetiracetam has minimal drug interactions, undergoes minimal hepatic metabolism, and has primarily renal clearance, making it safer in patients with cardiac conditions. The typical starting dose is 500 mg twice daily, which can be titrated up to 1500 mg twice daily based on seizure control and tolerability. Common side effects include somnolence, dizziness, and potential behavioral changes, but it generally has a favorable cardiovascular safety profile for patients with heart failure.
In the context of real-life clinical medicine, prioritizing the safety and efficacy of levetiracetam in patients with seizure disorders and HFpEF is essential to minimize the risk of serious arrhythmias and other cardiac complications. Therefore, levetiracetam is a suitable alternative medication for this patient, considering its pharmacological profile and the current clinical guidelines for managing HFpEF and seizure disorders 1.
From the Research
Alternative Medication Options
To reduce the risk of serious arrhythmias in a 61-year-old male with seizure disorders, currently taking lamotrigine and eslicarbazepine, and with a history of heart failure with preserved ejection fraction (HFpEF), alternative medication options may be considered.
- The patient is currently taking lamotrigine, which is a commonly used antiepileptic drug 2.
- Eslicarbazepine is also an antiepileptic drug, but there is limited information available on its use in patients with HFpEF 2.
- A network meta-analysis of individual participant data found that lamotrigine performs better than most other treatments in terms of treatment failure for any reason and due to adverse events, including carbamazepine, for individuals with focal seizures 3.
- For people with generalised onset seizures, evidence was more limited and of moderate certainty, but no other treatment performed better than first-line treatment sodium valproate, and there were no differences between sodium valproate, lamotrigine, or levetiracetam in terms of treatment failure 3.
- Levetiracetam may be a suitable alternative to lamotrigine, as it showed no significant difference in treatment failure outcomes and seemed to perform better than all other AEDs except lamotrigine 3.
Considerations for Patients with HFpEF
When considering alternative medication options for patients with HFpEF, it is essential to take into account the patient's comorbid conditions and the potential risks and benefits of each medication.
- HFpEF is a clinical syndrome characterized by symptoms and signs of heart failure with elevated left ventricular filling pressures at rest or during exercise 4, 5, 6.
- The diagnosis of HFpEF relies on the integration of clinical information, laboratory data, and interpretation of cardiac imaging and hemodynamic findings at rest and during exercise 6.
- Aggressive management of comorbidities, optimization of blood pressure control, and volume status using diuretics as needed are among the current treatment recommendations for HFpEF 6.
- There are no specific therapies that have shown to decrease mortality in HFpEF, but first-line pharmacologic therapy consists of sodium-glucose cotransporter type 2 inhibitors, such as dapagliflozin or empagliflozin, which reduced HF hospitalization or cardiovascular death by approximately 20% compared with placebo in randomized clinical trials 5.
Potential Alternative Medications
Based on the available evidence, potential alternative medications for the patient may include:
- Levetiracetam, which showed no significant difference in treatment failure outcomes compared to lamotrigine and seemed to perform better than all other AEDs except lamotrigine 3.
- Sodium valproate, which is a first-line treatment for generalised onset seizures and showed no differences in treatment failure outcomes compared to lamotrigine or levetiracetam 3.
- It is essential to note that the choice of alternative medication should be individualized and based on the patient's specific needs and medical history, and that any changes to the patient's medication regimen should be made under the guidance of a healthcare professional.