What to monitor in patients taking Keppra (Levetiracetam)?

Monitoring for Patients Taking Keppra (Levetiracetam)

Patients taking levetiracetam should be monitored primarily for suicidal thoughts/behaviors, behavioral changes, and minimal laboratory monitoring is required compared to other antiepileptic drugs. 1

Key Monitoring Parameters

Behavioral and Psychiatric Monitoring

• Suicidal thoughts and behaviors

  • Highest priority monitoring parameter
  • AEDs including levetiracetam approximately double the risk of suicidal thinking or behavior (adjusted Relative Risk 1.8) 1
  • Risk appears as early as one week after starting treatment and persists throughout treatment
  • Risk is higher in epilepsy patients compared to those taking the medication for other conditions 1

• Mood and behavioral changes

  • Monitor for emergence or worsening of depression
  • Watch for unusual changes in mood or behavior
  • Behavioral effects occur more frequently in epilepsy patients than in patients with cognitive or anxiety disorders 2

Physical Monitoring

• Somnolence, asthenia, and dizziness

  • Most common adverse effects
  • Occur predominantly during the first month of treatment 2
  • May require dose adjustment if severe

• Respiratory function

  • In overdose cases, respiratory depression has been reported 3
  • Particularly important in patients with underlying respiratory conditions

Laboratory Monitoring

• Minimal laboratory monitoring required

  • Unlike many other antiepileptic drugs, levetiracetam does not require routine blood level monitoring 4
  • No significant drug interactions requiring monitoring of other medication levels 5
  • Changes in laboratory values (RBCs, hematocrit, hemoglobin, WBCs, neutrophils) typically remain within normal range 2

• Baseline assessment

  • Baseline renal and hepatic function tests recommended 6
  • Particularly important in elderly patients who are more likely to have decreased renal function 1

Special Populations

• Renal impairment

  • Levetiracetam is substantially excreted by the kidneys 1
  • Monitor renal function and adjust dosing in patients with moderate to severe renal impairment
  • Supplemental doses should be given to patients after dialysis 1

• Elderly patients

  • No specific safety differences compared to younger patients, but renal function monitoring is important 1
  • Dose selection should be cautious due to potential decreased renal function

• Pregnant patients

  • Recommend enrollment in the North American Antiepileptic Drug (NAAED) pregnancy registry 1
  • Monitor for pregnancy outcomes

Follow-up Schedule

• Regular follow-up every 3-6 months to assess:
  • Seizure control
  • Medication tolerability
  • Potential side effects, including cognitive effects 6

Advantages of Levetiracetam Monitoring

• Simpler monitoring profile compared to other antiepileptic drugs
• No need for therapeutic drug level monitoring 4
• No significant drug-drug interactions requiring additional monitoring 5
• Not associated with cognitive impairment or drug-induced weight gain 5

Common Pitfalls to Avoid

• Failing to monitor for psychiatric symptoms

  • The most serious risks with levetiracetam are behavioral/psychiatric
  • Underestimating the importance of monitoring for suicidal ideation can lead to preventable adverse outcomes

• Unnecessary laboratory testing

  • Unlike other antiepileptic drugs, extensive laboratory monitoring is not required
  • Focus monitoring on renal function, especially in at-risk populations

• Missing early adverse effects

  • Most adverse effects occur in the first month of treatment 2
  • Early follow-up is important to identify and manage these effects

• Overlooking renal function in elderly

  • Elderly patients are more likely to have decreased renal function
  • Failure to adjust dosing based on renal function can lead to adverse effects 1

By focusing monitoring on these key parameters, clinicians can effectively manage patients on levetiracetam therapy while minimizing unnecessary testing and interventions.