Should Kepra (Levetiracetam) be taken prior to anesthesia?

Levetiracetam (Keppra) Should Be Continued Prior to Anesthesia

Patients taking levetiracetam (Keppra) should continue their regular dosing schedule prior to anesthesia to maintain seizure control and prevent complications.

Rationale for Continuing Levetiracetam

Levetiracetam is an antiepileptic medication that requires consistent blood levels to maintain seizure control. Unlike some medications that may need to be held before surgery, there are several important reasons to continue levetiracetam:

1. Risk of breakthrough seizures: Discontinuing antiepileptic medications can lead to breakthrough seizures, which could complicate anesthesia and surgical recovery.

2. No significant anesthetic interactions: Levetiracetam has minimal drug interactions with anesthetic agents compared to older generation antiepileptic drugs 1.

3. Minimal effect on metabolism: Unlike first-generation antiepileptic drugs (phenytoin, carbamazepine, phenobarbital), levetiracetam has fewer enzyme-inducing properties and causes fewer drug interactions 1.

4. No contraindications with anesthesia: There are no specific contraindications to continuing levetiracetam before anesthesia in current guidelines.

Perioperative Medication Management Guidelines

The Society for Perioperative Assessment and Quality Improvement (SPAQI) recommends continuing medications for chronic conditions throughout the perioperative period, particularly those used for seizure prevention 2. Unlike medications such as triptans that are recommended to be held on the day of surgery, chronic antiepileptic medications like levetiracetam should be maintained.

Clinical Considerations

Timing of Medication

• If the patient is NPO (nothing by mouth) before surgery, coordinate with the anesthesiologist to ensure levetiracetam is given with a small sip of water, which is permitted under current fasting guidelines.
• According to ASA guidelines, clear liquids may be ingested up to 2 hours before elective procedures requiring anesthesia 3.

Special Situations

• For patients unable to take oral medications, discuss with the surgical team about switching to intravenous levetiracetam temporarily during the perioperative period.
• IV levetiracetam has been shown to be safe and effective in multiple studies 4, 5.

Potential Risks of Discontinuation

Abrupt discontinuation of levetiracetam can lead to:

• Breakthrough seizures during or after anesthesia
• Increased risk of status epilepticus
• Complications with airway management if seizures occur during induction or emergence

Monitoring Considerations

• Ensure that the anesthesia team is aware of the patient's epilepsy diagnosis and levetiracetam regimen.
• Monitor for potential side effects, although studies show levetiracetam has minimal neurotoxicity even with continued use 6.

Conclusion

Maintaining antiepileptic therapy throughout the perioperative period is essential for patient safety. The benefits of continuing levetiracetam prior to anesthesia (seizure prevention, stable drug levels) outweigh any theoretical risks. This approach aligns with current perioperative medication management guidelines that emphasize continuing chronic medications, particularly those critical for neurological stability.