What antiepileptic medication is recommended for pediatric patients with ventriculoperitoneal (VP) shunt insertion at risk of seizures?

Levetiracetam is the Recommended Antiepileptic for Pediatric Patients with VP Shunt at Risk of Seizures

Levetiracetam is the recommended first-line antiepileptic medication for pediatric patients with ventriculoperitoneal (VP) shunt insertion who are at risk of seizures due to its favorable efficacy, safety profile, and minimal drug interactions. 1, 2

Rationale for Levetiracetam Use

• Levetiracetam is well-tolerated in the pediatric population with minimal adverse effects and drug interactions, making it ideal for patients with VP shunts who may be on multiple medications 3
• The recommended dosing for seizure prophylaxis in high-risk pediatric patients is 10 mg/kg (up to a maximum of 500 mg per dose) every 12 hours 1
• For acute seizure management in these patients, levetiracetam can be administered at 40 mg/kg IV (maximum 2,500 mg) as a loading dose 1
• Levetiracetam has demonstrated superior efficacy (70.9%) compared to phenytoin (58.1%) in controlling pediatric seizures, particularly in convulsive status epilepticus 2

Clinical Considerations for VP Shunt Patients

• Seizures are a common complication in children with VP shunts, with reported incidence ranging from 20% to 50% 4
• Risk factors for seizures in VP shunt patients include:
  • Young age at time of shunt placement (under 2 years) 4
  • Shunt revisions due to malfunction 4
  • Shunt infections 1
  • Catheter insertion trauma 4
  • Shunt over-drainage causing intracranial hypotension 5

Administration Guidelines

• For seizure prophylaxis: oral levetiracetam 10 mg/kg twice daily (maximum 500 mg per dose) 1
• For acute seizure management:
  • IV levetiracetam 40 mg/kg (maximum 2,500 mg) administered over 5-15 minutes 1, 6
  • Maintenance dosing after acute seizure resolution: 15-30 mg/kg IV every 12 hours 1
• Intravenous push (IVP) levetiracetam has been shown to be safe in pediatric patients over 12 months of age, with similar adverse event rates to IV piggyback administration but with faster delivery times 7

Advantages Over Alternative Antiepileptics

• Levetiracetam has fewer cardiovascular side effects compared to phenytoin (1.4% vs 23.3% adverse reaction rate) 2
• Unlike phenytoin, levetiracetam does not require serum level monitoring and has minimal drug interactions 3, 2
• Phenytoin and other first-line anti-seizure medications with unfavorable cardiotoxicity profiles should be avoided when possible in these patients 1
• Levetiracetam is primarily renally excreted and may require dose adjustment in patients with renal dysfunction 3

Management Algorithm for Seizures in VP Shunt Patients

1. For prophylaxis in high-risk patients (history of seizures, CNS disease):

   • Start levetiracetam 10 mg/kg twice daily (maximum 500 mg per dose) 1
   • Continue for at least 30 days following shunt insertion 1

2. For acute seizure management:

   • First-line: Lorazepam 0.05-0.1 mg/kg IV (maximum 2 mg) 1
   • Second-line: Levetiracetam 40 mg/kg IV (maximum 2,500 mg) over 5-15 minutes 1, 6
   • If seizures persist: Add phenobarbital 10-20 mg/kg IV (maximum 1,000 mg) 1

3. Maintenance after acute seizure resolution:

   • Levetiracetam 15-30 mg/kg every 12 hours 1
   • Consider neurology consultation for ongoing management 1

Important Considerations and Pitfalls

• Always rule out shunt malfunction or infection when seizures occur in a patient with a VP shunt 4, 5
• Shunt over-drainage can sometimes present with refractory seizures even in the absence of classic over-drainage symptoms 5
• Prophylactic antibiotics should be administered before VP shunt insertion to reduce infection risk, as infections can trigger seizures 1
• Continuous EEG monitoring may be beneficial in patients with refractory seizures to guide management 1