What is the best course of action for a patient with schizophrenia, major depressive disorder (MDD), and anxiety, who is taking Keppra (levetiracetam) 500 mg orally twice a day and Topamax (topiramate) 50 mg orally twice a day, when primary care claims she has no history of seizure disorder and the past medical history is unclear?

Management of Antiepileptic Medications in a Patient with Unclear Seizure History

You should discontinue Keppra (levetiracetam) and Topamax (topiramate) gradually under careful monitoring, as these medications were likely prescribed for behavioral health reasons rather than for seizure control.

Assessment of Current Situation

• The clinical scenario presents a complex case with conflicting information: psychiatric hospital documentation indicates seizure disorder, while primary care states the patient has never had seizures 1
• Both Keppra (levetiracetam) and Topamax (topiramate) are FDA-approved antiepileptic drugs, but they are also sometimes used off-label for psychiatric conditions 2, 3
• The addition of vitamin B6 for "Keppra associated agitation" suggests the patient may be experiencing behavioral side effects from levetiracetam 2, 4

Medication Review and Concerns

• Levetiracetam (Keppra) is associated with significant behavioral side effects including aggression, irritability, mood changes, and depression, which occur in approximately 13.3% of adults 2, 4
• Topiramate (Topamax) can cause cognitive impairment, confusion, problems with concentration, attention, memory, and speech 3
• Both medications require gradual tapering when discontinuing to minimize the risk of withdrawal seizures, even in patients without a confirmed seizure disorder 1, 2

Action Plan

1. Obtain EEG and neuroimaging:

   • An EEG and brain MRI should be performed to look for evidence of seizure activity or structural abnormalities that would warrant anticonvulsant therapy 1

2. Medication tapering approach:

   • If EEG and neuroimaging are negative for seizure activity or structural abnormalities, begin gradual tapering of both medications 1, 2
   • Start with one medication at a time, beginning with Topamax as it has more cognitive side effects 3, 5
   • Reduce Topamax by 25mg every 1-2 weeks until discontinued 3
   • After Topamax is discontinued, gradually taper Keppra by 250mg every 1-2 weeks 2

3. Psychiatric medication optimization:

   • Consider alternative medications specifically for the patient's psychiatric conditions (schizophrenia, MDD, anxiety) 6
   • Monitor closely for emergence or worsening of psychiatric symptoms during the tapering process 2, 4

Special Considerations

• If the patient has been taking these medications for behavioral health reasons, there may be worsening of psychiatric symptoms during tapering 4, 5
• Both medications may have been providing some mood stabilization benefit despite their side effect profile 7, 6
• The presence of vitamin B6 supplementation suggests previous recognition of behavioral side effects from Keppra 4

Common Pitfalls to Avoid

• Abrupt discontinuation of antiepileptic medications can precipitate withdrawal seizures even in patients without epilepsy 1, 2
• Assuming all behavioral changes during tapering are due to underlying psychiatric conditions rather than medication withdrawal effects 4, 5
• Failing to document the rationale for medication changes and the uncertainty regarding the original indication 1

Monitoring During Tapering

• Implement regular assessment of both psychiatric symptoms and potential seizure activity 2, 4
• Educate nursing home staff about signs of both withdrawal seizures and psychiatric decompensation 1, 4
• Consider more frequent visits during the tapering process to adjust the plan as needed 2, 3