Is azithromycin safe for a patient with epilepsy who is on Keppra (levetiracetam) and lamotrigine?

Safety of Azithromycin in Epilepsy Patients on Levetiracetam and Lamotrigine

Azithromycin is safe to use in patients with epilepsy who are taking levetiracetam (Keppra) and lamotrigine, as it does not have significant proconvulsive properties or interactions with these antiseizure medications. 1

Antibiotic Selection in Epilepsy Patients

• Azithromycin (a macrolide antibiotic) has a low proconvulsive potential compared to other antibiotics such as penicillins, cephalosporins, fluoroquinolones, and carbapenems, which are known to potentially trigger seizures 1
• When selecting antibiotics for epilepsy patients, those with low seizure-inducing potential should be preferred, particularly in patients with established epilepsy 1

Antiseizure Medication Considerations

Levetiracetam (Keppra)

• Levetiracetam acts primarily on the SV2A protein and has minimal drug interactions due to its lack of hepatic metabolism 2, 3
• It does not significantly interact with azithromycin, making this combination relatively safe 1
• Levetiracetam is commonly used for both focal and generalized epilepsy with good efficacy 3, 4

Lamotrigine

• Lamotrigine works primarily as a sodium channel modulator 2
• Unlike some other antiseizure medications, lamotrigine does not have significant interactions with macrolide antibiotics like azithromycin 2, 1
• Lamotrigine requires careful dosing and monitoring, especially when initiating therapy, due to risk of skin reactions 2

Important Antibiotic Considerations in Epilepsy

• High-risk antibiotics to avoid in epilepsy patients include:

  • Penicillins and cephalosporins (can lower seizure threshold) 1
  • Fluoroquinolones (may trigger seizures) 1
  • Carbapenems (can interact with antiseizure medications and lower seizure threshold) 1

• Some antibiotics can affect plasma concentrations of antiseizure medications through pharmacokinetic interactions:

  • Carbapenems can reduce valproate levels 1
  • Some macrolides can affect levels of certain antiseizure medications, but azithromycin has minimal effect on the metabolism of levetiracetam and lamotrigine 1

Clinical Monitoring Recommendations

• Monitor for any changes in seizure frequency during and shortly after antibiotic therapy 1

• Be vigilant for potential adverse effects common to both medication classes:

  • Levetiracetam: irritability, mood changes, fatigue 2, 3
  • Lamotrigine: rash, nausea, dizziness 2
  • Azithromycin: gastrointestinal effects (nausea, diarrhea) 1

• If seizure control worsens during antibiotic therapy, consider switching to an alternative antibiotic with even lower proconvulsive potential 1

Special Considerations

• In patients with renal impairment, appropriate dose adjustments of both azithromycin and levetiracetam may be necessary, as both are primarily excreted renally 1
• Avoid antibiotics that might interact with antiseizure medications or lower the seizure threshold, particularly in patients with poorly controlled epilepsy 1