What should be done for a patient with elevated Keppra (Levetiracetam) levels?

Management of Elevated Levetiracetam (Keppra) Level of 78

For a patient with a Keppra level of 78 μg/mL (significantly above the therapeutic range of 10-37 μg/mL), discontinue the medication temporarily and provide supportive care while monitoring for resolution of symptoms.

Assessment and Immediate Management

• Evaluate for signs of levetiracetam toxicity including somnolence, agitation, aggression, depressed level of consciousness, respiratory depression, and coma 1
• Assess vital signs and neurological status, including level of consciousness and respiratory function 1
• If the patient shows signs of respiratory depression, provide airway protection interventions and high-flow oxygen 2
• Check blood glucose level to rule out hypoglycemia as a contributing factor 2

Supportive Care

• If the ingestion was recent (within 1-2 hours), consider gastric lavage or induced emesis to eliminate unabsorbed drug 1
• Provide general supportive care with IV hydration and monitoring of vital signs 1
• Consider contacting a Poison Control Center for up-to-date management recommendations 1
• For severe toxicity with respiratory depression, intubation may be necessary 3

Specific Interventions

• For significant toxicity with high serum levels, hemodialysis should be considered as it can remove approximately 50% of levetiracetam in 4 hours 1
• Hemodialysis is particularly indicated in patients with significant renal impairment or severe clinical manifestations 1
• There is no specific antidote for levetiracetam overdose 1

Monitoring and Follow-up

• Monitor serum levetiracetam levels until they return to therapeutic range 3
• Expect relatively rapid recovery with supportive care as levetiracetam has a half-life of approximately 5-7 hours even at high concentrations 3
• Monitor for seizure recurrence during the period of medication adjustment 2

Seizure Management During Recovery

• If seizures occur during the recovery period, lorazepam 0.05-0.1 mg/kg IV (maximum 1-2 mg) can be administered 2
• For breakthrough seizures, alternative antiepileptic medications may be temporarily required 2

Resumption of Therapy

• Once levels have normalized and symptoms have resolved, consider resuming levetiracetam at a reduced dose with careful monitoring 2
• Investigate potential causes of the elevated level:
  • Renal dysfunction (levetiracetam is primarily eliminated through the kidneys) 4, 5
  • Medication interactions (although levetiracetam has minimal drug interactions) 4, 5
  • Dosing errors or intentional overdose 3

Common Pitfalls and Caveats

• Avoid administering medications that cause CNS depression which could worsen symptoms 2
• Do not abruptly discontinue levetiracetam long-term as this could precipitate withdrawal seizures 2
• Remember that levetiracetam toxicity can present with behavioral symptoms (agitation, aggression) that might be mistaken for other conditions 1, 4
• Elderly patients may be more susceptible to adverse effects and may require more careful monitoring 6