Can a patient who had two seizures, one lasting 5 minutes and the other 8 minutes, both terminating without benzodiazepines, be loaded with Levetiracetam (levetiracetam)?

From the Guidelines

You can consider loading this patient with levetiracetam (Keppra) after experiencing two self-terminating seizures of 5 and 8 minutes duration, as the most recent and highest quality study suggests that levetiracetam can be effective in stopping seizures in approximately half of all patients with benzodiazepine-resistant status epilepticus 1. A typical loading dose would be 20-60 mg/kg (commonly 1000-2000 mg in adults) administered intravenously over 15-30 minutes, followed by maintenance dosing of 500-1500 mg twice daily. The fact that both seizures terminated without requiring benzodiazepine intervention is somewhat reassuring, but seizures lasting more than 5 minutes are concerning and warrant treatment to prevent progression to status epilepticus. Some key points to consider when loading a patient with levetiracetam include:

• Levetiracetam is often chosen for its favorable side effect profile, minimal drug interactions, and effectiveness across multiple seizure types.
• It works primarily by binding to synaptic vesicle protein SV2A, modulating neurotransmitter release.
• Monitor the patient closely after loading for potential side effects including somnolence, dizziness, and rarely, behavioral changes.
• Renal function should be assessed as dosage adjustments may be needed in patients with impaired kidney function. The use of levetiracetam in this context is supported by recent studies, including a 2024 clinical policy statement that recommends its use in the management of adult patients presenting to the emergency department with seizures 1. While other studies have also examined the use of levetiracetam in status epilepticus, such as those published in 2014 1, the most recent and highest quality study should be prioritized when making treatment decisions. In this case, the 2024 study provides the most up-to-date guidance on the use of levetiracetam in patients with seizures, and its findings should be given the most weight when determining the best course of treatment.

From the FDA Drug Label

Levetiracetam can be initiated with either intravenous or oral administration. Treatment should be initiated with a daily dose of 1000 mg/day, given as twice-daily dosing (500 mg twice daily). Additional dosing increments may be given (1000 mg/day additional every 2 weeks) to a maximum recommended daily dose of 3000 mg

The patient had two seizures, one lasting 5 minutes and the other lasting 8 minutes, both terminated without benzodiazepines. Loading the patient with levetiracetam is not explicitly mentioned in the drug label. The label provides information on initiating treatment with a daily dose of 1000 mg/day. Key points to consider:

• The drug label does not provide guidance on loading doses for levetiracetam.
• The recommended initial dose is 1000 mg/day, given as twice-daily dosing.
• The label does not address the specific scenario of a patient having two seizures without benzodiazepines. Given the information available, it is not possible to determine a safe and effective loading dose for this patient based on the provided drug label 2.

From the Research

Loading a Patient with Levetiracetam

• The patient had two seizures, one lasting 5 minutes and the other lasting 8 minutes, both of which terminated without benzodiazepines.
• According to the study 3, levetiracetam is one of the anticonvulsant drugs that can be used to treat status epilepticus that is refractory to treatment with benzodiazepines.
• The study 3 found that levetiracetam led to seizure cessation and improved alertness by 60 minutes in approximately half the patients, with a posterior probability of 0.41 that it was the most effective drug.
• Another study 4 found that levetiracetam performed significantly better than carbamazepine and lamotrigine in terms of time to withdrawal of allocated treatment for individuals with partial seizures.
• Additionally, the study 5 found that levetiracetam had a probability of 47% of presenting the outcome "Seizure free" in the treatment of generalized tonic-clonic, tonic, and clonic seizures.

Considerations for Loading a Patient with Levetiracetam

• The patient's seizures terminated without benzodiazepines, which suggests that they may be a good candidate for levetiracetam.
• However, it is essential to consider the patient's individual characteristics, such as comorbid conditions and potential interactions with other medications, before loading them with levetiracetam.
• The study 6 suggests that antiepileptic drugs should usually be selected based on comorbid conditions, including depression, migraine, chronic pain, obesity, and nephrolithiasis, or patient characteristics, especially for women of childbearing potential and older adults.
• The study 7 highlights the importance of timely recognition and effective early treatment with first- and second-line antiepileptic drugs, including levetiracetam, to prevent unnecessary hospitalizations and improve quality of life.