What are the guidelines for initiating Levetiracetam (Keppra) after a seizure?

From the Guidelines

Keppra (levetiracetam) should be initiated post-seizure with a loading dose of 1,500 mg orally or a rapid IV loading dose of up to 60 mg/kg, as it has been shown to be safe and well-tolerated with no seizures within 24 hours of loading in some studies 1. When initiating Keppra, it is essential to consider the patient's renal function, as dose adjustment may be necessary for those with impaired kidney function.

• Common side effects of Keppra include fatigue, dizziness, and rarely, pain at the infusion site 1.
• The choice of administration route, oral or parenteral, is at the discretion of the emergency physician, as there is a lack of evidence to support one route over the other in terms of preventing early recurrent seizure 1.
• Recent guidelines suggest that in the setting of benzodiazepine-resistant status epilepticus, the use of levetiracetam will result in cessation of seizures in approximately half of all patients, with limited harms apart from potential adverse drug reactions 1.
• It is crucial to counsel patients to take the medication consistently and not to stop abruptly, as this can trigger seizures, and to report any concerning side effects, particularly mood changes or suicidal thoughts.
• Keppra's mechanism of action involves binding to synaptic vesicle protein SV2A, modulating neurotransmitter release, and stabilizing neuronal activity, effectively preventing abnormal electrical discharges that cause seizures.

From the Research

Keppra Initiation Post Seizure

• The decision to initiate Keppra (levetiracetam) post seizure depends on various factors, including the type and frequency of seizures, as well as the patient's medical history and current medications 2.
• According to a study published in 2011, levetiracetam is an established second-generation antiepileptic drug (AED) that is commonly used as adjunctive treatment for partial onset seizures with or without secondary generalization 2.
• The study also notes that levetiracetam has a novel structure and unique mechanisms of action, which involve neuronal binding to synaptic vesicle protein 2A, inhibiting calcium release from intraneuronal stores, and opposing the activity of negative modulators of GABA- and glycin-gated currents 2.
• In terms of efficacy, a systematic review and meta-analysis published in 2022 found that levetiracetam may be preferred post supratentorial neurosurgery, but its use in other conditions such as traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), and intracerebral hemorrhage (ICH) is still unclear 3.
• Another study published in 2022 compared the efficacy of levetiracetam, lamotrigine, and sodium valproate in patients with juvenile myoclonic epilepsy, and found that levetiracetam and sodium valproate had similar efficacy, while lamotrigine had a higher rate of failure in controlling seizures and myoclonic jerks 4.
• When to initiate treatment with Keppra or other AEDs is a complex decision that depends on various factors, including the patient's seizure history, medical history, and current medications, as well as the potential risks and benefits of treatment 5.
• A study published in 2005 notes that most patients who have had more than one well-documented or witnessed seizure require prophylactic AED therapy, and that the goal of treatment should be to maintain a normal lifestyle by complete seizure control with no or minimal side-effects 5.