Management of Brivaracetam Overdose
There is no specific antidote for brivaracetam overdose; management focuses on supportive care with airway protection, adequate oxygenation and ventilation, and continuous cardiac monitoring. 1
Initial Stabilization and Monitoring
Immediately secure the airway and ensure adequate oxygenation and ventilation, as brivaracetam overdose can cause respiratory depression and altered mental status. 1 Endotracheal intubation should be performed if respiratory depression is present or if airway protective reflexes are compromised. 2
Establish continuous cardiac monitoring to detect bradycardia, which has been reported in brivaracetam overdose cases. 1 Monitor cardiac rate, rhythm, and vital signs throughout the observation period. 1
Obtain IV access immediately and perform bedside glucose testing to exclude hypoglycemia as a contributing factor to altered mental status. 3
Expected Clinical Presentation
The adverse reactions associated with brivaracetam overdose include:
- Somnolence and dizziness (most common) 1
- Vertigo and balance disorder 1
- Fatigue and nausea 1
- Diplopia and anxiety 1
- Bradycardia 1
A patient who ingested 1400 mg (14 times the highest recommended single dose) experienced somnolence and dizziness as the primary manifestations. 1 The adverse reactions in overdose are generally consistent with the known side effect profile of therapeutic brivaracetam use. 1
Specific Treatment Considerations
Atropine 0.5-1.0 mg IV every 3-5 minutes should be administered for symptomatic bradycardia causing hemodynamic instability. 2 This is the only specific pharmacologic intervention that may be required beyond supportive care.
Do not administer flumazenil or naloxone, as these agents have no role in brivaracetam toxicity and will not reverse the effects. 2, 4 Brivaracetam is not a benzodiazepine or opioid despite causing CNS depression. 2
Hemodialysis is not expected to enhance brivaracetam clearance because less than 10% of the drug is excreted unchanged in urine. 1 Brivaracetam is primarily metabolized via hydrolysis and CYP2C8-mediated hydroxylation, with over 95% of the dose (including metabolites) excreted renally within 72 hours. 5
Ongoing Management
Contact a certified poison control center for updated management guidance specific to the clinical scenario. 1
Continue monitoring until all symptoms completely resolve and vital signs normalize for at least 24 hours. 3 Given brivaracetam's half-life of approximately 8 hours, patients may require extended observation. 5
Psychiatric evaluation is mandatory before discharge for intentional ingestions to assess suicide risk and ensure appropriate follow-up. 3
Critical Pitfalls to Avoid
Do not assume specific antidotes will help: Unlike some other drug overdoses, there is no reversal agent for brivaracetam toxicity. 1
Do not overlook co-ingestions: Always evaluate for other substances that may require specific antidotes or alter the clinical presentation. 2 Brivaracetam is commonly used with other antiepileptic drugs, and polypharmacy overdoses may complicate management. 6
Do not prematurely discontinue monitoring: The duration of symptoms may extend beyond initial presentation, particularly with large ingestions. 1