When to administer Keppra (levetiracetam) to a patient after a seizure?

From the Guidelines

Levetiracetam (Keppra) should be administered as soon as possible after a seizure, with a recommended oral loading dose of 1,500 mg or rapid IV loading safe and well tolerated in doses up to 60 mg/kg, as evidenced by a study published in the Annals of Emergency Medicine 1. When considering the administration of Keppra after a seizure, it's crucial to prioritize the patient's morbidity, mortality, and quality of life. The evidence suggests that loading with antiepileptic medication, such as Keppra, is commonly done, but there is a lack of evidence to support or refute this practice 1. However, the study provides guidance on the loading dose and route of administration for Keppra, which can inform clinical decision-making.

Some key points to consider when administering Keppra include:

• The oral loading dose is 1,500 mg, while the IV loading dose can be up to 60 mg/kg 1
• The medication has a favorable side effect profile, with fatigue, dizziness, and rarely pain at the infusion site being reported 1
• Keppra can be administered rapidly without significant cardiovascular side effects, making it a suitable option for emergency situations
• The medication works by binding to synaptic vesicle protein SV2A, inhibiting neurotransmitter release and reducing neuronal excitability

It's essential to ensure the patient is stabilized with proper airway management before administering Keppra and to monitor for potential side effects, such as somnolence, dizziness, and behavioral changes. By prioritizing the patient's morbidity, mortality, and quality of life, and following the guidance provided by the evidence, clinicians can make informed decisions about the administration of Keppra after a seizure.

From the Research

Administration of Levetiracetam (Keppra) after a Seizure

• The decision to administer levetiracetam (Keppra) after a seizure depends on various factors, including the type and severity of the seizure, the patient's medical history, and the presence of any underlying conditions 2, 3.
• According to a study published in 2017, levetiracetam performed significantly better than carbamazepine and lamotrigine in terms of time to withdrawal of allocated treatment for individuals with partial seizures 2.
• Another study published in 2022 found that levetiracetam can be a good alternative to sodium valproate, especially in women of childbearing age, due to its similar efficacy and lower risk of adverse effects 4.
• A systematic review and meta-analysis published in 2022 found that levetiracetam may be preferred for seizure prophylaxis in patients with supratentorial neurosurgery, but its efficacy in other conditions such as traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage is still unclear 5.
• A recent study published in 2023 found that levetiracetam can reduce the cumulative incidence of late post-traumatic seizures in patients with traumatic brain injury, whereas valproate did not show a significant effect 6.

Timing of Administration

• The optimal timing for administering levetiracetam after a seizure is not well established, but it is generally recommended to start treatment as soon as possible after the seizure has occurred 3, 6.
• A study published in 2012 suggested that immediate treatment after a first unprovoked seizure does not improve the long-term remission rate, but prophylactic treatment should be considered after a first unprovoked event in an elderly person at high risk of recurrence 3.

Considerations for Administration

• The choice of levetiracetam as a treatment option should be individualized, taking into account the patient's specific needs and medical history 2, 3.
• The drug should be started at a low dose and titrated slowly to the lowest maintenance dose possible, with enhanced quality of life as a focus of treatment 3.
• An assessment should be done to identify possible drug-drug interactions, and the patient should be monitored closely for adverse effects 2, 3.