Intravenous levetiracetam in children with epilepsy

Interactions between antiepileptic and chemotherapeutic drugs in children with brain tumors: is it time to change treatment?

Epileptic seizures are a common clinical problem in children with brain tumors. The conventional antiepileptic drugs (AEDs) permit a good seizure control in most of these children. An emerging problem is the possible interactions between AEDs and chemotherapeutic drugs, because many of these drugs are metabolized by the cytochrome P450. The aim of this article is to propose a novel therapeutic approach for new-onset epilepsy in children with brain tumors. Among the new AEDs not metabolized by the P450 system, levetiracetam seems to be a promising AED owing to its pharmacokinetic features, efficacy, and safety.

Management of refractory status epilepticus at a tertiary care centre in a developing country

BACKGROUND

Refractory status epilepticus (RSE) is a common Neurological Emergency with increased mortality and morbidity in developing countries where facilities of intubation, adequate ventilation, Intensive Care Units (ICUs) and general anaesthesia are not ubiquitously available. Treatment protocols use antiepileptic drugs (AEDs) and need ICU facilities after failure of standard AEDs. Our aim was to see the response to two additional drugs in the armamentarium against refractory status, that is, valproate and levetiracetam.

METHODS

Patients with generalized RSE admitted in neurology and neurosurgery services at AIIMS during December 2006 to June 2008 were included in the study. The patients were allotted to two groups based on certain criteria. Demographic details, reason for delay, etiology precipitating status, ongoing AEDs therapy, duration of status, the time taken for cessation along with clinical, EEG and MRI correlates were noted. Outcome parameters were analyzed by an independent blinded observer.

RESULTS

82 patients with RSE were studied out of which 41 patients were given IV valproate (Group A) and 41 patients were given IV levetiracetam (Group B). Cessation of status failed in 13 patients in valproate group and 11 patients in levetiracetam group. Majority of the patients did not require ICU settings despite being classified as refractory.

CONCLUSION

RSE can be controlled with intravenous loading and maintenance of valproate or levetiracetam which do not cause respiratory depression, hypotension, need of intubation and ICU care. These must always be considered in a developing country scenario where ICU facilities are not always available or while transporting to centres where these facilities are available.

Rapid infusion of a loading dose of intravenous levetiracetam with minimal dilution: a safety study

Intravenous antiepileptic drugs are required in patients needing urgent treatment or unable to take oral medication. The safety of intravenous levetiracetam has been established in prospective studies of adult epilepsy and healthy participants. The authors performed a prospective, single-center study to evaluate the safety of a rapid loading dose of intravenous levetiracetam. Patients were divided into 3 equal dosing groups (N = 15 each): 20, 40, and 60 mg/kg (corresponding to maximum doses of 1, 2, and 3 g). Electrocardiogram and safety assessment were performed during the infusion. Ages were 4 to 32 years. Postinfusion serum levetiracetam concentrations were 14 to 189 microg/mL. There were no significant changes in blood pressure, no local infusion site reactions, and no electrocardiogram abnormalities. The authors concluded that high serum levels of parenteral levetiracetam can be achieved rapidly and safely, in a small infusion volume. This finding has important implications for the treatment of status epilepticus.

Role of intravenous levetiracetam in acute seizure management of children

Status epilepticus is defined as a seizure lasting beyond 30 minutes. Children with intractable epilepsy undergo frequent hospital admissions secondary to status epilepticus or because of acute exacerbation of seizures. Intravenous levetiracetam became available in August 2006 for use in patients aged above 16 years. There are insufficient data about the efficacy and safety of intravenous levetiracetam in children. We retrospectively analyzed data from children treated with intravenous levetiracetam for status epilepticus and acute exacerbation of seizures. We acquired data from our institution's electronic medical records concerning patients with status epilepticus and acute exacerbation of seizures who received intravenous levetiracetam. Thirty-two patients (age range, 2 months to 18 years) had received a levetiracetam load of 25-50 mg/kg for status epilepticus. There were 17 (53.1%) males and 15 (46.8%) females. Response to intravenous levetiracetam in all patients was favorable. Status epilepticus ceased clinically and electrographically. Eighteen patients (56.5%) received intravenous levetiracetam after receiving fosphenytoin and Ativan with no response. No serious side effects were evident. Fifteen patients (46.8%) were discharged on levetiracetam monotherapy, and 9 (28.1%) received levetiracetam as adjunctive therapy after discharge from the hospital. Intravenous levetiracetam can be used adjunctively or as monotherapy in children with status epilepticus and acute exacerbation of seizures.

Intravenous levetiracetam in critically ill children with status epilepticus or acute repetitive seizures

OBJECTIVE

Intravenous (IV) levetiracetam (LEV) is approved for use in patients older than 16 years and may be useful in critically ill children, although there is little data available regarding pharmacokinetics. We aim to investigate the safety, an appropriate dosing, and efficacy of IV LEV in critically ill children.

DESIGN

We describe a cohort of critically ill children who received IV LEV for status epilepticus, including refractory or nonconvulsive status, or acute repetitive seizures.

RESULTS

There were no acute adverse effects noted. Children had temporary cessation of ongoing refractory status epilepticus, termination of ongoing nonconvulsive status epilepticus, cessation of acute repetitive seizures, or reduction in epileptiform discharges with clinical correlate.

CONCLUSIONS

IV LEV was effective in terminating status epilepticus or acute repetitive seizures and well tolerated in critically ill children. Further study is needed to elucidate the role of IV LEV in critically ill children.

New treatment options in status epilepticus: a critical review on intravenous levetiracetam

The effectiveness of Levetiracetam (LEV) in the treatment of focal and generalised epilepsies is well established. LEV has a wide spectrum of action, good tolerability and a favourable pharmacokinetic profile. An injectable formulation has been released as an intravenous (IV) infusion in 2006 for patients with epilepsy when oral administration is temporarily not feasible. Bioequivalence to the oral preparation has been demonstrated with good tolerability and safety enabling a smooth transition from oral to parenteral formulation and vice versa. Although IV LEV is not licensed for treatment of status epilepticus (SE), open-label experience in retrospective case series is accumulating. Until now (August 2008) 156 patients who were treated with IV LEV for various forms of SE have been reported with an overall success rate of 65.4%. The most often used initial dose was 2000-3000 mg over 15 minutes. Adverse events were reported in 7.1%, and were mild and transient. Although IV LEV is an interesting alternative for the treatment of SE due to the lack of centrally depressive effects and low potential of drug interactions, one has to be aware of the nonrandomised retrospective study design, the heterogenous patient population and treatment protocols, and the publication bias inherent in these type of studies. Only a large randomised controlled trial with an adequate comparator will reveal the efficacy and effectiveness of this promising new IV formulation.

Mechanistic and pharmacologic aspects of status epilepticus and its treatment with new antiepileptic drugs

We review recent advances in our understanding and treatment of status epilepticus (SE). Repeated seizures cause an internalization of gamma-aminobutyric acid (GABA)(A) receptors, together with a movement of N-methyl-d-aspartate (NMDA) receptors to the synapse. As a result, the response of experimental SE to treatment with GABAergic drugs (but not with NMDA antagonists) fades with increasing seizure duration. Prehospital treatment, which acts before these changes are established, is finding increased acceptance, and solid evidence of its efficacy is available, particularly in children. Rational polypharmacy aims at multiple receptors or ion channels to increase inhibition and simultaneously reduce excitation. Combining GABA(A) agonists with NMDA antagonists and with agents acting at other sites is successful in treating experimental SE, and in reducing SE-induced brain damage and epileptogenesis. The relevance of these experimental data to clinical SE is actively debated. Valproate and levetiracetam have recently become available for intravenous use, and the use of ketamine and of other agents (topiramate, felbamate, etc.) have seen renewed interest. A rapidly increasing but largely anecdotal body of literature reports success in seizure control at the price of relatively few complications with the clinical use of those agents in refractory SE.

Levetiracetam in children with refractory status epilepticus

The objective of this study was to investigate the utility of levetiracetam (LEV) in children with refractory status epilepticus (RSE). Records of children with RSE who received LEV as adjunctive therapy were reviewed. Over a 7-year period, 11 children had received LEV for RSE. Age ranged from 2 days to 9 years (median = 2.5 months). Prior to administration of LEV, the number of anticonvulsants used to treat RSE ranged from 2 to 7 (median = 3). Starting doses of LEV ranged from 15 to 70 mg/kg (median = 30 mg/kg). LEV was felt to be of benefit in 45% (5/11) of cases, resulting in either resolution of RSE or successful weaning of patients off continuous infusions of other anticonvulsants. In 27% (3/11), response to LEV was unclear as other medications were either added or increased concomitantly with LEV use. The median latency to cessation of RSE following LEV initiation was 1.5 days (range = 1-8 days). All responding patients were on LEV doses >or= 30 mg/kg/day (median 40 mg/kg/day). No significant adverse effects of LEV were reported. LEV may be an effective and safe adjuvant therapy in children with RSE.

Levetiracetam in the treatment of epilepsy

Epilepsy is a common chronic disorder that requires long-term antiepileptic drug therapy. Approximately one half of patients fail the initial antiepileptic drug and about 35% are refractory to medical therapy, highlighting the continued need for more effective and better tolerated drugs. Levetiracetam is an antiepileptic drug marketed since 2000. Its novel mechanism of action is modulation of synaptic neurotransmitter release through binding to the synaptic vesicle protein SV2A in the brain. Its pharmacokinetic advantages include rapid and almost complete absorption, minimal insignificant binding to plasma protein, absence of enzyme induction, absence of interactions with other drugs, and partial metabolism outside the liver. The availability of an intravenous preparation is yet another advantage. It has been demonstrated effective as adjunctive therapy for refractory partial-onset seizures, primary generalized tonic-clonic seizures, and myoclonic seizures of juvenile myoclonic epilepsy. In addition, it was found equivalent to controlled release carbamazepine as first-line therapy for partial-onset seizures, both in efficacy and tolerability. Its main adverse effects in randomized adjunctive trials in adults have been somnolence, asthenia, infection, and dizziness. In children, the behavioral adverse effects of hostility and nervousness were also noted. Levetiracetam is an important addition to the treatment of epilepsy.