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Mastrocco A, Prittie J, West C, Clark M. A review of the pharmacology and clinical applications of levetiracetam in dogs and cats. J Vet Emerg Crit Care (San Antonio) 2024; 34:9-22. [PMID: 37987141 DOI: 10.1111/vec.13355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/15/2022] [Accepted: 10/18/2022] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To review and summarize the pharmacology of the antiepileptic drug (AED), levetiracetam (LEV), and to discuss its clinical utility in dogs and cats. DATA SOURCES Veterinary and human peer-reviewed medical literature and the authors' clinical experience. SUMMARY LEV is an AED with mechanisms of action distinct from those of other AEDs. In people and small animals, LEV exhibits linear kinetics, excellent oral bioavailability, and minimal drug-drug interactions. Serious side effects are rarely reported in any species. LEV use is gaining favor for treating epilepsy in small animals and may have wider clinical applications in patients with portosystemic shunts, neuroglycopenia, and traumatic brain injury. In people, LEV may improve cognitive function in patients with dementia. CONCLUSION LEV is a well-tolerated AED with well-documented efficacy in human patients. Although its use is becoming more common in veterinary medicine, its role as a first-line monotherapy in small animal epileptics remains to be determined. This review of the human and animal literature regarding LEV describes its role in epileptic people and animals as well as in other disease states and provides recommendations for clinical usage.
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Affiliation(s)
- Alicia Mastrocco
- Department of Emergency and Critical Care, The Animal Medical Center, New York, New York, USA
| | - Jennifer Prittie
- Department of Emergency and Critical Care, The Animal Medical Center, New York, New York, USA
| | - Chad West
- Department of Neurology, The Animal Medical Center, New York, New York, USA
| | - Melissa Clark
- Department of Internal Medicine, Gulf Coast Veterinary Specialists, Houston, Texas, USA
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Rubinos C, Waters B, Hirsch LJ. Predicting and Treating Post-traumatic Epilepsy. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00727-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lee K, Klein P, Dongre P, Choi EJ, Rhoney DH. Intravenous Brivaracetam in the Management of Acute Seizures in the Hospital Setting: A Scoping Review. J Intensive Care Med 2022; 37:1133-1145. [PMID: 35306914 PMCID: PMC9393655 DOI: 10.1177/08850666211073598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Clinical considerations for drug treatment of acute seizures involve
variables such as safety, tolerability, drug-drug interactions, dosage,
route of administration, and alterations in pharmacokinetics because of
critical illness. Therapy options that are easily and quickly administered
without dilution, well tolerated, and effective are needed for the treatment
of acute seizures. The objective of this review is to focus on the clinical
considerations relating to the use of intravenous brivaracetam (IV BRV) for
the treatment of acute seizures in the hospital, focusing on critically ill
patients. Methods This was a scoping literature review of PubMed from inception to April 13,
2021, and search of the American Academy of Neurology (AAN) 2021 Annual
Meeting website for English language publications/conference abstracts
reporting the results of IV BRV use in hospitalized patients, particularly
in the critical care setting. Outcomes of interest relating to the clinical
pharmacology, safety, tolerability, efficacy, and effectiveness of IV BRV
were reviewed and are discussed. Results Twelve studies were included for analysis. One study showed that plasma
concentrations of IV BRV 15 min after the first dose were similar between
patients receiving IV BRV as bolus or infusion. IV BRV was generally well
tolerated in patients with acute seizures in the hospital setting, with a
low incidence of individual TEAEs classified as behavioral disorders. IV BRV
demonstrated efficacy and effectiveness and had a rapid onset, with clinical
and electrophysiological improvement in seizures observed within minutes.
Although outside of the approved label, findings from several studies
suggest that IV BRV reduces seizures and is generally well tolerated in
patients with status epilepticus. Conclusions IV BRV shows effectiveness, and is generally well tolerated in the management
of acute seizures in hospitalized patients where rapid administration is
needed, representing a clinically relevant antiseizure medication for
potential use in the critical care setting.
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Affiliation(s)
- Kiwon Lee
- Department of Neurology, Division of Stroke and Critical Care, Rutgers, The State University of New Jersey, 12287Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Pavel Klein
- Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA
| | | | | | - Denise H Rhoney
- 15521UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, NC, USA
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Gillinder L, Lehn A, Brown H, Dionisio S. Treatment outcomes after the introduction of a new seizure management protocol. Intern Med J 2018; 48:810-816. [DOI: 10.1111/imj.13765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 02/09/2018] [Accepted: 02/10/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Lisa Gillinder
- Department of Neurology; Princess Alexandra Hospital; Brisbane Queensland Australia
- Mater Advanced Epilepsy Unit; Mater Hospital; Brisbane Queensland Australia
| | - Alexander Lehn
- Department of Neurology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Helen Brown
- Department of Neurology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Sasha Dionisio
- Department of Neurology; Princess Alexandra Hospital; Brisbane Queensland Australia
- Mater Advanced Epilepsy Unit; Mater Hospital; Brisbane Queensland Australia
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Development and validation of a HPLC-UV assay for quantification of levetiracetam concentrations in critically ill patients undergoing continuous renal replacement therapy. Biomed Chromatogr 2018; 32:e4257. [DOI: 10.1002/bmc.4257] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/21/2018] [Accepted: 03/29/2018] [Indexed: 11/07/2022]
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Seizures and Choice of Antiepileptic Drugs Following Subarachnoid Hemorrhage: A Review. Can J Neurol Sci 2017; 44:643-653. [DOI: 10.1017/cjn.2017.206] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractSeizures are important complications following a subarachnoid hemorrhage (SAH). The evidence for the use of antiepileptic drugs (AEDs) in treatment and prevention of those seizures is conflicting. The purpose of this review is to provide an up-to-date evidence summary of the incidence and outcomes of seizures following an SAH as well as the use of different AEDs post-SAH in order to evaluate the need for seizure prophylaxis, the choice of AEDs, and their dosing considerations in SAH patients. A literature search of PubMed, Medline, Embase, and the Cochrane Library was performed. A total of 37 studies were reviewed, mostly observational. Definitions of seizures in temporal relation to initial hemorrhage were variable. Similarly, the rates of seizures varied in the literature, ranging from 0 to 31%. Given the reported adverse outcomes associated with AED usage, seizure prophylaxis is not warranted. Levetiracetam appears to be better tolerated than phenytoin in SAH patients, though further research is needed. Higher initial dosing of levetiracetam might be required due to its enhanced clearance in SAH patients. In conclusion, there is a lack of quality evidence to definitively recommend the use of one AED over another. Further prospective research comparing the use of different AEDs in patients with an SAH is needed.
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Van Matre ET, Mueller SW, Fish DN, MacLaren R, Cava LF, Neumann RT, Kiser TH. Levetiracetam Pharmacokinetics in a Patient with Intracranial Hemorrhage Undergoing Continuous Veno-Venous Hemofiltration. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:458-462. [PMID: 28446744 PMCID: PMC5414484 DOI: 10.12659/ajcr.902709] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patient: Male, 78 Final Diagnosis: Right thalamic intraparenchymal hemorrhage with intraventricular extension Symptoms: Altered mental status • left sided weakness Medication: Levetiracetam Clinical Procedure: Continuous renal replacement therapy Specialty: Critical Care Medicine
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Affiliation(s)
- Edward T Van Matre
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Scott W Mueller
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Douglas N Fish
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Luis F Cava
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert T Neumann
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Abstract
PURPOSE Subdural hematomas (SDH) are associated with seizures and epileptiform discharges, but little is known about the prevalence and impact of seizures, status epilepticus (SE), and epileptiform discharges on outcomes in patients with isolated acute SDH (aSDH). METHODS Continuous EEG reports from 76 adult patients admitted to Rush University Medical Center with aSDH between January 2009 and March 2012 were reviewed. Clinical and radiographic findings, comorbidities, treatment, and outcome parameters, such as mortality, discharge destination, need for tracheostomy/percutaneous endoscopic gastrostomy placement, and length of stay (LOS), were assessed. Univariate and multivariate analyses were performed to assess the impact of clinical seizures, SE, and epileptiform EEG on outcomes. RESULTS Of 76 patients with aSDH who underwent EEG monitoring, 74 (97.4%) received antiseizure prophylaxis. Thirty-two (41.1%) patients had seizures, most of which were clinical seizures. Twenty-four (32%) patients had epileptiform EEG findings. Clinical or nonconvulsive SE was diagnosed in 12 (16%) patients. Clinical seizures were not associated with outcome parameters. Epileptiform EEG findings were independently associated with longer hospital LOS (13 vs. 8 days, P = 0.04) and intensive care unit LOS (10 vs. 4 days, P = 0.002). The SE also predicted longer intensive care unit LOS (10 vs. 4 days, P = 0.002). Neither epileptiform EEG nor SE was significantly related to mortality, discharge destination, or need for tracheostomy/percutaneous endoscopic gastrostomy placement. CONCLUSIONS Seizures and epileptiform EEG findings are very common in patients with aSDH despite antiseizure prophylaxis. While clinical seizures did not affect outcomes, the presence of epileptiform EEG findings and SE was independently associated with longer intensive care unit LOS and hospital LOS.
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Caudle KL, Lu XCM, Mountney A, Shear DA, Tortella FC. Neuroprotection and anti-seizure effects of levetiracetam in a rat model of penetrating ballistic-like brain injury. Restor Neurol Neurosci 2016; 34:257-70. [PMID: 26890099 DOI: 10.3233/rnn-150580] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE We assessed the therapeutic efficacy of FDA-approved anti-epileptic drug Levetiracetam (LEV) to reduce post-traumatic nonconvulsive seizure (NCS) activity and promote neurobehavioral recovery following 10% frontal penetrating ballistic-like brain injury (PBBI) in male Sprague-Dawley rats. METHODS Experiment 1 anti-seizure study: 50 mg/kg LEV (25 mg/kg maintenance doses) was given twice daily for 3 days (LEV3D) following PBBI; outcome measures included seizures incidence, frequency, duration, and onset. Experiment 2 neuroprotection studies: 50 mg/kg LEV was given twice daily for either 3 (LEV3D) or 10 days (LEV10D) post-injury; outcome measures include motor (rotarod) and cognitive (water maze) functions. RESULTS LEV3D treatment attenuated seizure activity with significant reductions in NCS incidence (54%), frequency, duration, and delayed latency to seizure onset compared to vehicle treatment. LEV3D treatment failed to improve cognitive or motor performance; however extending the dosing regimen through 10 days post-injury afforded significant neuroprotective benefit. Animals treated with the extended LEV10D dosing regimen showed a twofold improvement in rotarod task latency to fall as well as significantly improved spatial learning performance (24%) in the MWM task. CONCLUSIONS These findings support the dual anti- seizure and neuroprotective role of LEV, but more importantly identify the importance of an extended dosing protocol which was specific to the therapeutic targets studied.
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García-Salido A, Nieto-Moro M, Iglesias-Bouzas MI, González-Vicent M, Serrano-González A, Casado-Flores J. Critically ill pediatric hemato-oncology patient: What we do is what we should do? ANALES DE PEDIATRÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.anpede.2015.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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García-Salido A, Nieto-Moro M, Iglesias-Bouzas MI, González-Vicent M, Serrano-González A, Casado-Flores J. [Critically ill pediatric hemato-oncology patient: What we do is what we should do?]. An Pediatr (Barc) 2015; 85:61-69. [PMID: 26619931 DOI: 10.1016/j.anpedi.2015.07.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 07/17/2015] [Accepted: 07/20/2015] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Primary objective, to describe the management and monitorization of critically ill pediatric hemato-oncology patient (CIPHO) in the Spanish pediatric intensive care units (PICU). Secondary objective, through a literature review, to identify possible areas of improvement. MATERIAL AND METHODS Observational transversal descriptive study. An anonymous web-based survey was sent to 324 Spanish pediatric intensivists from April 2011 to May 2011. None of them were pediatric residents. RESULTS The survey was answered by 105 intensivists, 59/105 always agreed their treatment with the oncologist. In case of hemodynamic instability, non-invasive blood pressure monitoring is always done by 85/105 and almost always optimized by intra-arterial measuring (85/105) and central venous pressure (70/105). If respiratory failure the use of non-invasive ventilation (NIPPV) is always (36/105) or frequently (60/105) established prior to conventional mechanical ventilation. To replace or withdraw non-invasive ventilation only 44/96 of the respondents to this question use a clinical protocol. Before the instauration of conventional mechanical ventilation the oncological prognosis is considered by 72/105. In case of acute oliguric renal failure the renal replacement techniques are widely used (74/105). The withdrawal of sustaining life support is frequently discussed (75/103) and agreed with the oncologist (91/103) and caregivers (81/103). CONCLUSIONS In our study, despite there is not a defined standard-of-care, the respondents showed similar therapeutics and monitorization choices. The use of NIPPV as first respiratory assistance is extended. Prospective, observational and multicenter studies should be developed to establish the results of this management in this population.
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Affiliation(s)
- Alberto García-Salido
- Unidad de Cuidados Intensivos Pediátricos, Hospital Infantil Universitario Niño Jesús, Madrid, España.
| | - Montserrat Nieto-Moro
- Unidad de Cuidados Intensivos Pediátricos, Hospital Infantil Universitario Niño Jesús, Madrid, España
| | | | - Marta González-Vicent
- Unidad de Trasplante de progenitores hematopoyéticos, Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Ana Serrano-González
- Unidad de Cuidados Intensivos Pediátricos, Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Juan Casado-Flores
- Unidad de Cuidados Intensivos Pediátricos, Hospital Infantil Universitario Niño Jesús, Madrid, España
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Thompson K, Pohlmann‐Eden B, Campbell LA, Abel H. Pharmacological treatments for preventing epilepsy following traumatic head injury. Cochrane Database Syst Rev 2015; 2015:CD009900. [PMID: 26259048 PMCID: PMC9237755 DOI: 10.1002/14651858.cd009900.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Head injury is a common event and can cause a spectrum of motor and cognition disabilities. A frequent complication is seizures. Antiepileptic drugs (AED) such as phenytoin are often used in clinical practice with the hopes of preventing post-traumatic epilepsy. Whether immediate medical intervention following head trauma with either AEDs or neuroprotective drugs can alter the process of epileptogenesis and lead to a more favorable outcome is currently unknown. This review attempted to address the effectiveness of these treatment interventions. This review updates and expands on the earlier Cochrane review. OBJECTIVES To compare the efficacy of antiepileptic drugs and neuroprotective agents with placebo, usual care or other pharmacologic agents for the prevention of post-traumatic epilepsy in people diagnosed with any severity of traumatic brain injury. SEARCH METHODS We searched The Cochrane Epilepsy Group's specialized register, CENTRAL, MEDLINE, ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (ICTRP) in January 2015. We searched EMBASE, Biological Abstracts and National Research Register in September 2014 and SCOPUS in December 2013. The Cochrane Epilepsy Group performed handsearches of relevant journals. SELECTION CRITERIA We included randomized controlled trials (RCTs) that include AEDs or neuroprotective agents compared with placebo, another pharmacologic agent or a usual care group. The outcomes measured included a seizure occurring within one week of trauma (early seizure), seizure occurring later than one week post-trauma (late seizure), mortality and any adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study quality and extracted the data. We calculated risk ratios (RR) and 95% confidence intervals (CI) for each outcome. We used random-effects models in the meta-analyses and performed pre-defined subgroup and sensitivity analyses. MAIN RESULTS This review included 10 RCTs (reported in 12 articles) consisting of 2326 participants The methodological quality of the studies varied. The type of intervention was separated into three categories; AED versus placebo or standard care, alternative neuroprotective agent versus placebo or standard care and AED versus other AED. Treatment with an AED (phenytoin or carbamazepine) decreased the risk of early seizure compared with placebo or standard care (RR 0.42, 95% CI 0.23 to 0.73; very low quality evidence). There was no evidence of a difference in the risk of late seizure occurrence between AEDs and placebo or standard care (RR 0.91, 95% CI 0.57 to 1.46; very low quality evidence). There was no evidence of a significant difference in all-cause mortality between AEDs and placebo or standard care (RR 1.08 95% CI 0.79 to 1.46,very low quality of evidence). Only one study looked at other potentially neuroprotective agents (magnesium sulfate) compared with placebo. The risk ratios were: late seizure 1.07 (95% CI 0.53 to 2.17) and all-cause mortality 1.20 (95% CI 0.80 to 1.81). The risk ratio for occurrence of early seizure was not estimable.Two studies looked at comparison of two AEDs (levetiracetam, valproate) with phenytoin used as the main comparator in each study. The risk ratio for all-cause mortality was 0.53 (95% CI 0.30 to 0.94). There was no evidence of treatment benefit of phenytoin compared with another AED for early seizures (RR 0.66, 95% 0.20 to 2.12) or late seizures(RR 0.77, 95% CI 0.46 to 1.30).Only two studies reported adverse events. The RR of any adverse event with AED compared with placebo was 1.65 (95% CI 0.73 to 3.66; low quality evidence). There were insufficient data on adverse events in the other treatment comparisons. AUTHORS' CONCLUSIONS This review found low-quality evidence that early treatment with an AED compared with placebo or standard care reduced the risk of early post-traumatic seizures. There was no evidence to support a reduction in the risk of late seizures or mortality. There was insufficient evidence to make any conclusions regarding the effectiveness or safety of other neuroprotective agents compared with placebo or for the comparison of phenytoin, a traditional AED, with another AED.
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Affiliation(s)
- Kara Thompson
- Dalhousie UniversityDepartment of MedicineRm 204, Centre for Clinical Research5790 University AvenueHalifaxNSCanadaB3H 1V7
| | | | - Leslie A Campbell
- Dalhousie UniversityDepartment of Community Health and EpidemiologyRoom 415, 5790 University AvenueHalifaxNSCanadaB3K 1V7
| | - Hannah Abel
- Dalhousie UniversityCommunity Health and Epidemiologyc/o Center for Clinical Research4th Floors, 5790 University AvenueHalifaxNSCanadaB3H 1V7
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Chakravarthi S, Goyal MK, Modi M, Bhalla A, Singh P. Levetiracetam versus phenytoin in management of status epilepticus. J Clin Neurosci 2015; 22:959-63. [PMID: 25899652 DOI: 10.1016/j.jocn.2014.12.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 12/09/2014] [Accepted: 12/14/2014] [Indexed: 10/23/2022]
Abstract
The purpose of this study was to compare safety and efficacy of intravenous (IV) levetiracetam (LEV) with IV phenytoin (PHT) in management of status epilepticus (SE). The second-line treatment of SE is limited to a few drugs available in an IV formulation such as PHT, fosphenytoin and valproate. The relative lack of serious side effects and favourable pharmacokinetics of LEV made it a promising option in management of SE. Randomized trials comparing relative efficacy of second-line agents are remarkably lacking. In this study, consecutive patients of SE (n=44) were randomized to receive either IV PHT (20mg/kg) or IV LEV (20mg/kg). The primary end point was successful clinical termination of seizure activity within 30min after the beginning of the drug infusion. Secondary end points included recurrence of seizures within 24 hours, drug related adverse effects, neurological outcome at discharge, need for ventilatory assistance, and mortality during hospitalization. Both LEV and PHT were equally effective with regard to primary and secondary outcome measures. PHT achieved control of SE in 15 (68.2%) patients compared to LEV in 13 (59.1%; p=0.53). Both the groups showed comparable results with respect to recurrence of seizures within 24 hours (p=0.34), outcome at discharge as assessed by functional independence measure (p=0.68), need of ventilatory assistance (p=0.47) and death (p=1). From this study it can be concluded that LEV may be an attractive and effective alternative to PHT in management of SE.
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Affiliation(s)
- Sudheer Chakravarthi
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
| | - Manoj Kumar Goyal
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
| | - Manish Modi
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India.
| | - Ashish Bhalla
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
| | - Parampreet Singh
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
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Cranley MR, Craner M, McGilloway E. Antiepileptic prophylaxis following severe traumatic brain injury within a military cohort. J ROY ARMY MED CORPS 2015; 162:109-14. [PMID: 25712562 DOI: 10.1136/jramc-2014-000392] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 01/28/2015] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Traumatic brain injury increases the risk of both early and late seizures. Antiepileptic prophylaxis reduces early seizures, but their use beyond 1 week does not prevent the development of post-traumatic epilepsy. Furthermore, prolonged prophylaxis exposes patients to side effects of the drugs and has occupational implications. The American Academy of Neurology recommends that antiepileptic prophylaxis should be started for patients with severe traumatic brain injury and discontinued after 1 week. An audit is presented here that investigates the use of prophylaxis in a cohort of military patients admitted to the UK Defence Medical Rehabilitation Centre (DMRC). METHODS Data were collected and analysed retrospectively from electronic and paper records between February 2009 and August 2012. The timing and duration of antiepileptic drug use and the incidence of seizures were recorded. RESULTS During the study period, 52 patients with severe traumatic brain injury were admitted to the rehabilitation centre: 25 patients (48%) were commenced on prophylaxis during the first week following injury while 27 (52%) did not receive prophylaxis. Only one patient (2%) received prophylaxis for the recommended period of 1 week, 22 patients (42%) received prophylaxis for longer than 1 week with a mean duration of 6.2 months. Two patients (4%) had post-traumatic epilepsy and started on treatment at DMRC. CONCLUSIONS The use of antiepileptic prophylaxis varies widely and is generally inconsistent with evidence-based guidance. This exposes some patients to a higher risk of early seizures and others to unnecessary use of antiepileptics. Better implementation of prophylaxis is required.
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Affiliation(s)
- Mark R Cranley
- Royal Army Medical Corps, Defence Medical Rehabilitation Centre, Epsom, Surrey, UK
| | - M Craner
- Royal Navy Medical Service, Department of Neurology John Radcliffe Hospital, Oxford, UK Department of Neurology, Frimley Park Hospital, UK
| | - E McGilloway
- Department of Neuro-Rehabilitation, Defence Medical Rehabilitation Centre, Epsom, UK
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Kochanek PM, Jackson TC, Ferguson NM, Carlson SW, Simon DW, Brockman EC, Ji J, Bayir H, Poloyac SM, Wagner AK, Kline AE, Empey PE, Clark RS, Jackson EK, Dixon CE. Emerging therapies in traumatic brain injury. Semin Neurol 2015; 35:83-100. [PMID: 25714870 PMCID: PMC4356170 DOI: 10.1055/s-0035-1544237] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Despite decades of basic and clinical research, treatments to improve outcomes after traumatic brain injury (TBI) are limited. However, based on the recent recognition of the prevalence of mild TBI, and its potential link to neurodegenerative disease, many new and exciting secondary injury mechanisms have been identified and several new therapies are being evaluated targeting both classic and novel paradigms. This includes a robust increase in both preclinical and clinical investigations. Using a mechanism-based approach the authors define the targets and emerging therapies for TBI. They address putative new therapies for TBI across both the spectrum of injury severity and the continuum of care, from the field to rehabilitation. They discussTBI therapy using 11 categories, namely, (1) excitotoxicity and neuronal death, (2) brain edema, (3) mitochondria and oxidative stress, (4) axonal injury, (5) inflammation, (6) ischemia and cerebral blood flow dysregulation, (7) cognitive enhancement, (8) augmentation of endogenous neuroprotection, (9) cellular therapies, (10) combination therapy, and (11) TBI resuscitation. The current golden age of TBI research represents a special opportunity for the development of breakthroughs in the field.
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Affiliation(s)
- Patrick M. Kochanek
- Safar Center for Resuscitation Research, University of Pittburgh School of Medicine, Pittsburgh, Pennsylvania
- Departments of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Travis C. Jackson
- Safar Center for Resuscitation Research, University of Pittburgh School of Medicine, Pittsburgh, Pennsylvania
- Departments of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nikki Miller Ferguson
- Safar Center for Resuscitation Research, University of Pittburgh School of Medicine, Pittsburgh, Pennsylvania
- Departments of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shaun W. Carlson
- Safar Center for Resuscitation Research, University of Pittburgh School of Medicine, Pittsburgh, Pennsylvania
- Departmentol Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Dennis W. Simon
- Safar Center for Resuscitation Research, University of Pittburgh School of Medicine, Pittsburgh, Pennsylvania
- Departments of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Erik C. Brockman
- Safar Center for Resuscitation Research, University of Pittburgh School of Medicine, Pittsburgh, Pennsylvania
- Departments of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jing Ji
- Safar Center for Resuscitation Research, University of Pittburgh School of Medicine, Pittsburgh, Pennsylvania
- Departments of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Hülya Bayir
- Safar Center for Resuscitation Research, University of Pittburgh School of Medicine, Pittsburgh, Pennsylvania
- Departments of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Environmental and Occupational Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Samuel M. Poloyac
- Safar Center for Resuscitation Research, University of Pittburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Environmental and Occupational Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Amy K. Wagner
- Safar Center for Resuscitation Research, University of Pittburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anthony E. Kline
- Safar Center for Resuscitation Research, University of Pittburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Philip E. Empey
- Safar Center for Resuscitation Research, University of Pittburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Environmental and Occupational Health, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert S.B. Clark
- Safar Center for Resuscitation Research, University of Pittburgh School of Medicine, Pittsburgh, Pennsylvania
- Departments of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edwin K. Jackson
- Safar Center for Resuscitation Research, University of Pittburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - C. Edward Dixon
- Safar Center for Resuscitation Research, University of Pittburgh School of Medicine, Pittsburgh, Pennsylvania
- Departmentol Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Burakgazi E, Bashir S, Doss V, Pellock J. The safety and tolerability of different intravenous administrations of levetiracetam, bolus versus infusion, in intensive care unit patients. Clin EEG Neurosci 2014; 45:89-91. [PMID: 24357676 DOI: 10.1177/1550059413496777] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study reviews our experience with the safety and tolerability of levetiracetam (LVM) with different methods of intravenous administration in intensive care unit (ICU) patients. We used retrospective chart review to identify 33 ICU patients who received intravenous LVM for treatment of seizures. Collected data included age, gender, diagnosis on admission, dosing regimen, documented seizure activity, adverse reactions, concomitant use of other antiepileptic drugs, and condition on discharge. A total of 33 ICU patients were given intravenous (IV) LVM as add-on treatment to standard regimen for treatment of breakthrough seizures or status epilepticus or given as preventive medication postoperatively. Among these 33 patients, 16 received intravenous LVM as bolus, and 17 received intravenous LVM as continuous infusion. Safety and tolerability of intravenous LVM were evaluated on the basis of the occurrence of adverse or side effects reported in daily progress notes of the physicians and nurses. There were no significant adverse or side effects reported in daily progress notes. The addition of intravenous LVM to the standard regimen for controlling seizures in ICU patients seems feasible and tolerable.
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Affiliation(s)
- Evren Burakgazi
- Department of Neurology, Cooper Medical School of Rowan University, Camden, NJ, USA
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Peters RK, Schubert T, Clemmons R, Vickroy T. Levetiracetam rectal administration in healthy dogs. J Vet Intern Med 2014; 28:504-9. [PMID: 24417468 PMCID: PMC4857990 DOI: 10.1111/jvim.12269] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 09/24/2013] [Accepted: 11/05/2013] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Levetiracetam is used to manage status epilepticus (SE) and cluster seizures (CS) in humans. The drug might be absorbed after rectal administration and could offer a practical adjunct to rectal administration of diazepam in managing SE and CS. HYPOTHESIS Levetiracetam is rapidly absorbed after rectal administration in dogs and maintains target serum concentrations for at least 9 hours. ANIMALS Six healthy privately owned dogs between 2 and 6 years of age and weighing 10-20 kg. METHODS Levetiracetam (40 mg/kg) was administered rectally and blood samples were obtained immediately before (time zero) and at 10, 20, 40, 60, 90, 180, 360, and 540 minutes after drug administration. Dogs were observed for signs of adverse effects over a 24-hour period after drug administration. RESULTS CLEV at 10 minutes was 15.3 ± 5.5 μg/mL (mean, SD) with concentrations in the target range (5-40 μg/mL) for all dogs throughout the sampling period. Cmax (36.0 ± 10.7 μg/mL) and Tmax (103 ± 31 minutes) values were calculated and 2 disparate groups were appreciated. Dogs with feces in the rectum at the time of drug administration had lower mean Cmax values (26.7 ± 3.4 μg/mL) compared with those without (45.2 ± 4.4 μg/mL). Mild sedation was observed between 60 and 90 minutes without other adverse effects noted. CONCLUSIONS AND CLINICAL IMPORTANCE This study supports the use of rectally administered levetiracetam in future studies of clinical effectiveness in the management of epileptic dogs.
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Affiliation(s)
- R K Peters
- Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL
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Szaflarski JP, Nazzal Y, Dreer LE. Post-traumatic epilepsy: current and emerging treatment options. Neuropsychiatr Dis Treat 2014; 10:1469-77. [PMID: 25143737 PMCID: PMC4136984 DOI: 10.2147/ndt.s50421] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Traumatic brain injury (TBI) leads to many undesired problems and complications, including immediate and long-term seizures/epilepsy, changes in mood, behavioral, and personality problems, cognitive and motor deficits, movement disorders, and sleep problems. Clinicians involved in the treatment of patients with acute TBI need to be aware of a number of issues, including the incidence and prevalence of early seizures and post-traumatic epilepsy (PTE), comorbidities associated with seizures and anticonvulsant therapies, and factors that can contribute to their emergence. While strong scientific evidence for early seizure prevention in TBI is available for phenytoin (PHT), other antiepileptic medications, eg, levetiracetam (LEV), are also being utilized in clinical settings. The use of PHT has its drawbacks, including cognitive side effects and effects on function recovery. Rates of recovery after TBI are expected to plateau after a certain period of time. Nevertheless, some patients continue to improve while others deteriorate without any clear contributing factors. Thus, one must ask, 'Are there any actions that can be taken to decrease the chance of post-traumatic seizures and epilepsy while minimizing potential short- and long-term effects of anticonvulsants?' While the answer is 'probably,' more evidence is needed to replace PHT with LEV on a permanent basis. Some have proposed studies to address this issue, while others look toward different options, including other anticonvulsants (eg, perampanel or other AMPA antagonists), or less established treatments (eg, ketamine). In this review, we focus on a comparison of the use of PHT versus LEV in the acute TBI setting and summarize the clinical aspects of seizure prevention in humans with appropriate, but general, references to the animal literature.
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Affiliation(s)
- Jerzy P Szaflarski
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA ; UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yara Nazzal
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA ; UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Laura E Dreer
- Department of Ophthalmology, University of Alabama at Birmingham, Birmingham, AL, USA
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Dewolfe JL, Szaflarski JP. Levetiracetam use in the critical care setting. Front Neurol 2013; 4:121. [PMID: 23986742 PMCID: PMC3750522 DOI: 10.3389/fneur.2013.00121] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 08/08/2013] [Indexed: 11/22/2022] Open
Abstract
Intravenous (IV) levetiracetam (LEV) is currently approved as an alternative or replacement therapy for patients unable to take the oral form of this antiepileptic drug (AED). The oral form has Food and Drug Administration (FDA) indications for adjunctive therapy in the treatment of partial onset epilepsy ages 1 month or more, myoclonic seizures associated with juvenile myoclonic epilepsy starting with the age of 12 and primary generalized tonic-clonic seizures in people 6 years and older. Since the initial introduction, oral and IV LEV has been evaluated in various studies conducted in the critical care setting for the treatment of status epilepticus, stroke-related seizures, seizures following subarachnoid or intracerebral hemorrhage, post-traumatic seizures, tumor-related seizures, and seizures in critically ill patients. Additionally, studies evaluating rapid infusion of IV LEV and therapeutic monitoring of serum LEV levels in different patient populations have been performed. In this review we present the current state of knowledge on LEV use in the critical care setting focusing on the IV uses and discuss future research needs.
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Affiliation(s)
- Jennifer L Dewolfe
- Department of Neurology, UAB Epilepsy Center, University of Alabama at Birmingham (UAB) , Birmingham, AL , USA
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Abstract
PURPOSE OF REVIEW Various antiepileptics, sedative and anesthetic agents are used in the neurocritical care setting and therapeutic drug monitoring (TDM) has been proposed as a means to individualize dosing to ensure efficacy, avoid toxicity, and to account for drug-drug interactions. The purpose of this review is to highlight key articles relating to TDM published in the last 5 years with a focus on drug therapy for seizures, status epilepticus, and traumatic brain injury. RECENT FINDINGS Current evidence supports TDM of first-generation antiepileptics, and free-level monitoring for phenytoin and valproic acid is recommended in the neurocritical care population. There are insufficient data to recommend routine TDM of second-generation antiepileptics at this time. In traumatic brain injury, routine TDM of barbiturate infusions appears to be of little value in guiding or evaluating patient response to therapy except to differentiate between drug-induced coma and brain death. Although TDM of sedative agents has been studied, the use of clinical sedation scales is preferred over TDM in evaluating a patient's level of sedation. SUMMARY Therapeutic drug monitoring plays an important role in the care of patients in the neurocritical care setting but is applicable only to a limited number of drugs.
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Zafar SN, Khan AA, Ghauri AA, Shamim MS. Phenytoin versus Leviteracetam for seizure prophylaxis after brain injury - a meta analysis. BMC Neurol 2012; 12:30. [PMID: 22642837 PMCID: PMC3406949 DOI: 10.1186/1471-2377-12-30] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 05/29/2012] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Current standard therapy for seizure prophylaxis in Neuro-surgical patients involves the use of Phenytoin (PHY). However, a new drug Levetiracetam (LEV) is emerging as an alternate treatment choice. We aimed to conduct a meta-analysis to compare these two drugs in patients with brain injury. METHODS An electronic search was performed in using Pubmed, Embase, and CENTRAL. We included studies that compared the use of LEV vs. PHY for seizure prophylaxis for brain injured patients (Traumatic brain injury, intracranial hemorrhage, intracranial neoplasms, and craniotomy). Data of all eligible studies was extracted on to a standardized abstraction sheet. Data about baseline population characteristics, type of intervention, study design and outcome was extracted. Our primary outcome was seizures. RESULTS The literature search identified 2489 unduplicated papers. Of these 2456 papers were excluded by reading the abstracts and titles. Another 25 papers were excluded after reading their complete text. We selected 8 papers which comprised of 2 RCTs and 6 observational studies. The pooled estimate's Odds Ratio 1.12 (95% CI = 0.34, 3.64) demonstrated no superiority of either drug at preventing the occurrence of early seizures. In a subset analysis of studies in which follow up for seizures lasted either 3 or 7 days, the effect estimate remained insignificant with an odds ratio of 0.96 (95% CI = 0.34, 2.76). Similarly, 2 trials reporting seizure incidence at 6 months also had insignificant pooled results while comparing drug efficacy. The pooled odds ratio was 0.96 (95% CI = 0.24, 3.79). CONCLUSIONS Levetiracetam and Phenytoin demonstrate equal efficacy in seizure prevention after brain injury. However, very few randomized controlled trials (RCTs) on the subject were found. Further evidence through a high quality RCT is highly recommended.
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Taylor S, Heinrichs RJ, Janzen JM, Ehtisham A. Levetiracetam is associated with improved cognitive outcome for patients with intracranial hemorrhage. Neurocrit Care 2012; 15:80-4. [PMID: 20890680 DOI: 10.1007/s12028-010-9341-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND To date, common therapy in patients with intracranial hemorrhage (ICH) includes prophylaxis of seizure using antiepileptic drugs, commonly phenytoin. Phenytoin therapy is associated with a high incidence of cognitive disturbance. Levetiracetam is known to cause less cognitive disruption and may be a suitable alternative for seizure prophylaxis. Cognitive outcomes in ICH patients receiving seizure prophylaxis with levetiracetam or phenytoin are compared. METHOD A retrospective chart review was conducted with 269 patients who received prophylactic levetiracetam or phenytoin between August 2005 and May 2008. A total of 85 reviewed patients met inclusion criteria (phenytoin n = 25, levetiracetam n = 60). RESULTS Statistically significant results included higher Glasgow Coma Scores (GCS) at dismissal (median, 14 vs. 11, P = 0.023), lower seizure incidence (0.0 vs. 8%, P = 0.03) for patients receiving levetiracetam than those treated with phenytoin and patients being discharged home (21.7% vs. 16%, P = 0.03). Observed trends included greater cognitive function retention rate (56.7% vs. 36%, P = 0.08). CONCLUSION Despite similarities in hemorrhage type and severity at onset, patients receiving levetiracetam had better cognition at discharge and fewer seizures than patients receiving phenytoin. These data suggest that levetiracetam is more effective than phenytoin for seizure prophylaxis without suppression of cognitive abilities in patients with ICH.
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Affiliation(s)
- Scott Taylor
- Department of Pharmacy, Via Christi Regional Medical Center, University of Kansas School of Medicine, KS, Wichita, USA.
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Effects of valproic acid and levetiracetam on viability and cell cycle regulatory genes expression in the OVCAR-3 cell line. Pharmacol Rep 2012; 64:157-65. [DOI: 10.1016/s1734-1140(12)70742-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 09/23/2011] [Indexed: 12/29/2022]
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Cost-utility analysis of levetiracetam and phenytoin for posttraumatic seizure prophylaxis. ACTA ACUST UNITED AC 2011; 71:375-9. [PMID: 21825941 DOI: 10.1097/ta.0b013e318224d307] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The standard for early posttraumatic brain injury (TBI) seizure prophylaxis is phenytoin. Despite its effectiveness, some argue for the use of newer antiepileptics (e.g., levetiracetam) because phenytoin requires close monitoring to maintain its therapeutic window and is associated with rare cutaneous hypersensitivity reactions. The purpose of this study was to evaluate whether phenytoin or levetiracetam would be more cost-effective in preventing early post-TBI seizures and reducing their negative impact on TBI outcomes. METHODS Cost-effectiveness analysis with the following base case assumptions: (1) phenytoin patients receive 1.0 g fosphenytoin load + 3 days of 100 mg three times a day (TID), have level drawn on day 3, "therapeutic" patients receive 100 mg TID on days 4 to 7, and "subtherapeutic" patients receive 200 mg TID on days 4 to 7; (2) levetiracetam patients receive 500 mg load + 7 days of 500 mg two times a day. Glasgow Outcome Scale (GOS) scores 4 to 5 represent good outcome, and GOS scores 2 to 3 represent poor outcome. Patients who develop early seizures: 40% good outcome, 50% poor outcome, and 10% death. Those who do not develop seizures: 75% good outcome, 20% poor outcome, and 5% death. Quality of life outcomes by GOS: good = 0.7, poor = 0.3, and death = 0.0. Severe adverse events and those impacting costs are rare for each agent. Assumptions were obtained through hospital query and exhaustive literature review. RESULTS The cost of a 7-day course of fosphenytoin, phenytoin, and free phenytoin level was $37.50, whereas the cost of a 7-day course of levetiracetam was $480.00. Literature review noted phenytoin to be as effective as levetiracetam in preventing early post-TBI seizures (and more effective in subclinical seizures). Quality-adjusted life years (QALY) were 23.6 for phenytoin and 23.2 for levetiracetam. As a result, the cost/effectiveness ratios were $1.58/QALY for phenytoin and $20.72/QALY for levetiracetam. All sensitivity analyses favored phenytoin unless levetiracetam prevented 100% of seizures and cost <$400 for 7-day course. CONCLUSIONS Phenytoin is more cost-effective than levetiracetam at all reasonable prices and at all clinically plausible reductions in post-TBI seizure potential.
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Spencer DD, Jacobi J, Juenke JM, Fleck JD, Kays MB. Steady-State Pharmacokinetics of Intravenous Levetiracetam in Neurocritical Care Patients. Pharmacotherapy 2011; 31:934-41. [DOI: 10.1592/phco.31.10.934] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Murphy-Human T, Welch E, Zipfel G, Diringer MN, Dhar R. Comparison of short-duration levetiracetam with extended-course phenytoin for seizure prophylaxis after subarachnoid hemorrhage. World Neurosurg 2011; 75:269-74. [PMID: 21492729 DOI: 10.1016/j.wneu.2010.09.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Accepted: 09/10/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND The optimal regimen for seizure prophylaxis after subarachnoid hemorrhage (SAH) remains uncertain. Based on data suggesting that a short course may be adequate, coupled with an association between phenytoin exposure and poor cognitive outcome, our institution modified their seizure prophylaxis protocol for patients with SAH from an extended course of phenytoin to 3 days of levetiracetam. This study sought to compare the incidence of seizures before and after this change to evaluate whether a short course of levetiracetam would be as effective in preventing in-hospital seizures. METHODS This study analyzed 442 consecutive patients admitted with SAH between January 2003 and January 2008, including 297 patients treated before the protocol change (PHT group) and 145 treated afterward (LEV group). Occurrence of all seizures was extracted from a prospectively collected intensive care unit database and further review of medical records. In-hospital seizures were divided into early (occurring on or before day 3, all patients on prophylaxis) and those occurring late (after day 3, LEV group off prophylaxis). RESULTS In-hospital seizures occurred in 3.4% of the PHT group and 8.3% of the LEV group (P = 0.03). Although the rate of early seizures was not different (1.4% PHT vs. 2.8% LEV, P = 0.45), there was a higher rate of late seizures (2% PHT vs. 5.5% LEV, P = 0.05). CONCLUSIONS The use of short-duration levetiracetam for seizure prophylaxis after SAH was associated with a higher rate of in-hospital seizures than an extended course of phenytoin, mainly related to an increase in late seizures, when the levetiracetam had been discontinued. This suggests that a longer duration of prophylaxis may be required to minimize seizures in patients with SAH, although confirmatory studies are required.
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Abend NS, Gutierrez-Colina AM, Monk HM, Dlugos DJ, Clancy RR. Levetiracetam for treatment of neonatal seizures. J Child Neurol 2011; 26:465-70. [PMID: 21233461 PMCID: PMC3082578 DOI: 10.1177/0883073810384263] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Neonatal seizures are often refractory to treatment with initial antiseizure medications. Consequently, clinicians turn to alternatives such as levetiracetam, despite the lack of published data regarding its safety, tolerability, or efficacy in the neonatal population. We report a retrospectively identified cohort of 23 neonates with electroencephalographically confirmed seizures who received levetiracetam. Levetiracetam was considered effective if administration was associated with a greater than 50% seizure reduction within 24 hours. Levetiracetam was initiated at a mean conceptional age of 41 weeks. The mean initial dose was 16 ± 6 mg/kg and the mean maximum dose was 45 ± 19 mg/kg/day. No respiratory or cardiovascular adverse effects were reported or detected. Levetiracetam was associated with a greater than 50% seizure reduction in 35% (8 of 23), including seizure termination in 7. Further study is warranted to determine optimal levetiracetam dosing in neonates and to compare efficacy with other antiseizure medications.
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Affiliation(s)
- Nicholas S. Abend
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA, Department of Neurology, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | - Heather M. Monk
- Department of Pharmacy Services, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dennis J. Dlugos
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA, Department of Neurology, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Robert R. Clancy
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA, Department of Neurology, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Szaflarski JP, Sangha KS, Lindsell CJ, Shutter LA. Prospective, randomized, single-blinded comparative trial of intravenous levetiracetam versus phenytoin for seizure prophylaxis. Neurocrit Care 2010; 12:165-72. [PMID: 19898966 DOI: 10.1007/s12028-009-9304-y] [Citation(s) in RCA: 183] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Anti-epileptic drugs are commonly used for seizure prophylaxis after neurological injury. We performed a study comparing intravenous (IV) levetiracetam (LEV) to IV phenytoin (PHT) for seizure prophylaxis after neurological injury. METHODS In this prospective, single-center, randomized, single-blinded comparative trial of LEV versus PHT (2:1 ratio) in patients with severe traumatic brain injury (sTBI) or subarachnoid hemorrhage (NCT00618436) patients received IV load with either LEV or fosphenytoin followed by standard IV doses of LEV or PHT. Doses were adjusted to maintain therapeutic serum PHT concentrations or if patients had seizures. Continuous EEG (cEEG) monitoring was performed for the initial 72 h; outcome data were collected. RESULTS A total of 52 patients were randomized (LEV = 34; PHT = 18); 89% with sTBI. When controlling for baseline severity, LEV patients experienced better long-term outcomes than those on PHT; the Disability Rating Scale score was lower at 3 months (P = 0.042) and the Glasgow Outcomes Scale score was higher at 6 months (P = 0.039). There were no differences between groups in seizure occurrence during cEEG (LEV 5/34 vs. PHT 3/18; P = 1.0) or at 6 months (LEV 1/20 vs. PHT 0/14; P = 1.0), mortality (LEV 14/34 vs. PHT 4/18; P = 0.227). There were no differences in side effects between groups (all P > 0.15) except for a lower frequency of worsened neurological status (P = 0.024), and gastrointestinal problems (P = 0.043) in LEV-treated patients. CONCLUSIONS This study of LEV versus PHT for seizure prevention in the NSICU showed improved long-term outcomes of LEV-treated patients vis-à-vis PHT-treated patients. LEV appears to be an alternative to PHT for seizure prophylaxis in this setting.
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Affiliation(s)
- Jerzy P Szaflarski
- Department of Neurology, University of Cincinnati Academic Health Center, 260 Stetson Street, Rm 2350, Cincinnati, OH 45267-0525, USA.
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Utility of levetiracetam in patients with subarachnoid hemorrhage. Seizure 2009; 18:676-9. [DOI: 10.1016/j.seizure.2009.09.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Revised: 09/11/2009] [Accepted: 09/17/2009] [Indexed: 11/19/2022] Open
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Gámez-Leyva G, Aristín JL, Fernández E, Pascual J. Experience with intravenous levetiracetam in status epilepticus: a retrospective case series. CNS Drugs 2009; 23:983-7. [PMID: 19845418 DOI: 10.2165/11311100-000000000-00000] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Status epilepticus is a medical emergency associated with significant morbidity and mortality. OBJECTIVE To report our experience with the use of intravenous (IV) levetiracetam in patients with status epilepticus who had not responded to IV benzodiazepines. METHODS A retrospective review of the clinical charts of patients with status epilepticus who were treated with IV levetiracetam from July 2007 to July 2008 in our department was performed. Data on demographics, epileptic syndrome, aetiology, treatment dosage and adverse effects were analysed. IV levetiracetam was administered over a period of 15-30 minutes; each 500 mg of levetiracetam was diluted in 100 mL of normal saline. RESULTS Thirty-four patients (19 men and 15 women, 11-90 years old) with status epilepticus were treated with IV levetiracetam. Six patients (18%) had primarily generalized status epilepticus and 28 (82%) had focal status epilepticus. The aetiologies were: vascular (47%), cryptogenic (24%), tumours (12%), metabolic (12%) and brain anoxia (6%). The indications for administering IV levetiracetam were: no response to IV phenytoin and/or IV valproic acid (53% of patients) or to avoid adverse effects, contraindications or potential interactions (47% of patients). The median loading dose of IV levetiracetam was 1000 mg and the maintenance dosage ranged from 500 to 1500 mg/12 hours (median 1000 mg/12 hours). Status epilepticus stopped in a clear temporal relationship with IV levetiracetam in 71% of patients. IV levetiracetam was especially effective in older patients with vascular status epilepticus, while cryptogenic status epilepticus, primarily generalized status epilepticus, previous therapy with IV phenytoin and/or valproic acid and status epilepticus due to brain anoxia were associated with a poor response. There were no serious adverse events documented in the patients' charts. CONCLUSIONS While waiting for large, controlled studies, our data suggest that IV levetiracetam might be an alternative for the treatment of status epilepticus, especially in elderly patients with vascular status epilepticus and concomitant medical conditions.
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Intravenous levetiracetam terminates refractory status epilepticus in two patients with migrating partial seizures in infancy. Epilepsy Res 2009; 86:66-71. [DOI: 10.1016/j.eplepsyres.2009.05.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Revised: 04/27/2009] [Accepted: 05/10/2009] [Indexed: 11/23/2022]
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Safety and Efficacy of Levetiracetam for Critically Ill Patients with Seizures. Neurocrit Care 2009; 11:34-7. [DOI: 10.1007/s12028-009-9185-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Accepted: 01/06/2009] [Indexed: 10/21/2022]
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Intravenous levetiracetam in critically ill children with status epilepticus or acute repetitive seizures. Pediatr Crit Care Med 2009; 10:505-10. [PMID: 19325512 PMCID: PMC2946960 DOI: 10.1097/pcc.0b013e3181a0e1cf] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Jones KE, Puccio AM, Harshman KJ, Falcione B, Benedict N, Jankowitz BT, Stippler M, Fischer M, Sauber-Schatz EK, Fabio A, Darby JM, Okonkwo DO. Levetiracetam versus phenytoin for seizure prophylaxis in severe traumatic brain injury. Neurosurg Focus 2009; 25:E3. [PMID: 18828701 DOI: 10.3171/foc.2008.25.10.e3] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Current standard of care for patients with severe traumatic brain injury (TBI) is prophylactic treatment with phenytoin for 7 days to decrease the risk of early posttraumatic seizures. Phenytoin alters drug metabolism, induces fever, and requires therapeutic-level monitoring. Alternatively, levetiracetam (Keppra) does not require serum monitoring or have significant pharmacokinetic interactions. In the current study, the authors compare the EEG findings in patients receiving phenytoin with those receiving levetiracetam monotherapy for seizure prophylaxis following severe TBI. METHODS Data were prospectively collected in 32 cases in which patients received levetiracetam for the first 7 days after severe TBI and compared with data from a historical cohort of 41 cases in which patients received phenytoin monotherapy. Patients underwent 1-hour electroencephalographic (EEG) monitoring if they displayed persistent coma, decreased mental status, or clinical signs of seizures. The EEG results were grouped into normal and abnormal findings, with abnormal EEG findings further categorized as seizure activity or seizure tendency. RESULTS Fifteen of 32 patients in the levetiracetam group warranted EEG monitoring. In 7 of these 15 cases the results were normal and in 8 abnormal; 1 patient had seizure activity, whereas 7 had seizure tendency. Twelve of 41 patients in the phenytoin group received EEG monitoring, with all results being normal. Patients treated with levetiracetam and phenytoin had equivalent incidence of seizure activity (p = 0.556). Patients receiving levetiracetam had a higher incidence of abnormal EEG findings (p = 0.003). CONCLUSIONS Levetiracetam is as effective as phenytoin in preventing early posttraumatic seizures but is associated with an increased seizure tendency on EEG analysis.
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Affiliation(s)
- Kristen E Jones
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
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Komotar RJ, Schmidt JM, Starke RM, Claassen J, Wartenberg KE, Lee K, Badjatia N, Connolly ES, Mayer SA. RESUSCITATION AND CRITICAL CARE OF POOR-GRADE SUBARACHNOID HEMORRHAGE. Neurosurgery 2009; 64:397-410; discussion 410-1. [DOI: 10.1227/01.neu.0000338946.42939.c7] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Abstract
AS OUTCOMES HAVE improved for patients with aneurysmal subarachnoid hemorrhage, most mortality and morbidity that occur today are the result of severe diffuse brain injury in poor-grade patients. The premise of this review is that aggressive emergency cardiopulmonary and neurological resuscitation, coupled with early aneurysm repair and advanced multimodality monitoring in a specialized neurocritical care unit, offers the best approach for achieving further improvements in subarachnoid hemorrhage outcomes. Emergency care should focus on control of elevated intracranial pressure, optimization of cerebral perfusion and oxygenation, and medical and surgical therapy to prevent rebleeding. In the postoperative period, advanced monitoring techniques such as continuous electroencephalography, brain tissue oxygen monitoring, and microdialysis can detect harmful secondary insults, and may eventually be used as end points for goal-directed therapy, with the aim of creating an optimal physiological environment for the comatose injured brain. As part of this paradigm shift, it is essential that aggressive surgical and medical support be linked to compassionate end-of-life care. As neurosurgeons become confident that comfort care can be implemented in a straightforward fashion after a failed trial of early maximal intervention, the usual justification for withholding treatment (survival with neurological devastation) becomes less relevant, and lives may be saved as more patients recover beyond expectations.
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Affiliation(s)
- Ricardo J. Komotar
- Department of Neurological Surgery, Columbia University, New York, New York (Komotar)
| | - J. Michael Schmidt
- Neurological Intensive Care Unit, Department of Neurology, Columbia University, New York, New York
| | - Robert M. Starke
- Department of Neurological Surgery, Columbia University, New York, New York (Komotar)
| | - Jan Claassen
- Department of Neurological Surgery, Columbia University, New York, New York (Komotar)
- Neurological Intensive Care Unit, Department of Neurology, Columbia University, New York, New York
| | | | - Kiwon Lee
- Department of Neurological Surgery, Columbia University, New York, New York (Komotar)
- Neurological Intensive Care Unit, Department of Neurology, Columbia University, New York, New York
| | - Neeraj Badjatia
- Neurological Intensive Care Unit, Department of Neurology, Columbia University, New York, New York
| | - E. Sander Connolly
- Neurological Intensive Care Unit, Department of Neurological Surgery, Columbia University, New York, New York
| | - Stephan A. Mayer
- Department of Neurological Surgery, Columbia University, New York, New York (Komotar)
- Neurological Intensive Care Unit, Department of Neurology, Columbia University, New York, New York
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Cáceres-Agra JJ, Santana-Cabrera L, Fernández-Arroyo M, Sánchez-Palacios M. Uso del levetiracetam en el estado mioclónico postanóxico. Med Clin (Barc) 2009; 132:369. [DOI: 10.1016/j.medcli.2008.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Accepted: 11/06/2008] [Indexed: 11/26/2022]
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Arciniegas DB, McAllister TW. Neurobehavioral management of traumatic brain injury in the critical care setting. Crit Care Clin 2008; 24:737-65, viii. [PMID: 18929941 DOI: 10.1016/j.ccc.2008.06.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Traumatic brain injury (TBI) results in approximately 230,000 hospitalizations annually in the United States. Advances in the acute management of TBI have improved survival after TBI. Many TBI survivors develop neurobehavioral disturbances in the acute post-injury period. Neurobehavioral sequelae present clinical management challenges for critical care professionals. This article defines and describes TBI and reviews its common neuroanatomic and neurobehavioral consequences. These disturbances are organized under the framework of posttraumatic encephalopathy, and the characteristic forms and stages of recovery of this condition are discussed. Recommendations regarding evaluation and management of posttraumatic neurobehavioral problems in the critical care setting are offered.
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Affiliation(s)
- David B Arciniegas
- Brain Injury Rehabilitation Unit, HealthONE Spalding Rehabilitation Hospital, Aurora, CO 80011, USA
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Testai FD, Aiyagari V. Acute Hemorrhagic Stroke Pathophysiology and Medical Interventions: Blood Pressure Control, Management of Anticoagulant-Associated Brain Hemorrhage and General Management Principles. Neurol Clin 2008; 26:963-85, viii-ix. [DOI: 10.1016/j.ncl.2008.06.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Seizures are common in pediatric emergency care units, either as the main medical issue or in association with an additional neurological problem. Rapid treatment prolonged and repetitive seizures or status epilepticus is important. Multiple anti-convulsant medications are useful in this setting, and each has various indications and potential adverse effects that must be considered in regard to individual patients. This review discusses new data regarding anticonvulsants that are useful in these settings, including fosphenytoin, valproic acid, levetiracetam, and topiramate. A status epilepticus treatment algorithm is suggested, incorporating changes from traditional algorithms based on these new data. Treatment issues specific to complex medical patients, including patients with brain tumors, renal dysfunction, hepatic dysfunction, transplant, congenital heart disease, and anticoagulation, are also discussed.
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Abstract
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.
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Affiliation(s)
- Bassel Abou-Khalil
- Department of Neurology, Vanderbilt University Medical Center, A-0118 Medical Center North, Nashville, Tennessee, USA.
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Abend NS, Dlugos DJ. Treatment of refractory status epilepticus: literature review and a proposed protocol. Pediatr Neurol 2008; 38:377-90. [PMID: 18486818 DOI: 10.1016/j.pediatrneurol.2008.01.001] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Revised: 09/06/2007] [Accepted: 01/14/2009] [Indexed: 11/18/2022]
Abstract
Refractory status epilepticus describes continuing seizures despite adequate initial pharmacologic treatment. This situation is common in children, but few data are available to guide management. We review the literature related to the pharmacologic treatment and overall management of refractory status epilepticus, including midazolam, pentobarbital, phenobarbital, propofol, inhaled anesthetics, ketamine, valproic acid, topiramate, levetiracetam, pyridoxine, corticosteroids, the ketogenic diet, and electroconvulsive therapy. Based on the available data, we present a sample treatment algorithm that emphasizes the need for rapid therapeutic intervention, employs consecutive medications with different mechanisms of action, and attempts to minimize the risk of hypotension. The initial steps suggest using benzodiazepines and phenytoin. Second steps suggest using levetiracetam or valproic acid, which exert few hemodynamic adverse effects and have multiple mechanisms of action. Additional management strategies that could be employed in tertiary-care settings, such as coma induction guided by continuous electroencephalogram monitoring and surgical options, are also discussed.
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Affiliation(s)
- Nicholas S Abend
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
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Intravenous levetiracetam: treatment experience with the first 50 critically ill patients. Epilepsy Behav 2008; 12:477-80. [PMID: 18291724 DOI: 10.1016/j.yebeh.2008.01.004] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2007] [Revised: 01/10/2008] [Accepted: 01/11/2008] [Indexed: 10/22/2022]
Abstract
Levetiracetam (LEV) is a broad-spectrum antiepileptic drug with no known interactions and a favorable profile of adverse events. These properties make it a good candidate for use in critically ill patients. An intravenous formulation of LEV was recently approved. The present study retrospectively assesses the safety and efficacy of LEV in the first 50 critically ill patients treated with intravenous LEV. Indications for use were seizure prophylaxis, acute symptomatic seizures, and all forms of status epilepticus. There were no major adverse effects, although less prominent changes may have been masked by the already severely compromised condition of these patients. Two patients (4%) had transiently lowered platelet counts (55,000 and 82,000, respectively). Efficacy, defined as cessation of seizure activity or prevention of its recurrence, was observed in 41 of 50 patients (82%). Antiepileptic treatment of critically ill patients with LEV seems to be effective and safe according to the data for this small cohort, but this observation warrants further prospective investigation in a larger number of patients.
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Abstract
Seizures represent stereotypic electroencephalographic (EEG) and behavioral paroxysms as a consequence of electrical neurologic derangement. Seizures are usually described as focal or generalized motor convulsions; however, nonconvulsive seizures that occur in the absence of motor activity may escape clinical detection. Because of the admission diagnoses and dramatic physiologic and metabolic derangements common to critically ill patients, the entire spectrum of seizure disorders may be encountered in the ICU. Seizures in the ICU are attributable to primary neurologic pathology or secondary to critical illness and clinical management. For optimal treatment, early diagnosis of the seizure type and its cause is important to ensure appropriate therapy. Convulsive status epilepticus requires emergent treatment before irreversible brain injury and severe metabolic disturbances occur.
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