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Giannaccini C, Almendras C, Li I, DiNapoli M, Macnow T. Determining the Safety and Tolerability of Rapid Administration of Undiluted Intravenous Levetiracetam in Pediatrics. J Child Neurol 2024:8830738241255992. [PMID: 38798130 DOI: 10.1177/08830738241255992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Objective: Levetiracetam is widely used in the emergency setting. Safety and tolerability of undiluted levetiracetam is prevalent in adults but is limited in pediatrics. The purpose is to determine the safety and tolerability of rapid administration of undiluted levetiracetam in pediatric patients. Methods: A retrospective, single-center, observational study was conducted in pediatric patients who received undiluted levetiracetam intravenous push. The primary outcome was adverse reactions, extravasation, need for intravenous line replacement, and discontinuation due to adverse reactions. The secondary outcome was turnaround time between ordering and administering first doses. Results: One hundred fourteen patients were included. Injection site reactions occurred in 7 patients. Extravasation occurred in 4 patients. Two patients required intravenous line replacement. There were no adverse events leading to discontinuation of levetiracetam. No difference was seen in the time from order to administration. Conclusion: Rapid administration of undiluted levetiracetam in pediatric patients was safe and well tolerated.
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Affiliation(s)
| | | | - Irene Li
- Department of Pharmacy, UMass Memorial Medical Center, Worcester, MA, USA
| | - Michael DiNapoli
- Department of Pharmacy, UMass Memorial Medical Center, Worcester, MA, USA
| | - Theodore Macnow
- Department of Pediatrics, UMass Chan Medical School, Worcester, MA, USA
- Department of Pediatrics, UMass Memorial Children's Medical Center, Worcester, MA, USA
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Direk MÇ, Epcacan S, Özdemir AA, Uysal F, Okuyaz Ç. Effects of levetiracetam treatment on autonomic nervous system functions in pediatric epilepsy patients. Pediatr Int 2023; 65:e15636. [PMID: 37795856 DOI: 10.1111/ped.15636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 06/14/2023] [Accepted: 06/23/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND This study investigated the effects of levetiracetam (LEV) treatment on cardiac rhythm and heart rate variability. METHODS The study included two groups of patients diagnosed with non-lesional epilepsy who had not yet been treated and who presented to the outpatient pediatric neurology clinic at Van Training and Research Hospital, Van, Turkey, between 2019 and 2020. The heart rate variability (HRV) of 47 patients in the first group, before and at the 3rd month of treatment, and intravenous (IV) LEV loading in 13 patients in the second group was evaluated by Holter electrocardiography (ECG). RESULTS It was determined that the values of triangular index, standard deviation of the RR intervals over a 24-hour period (SDNN), standard deviation of all 5-minute mean RR intervals (SDANN), mean of standard deviations of all normal RR intervals (SDNNI), the percentage of RR intervals with >50-millisecond variation (PNN50), and the square root of mean squared differences of successive RR intervals (RMSSD). HRV of 47 patients under LEV treatment significantly increased in the 3rd month of treatment compared to baseline (p < 0.05). No difference was found in HRV between the intravenous loading and the control group (p > 0.05). CONCLUSIONS Our study suggests that the sympathovagal balance before treatment in the patient group is in favor of the sympathetic nervous system and that the sympathovagal imbalance improves after treatment. Our results show that LEV monotherapy and loading have no negative effect on HRV and potential cardiac arrhythmia risk in children with epilepsy.
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Affiliation(s)
| | - Serdar Epcacan
- Department of Pediatric Cardiology, University of Health Sciences, Van Training and Research Hospital, Van, Turkey
| | - Asena Ayca Özdemir
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Fahrettin Uysal
- Department of Turkey Pediatric Cardiology, Faculty of Medicine, Uludag University, Bursa, Turkey
| | - Çetin Okuyaz
- Department of Pediatric Neurology, Faculty of Medicine, Mersin University, Mersin, Turkey
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Zhou YF, Huang Y, Liu GH. Effects of Levetiracetam on the Serum C-Reactive Protein in Children With Epilepsy: A Meta-Analysis. Front Pharmacol 2022; 13:810617. [PMID: 35517802 PMCID: PMC9065341 DOI: 10.3389/fphar.2022.810617] [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] [Received: 11/07/2021] [Accepted: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
This meta-analysis aims to evaluate the effect of levetiracetam on serum C-reactive protein (CRP) in children with epilepsy. Articles published up to April 15, 2021 were searched from Google Scholar databases, PubMed, Science Direct, Springer, Wiely, NIH and Baidu Scholar databases to analyzed the difference of serum CRP in epilepsy children compared to healthy controls, and the effect of levetiracetam on serum CRP in children with epilepsy was also assessed. All the included studies met the inclusion criteria. 103 publications were selected and eight articles were included in this study with sample size n = 246. The serum CRP level in childhood epilepsy was significantly higher than the healthy controls (pooled standardized mean difference (SMD): 6.930, 95% CI: 2.716–11.143, z = 3.22, p < 0.01). A significant level of between-study heterogeneity was found (τ2 = 17.911, Chi2 = 148.67, df = 3, p < 0.01, I2 = 98.0%). Besides, serum CRP level was significantly decreased by the treatment of levetiracetam in childhood epilepsy (pooled SMD: 3.505, 95% CI: 1.638–5.373, z = 3.68, p < 0.01). A significant level of between-study heterogeneity was found (τ2 = 4.346, Chi2 = 97.17, df = 4, p < 0.01, I2 = 95.9%). The funnel plot showed there was no significant publication bias in the meta-analysis. Serum CRP levels are upregulated in childhood epilepsy and reduced by levetiracetam in children with epilepsy.
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Affiliation(s)
- You-Feng Zhou
- Department of Pediatrics, Fujian Provincial Maternity and Children's Hospital, The Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yan Huang
- Department of Children's Healthcare, Fujian Provincial Maternity and Children's Hospital, The Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Guang-Hua Liu
- Department of Pediatrics, Fujian Provincial Maternity and Children's Hospital, The Affiliated Hospital of Fujian Medical University, Fuzhou, China
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Nazir M, Tarray RA, Asimi R, Syed WA. Comparative Efficacy of IV Phenytoin, IV Valproate, and IV Levetiracetam in Childhood Status Epilepticus. J Epilepsy Res 2021; 10:69-73. [PMID: 33659198 PMCID: PMC7903044 DOI: 10.14581/jer.20011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 05/10/2020] [Accepted: 06/12/2020] [Indexed: 11/06/2022] Open
Abstract
Background and Purpose Status epilepticus (SE) is a common pediatric neurological emergency that requires immediate and vigorous management. Currently, phenytoin is the most common agent used in the setting of SE following benzodiazepine for further seizure prevention. Other drugs recently introduced for management of SE are valproic acid and levetiracetam. Methods This prospective randomized study included 150 pediatric patients admitted as SE. Patients were randomized into three equal groups (50 each) to receive one of the three anticonvulsants in addition to standard treatment. Patients were monitored in hospital regarding their vitals, time to regain consciousness, and seizure recurrence. Results At 24 hours seizures were controlled in 44 patients (88%) in phenytoin group, 39 patients (78%) in levetiracetam (LEV) group and 46 patients (92%) in valproate (VAL) group (p=0.115). The mean time to regain consciousness in phenytoin, LEV and VAL groups was 122.3±45.4, 120.8±42.8, and 75.0±30.7 minutes (mean±standard deviation) respectively. Patients in VAL group regained consciousness earlier than both phenytoin and LEV group patients (p<0.0001). At 3 months follow-up, seven (14.28%) out of 49 patients in phenytoin group, 14 (28.57%) out of 49 in LEV group and two (4%) out of 50 patients in VAL group had a seizure recurrence (p=0.0032). Conclusions In our study we found that both IV LEV and IV VAL safe and efficacious. The primary outcome, seizure recurrence at 24 hours, did not show a statistically significant difference in three groups (p>0.05). Also, seizure recurrence at 1 week did not reach a statistically significant difference. However, time to regain consciousness and seizure recurrence at 3 months was significantly less in VAL group (p<0.05).
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Clinical Effectiveness of Levetiracetam Compared to Fosphenytoin in the Treatment of Benzodiazepine Refractory Convulsive Status Epilepticus. Indian J Pediatr 2020; 87:512-519. [PMID: 32088913 DOI: 10.1007/s12098-020-03221-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 01/27/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To determine whether levetiracetam is an alternative to fosphenytoin to control Benzodiazepine Refractory Status Epilepticus (BRSE) in pediatric population and also to compare the acute drug related side-effects and ventilation requirement among the both arms of anti-epileptic drug therapy. METHODS All consecutive children admitted with BRSE were randomized to group A, who received fosphenytoin at 20 mg/kg phenytoin equivalents (PE) dose and group B who received levetiracetam at 40 mg/kg over 10 min. Time to terminate seizure (response latency) was measured. If seizure remained refractory after 20 min of test drug administration, appropriate drug escalation was made according to pediatrician's discretion. All primary and secondary outcome measures were compared between the two therapeutic groups. RESULTS Of 61 children enrolled over 18 mo period, 29 (47.5%) were randomized to group A and 32 (52.5%) were randomized to Group B. Baseline characteristics were comparable between the two groups. Among 61 children, 58(98%) required Pediatric Intensive Care Unit (PICU) admission and among those 5(8.2%) children required mechanical ventilation. Duration of PICU stay, hospital stay, the response latency and seizure recurrence were compared between both groups. Significant number of children received additional anti-epileptic drugs (AEDs) in fosphenytoin group [9/29(31%)] compared to levetiracetam group [2/32(7%)] to control seizure. CONCLUSIONS Levetiracetam may be an effective alternative to fosphenytoin in management of BRSE in children but multicentric trials with large sample size are needed to substantiate this observation.
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The effects of acupuncture on occipital neuralgia: a systematic review and meta-analysis. BMC Complement Med Ther 2020; 20:171. [PMID: 32493452 PMCID: PMC7268636 DOI: 10.1186/s12906-020-02955-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 05/19/2020] [Indexed: 12/26/2022] Open
Abstract
Background Occipital neuralgia is one of the main causes of occipital pain. This systematic review aims to assess the level of evidence in randomized controlled trials (RCTs) on the effects of acupuncture on occipital neuralgia. Methods We searched 11 databases and a journal archive from their inception up to December 2019 for relevant RCTs. We did not place any specific restrictions on patients diagnosed with occipital neuralgia, such as age or gender. We included studies that used an acupuncture intervention group, with or without the control group treatment, and that set a control group receiving active, interventional treatment such as medication. For outcomes, we used visual analogue scale (VAS) and effective rate. Results We included a total of 11 RCTs. All VAS scores (mean difference [MD] –2.35, 95% confidence interval [CI] –2.84, − 1.86) and effective rate values (odds ratio [OR] 4.96, 95% CI 2.24, 10.96) showed significant differences in effect between acupuncture treatment alone and the control group treatment. Similarly, combined acupuncture treatment with control group treatment also showed significant effects in effective rate (OR 6.68, 95% CI 1.11, 40.37). We performed a subgroup analysis on studies that used acupuncture only as the intervention and reported the effective rate, and found that all acupuncture subgroups showed significant effects compared to the control group treatments. None of the studies reported severe adverse effects. Conclusions Although acupuncture only and combined acupuncture treatments showed significant effects compared to medication, the results of this study are inconclusive. Studies with rigorous study design and larger sample sizes are needed to confirm the role of acupuncture in this field. Trial registration International prospective register for systematic review (PROSPERO) number CRD42019128050.
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Dalziel SR, Borland ML, Furyk J, Bonisch M, Neutze J, Donath S, Francis KL, Sharpe C, Harvey AS, Davidson A, Craig S, Phillips N, George S, Rao A, Cheng N, Zhang M, Kochar A, Brabyn C, Oakley E, Babl FE. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial. Lancet 2019; 393:2135-2145. [PMID: 31005386 DOI: 10.1016/s0140-6736(19)30722-6] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/06/2019] [Accepted: 03/14/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Phenytoin is the current standard of care for second-line treatment of paediatric convulsive status epilepticus after failure of first-line benzodiazepines, but is only effective in 60% of cases and is associated with considerable adverse effects. A newer anticonvulsant, levetiracetam, can be given more quickly, is potentially more efficacious, and has a more tolerable adverse effect profile. We aimed to determine whether phenytoin or levetiracetam is the superior second-line treatment for paediatric convulsive status epilepticus. METHODS ConSEPT was an open-label, multicentre, randomised controlled trial conducted in 13 emergency departments in Australia and New Zealand. Children aged between 3 months and 16 years, with convulsive status epilepticus that failed first-line benzodiazepine treatment, were randomly assigned (1:1) using a computer-generated permuted block (block sizes 2 and 4) randomisation sequence, stratified by site and age (≤5 years, >5 years), to receive 20 mg/kg phenytoin (intravenous or intraosseous infusion over 20 min) or 40 mg/kg levetiracetam (intravenous or intraosseous infusion over 5 min). The primary outcome was clinical cessation of seizure activity 5 min after the completion of infusion of the study drug. Analysis was by intention to treat. This trial is registered with the Australian and New Zealand Clinical Trials Registry, number ACTRN12615000129583. FINDINGS Between March 19, 2015, and Nov 29, 2017, 639 children presented to participating emergency departments with convulsive status epilepticus; 127 were missed, and 278 did not meet eligibility criteria. The parents of one child declined to give consent, leaving 233 children (114 assigned to phenytoin and 119 assigned to levetiracetam) in the intention-to-treat population. Clinical cessation of seizure activity 5 min after completion of infusion of study drug occurred in 68 (60%) patients in the phenytoin group and 60 (50%) patients in the levetiracetam group (risk difference -9·2% [95% CI -21·9 to 3·5]; p=0·16). One participant in the phenytoin group died at 27 days because of haemorrhagic encephalitis; this death was not thought to be due to the study drug. There were no other serious adverse events. INTERPRETATION Levetiracetam is not superior to phenytoin for second-line management of paediatric convulsive status epilepticus. FUNDING Health Research Council of New Zealand, A+ Trust, Emergency Medicine Foundation, Townsville Hospital Private Practice Fund, Eric Ormond Baker Charitable Fund, and Princess Margaret Hospital Foundation.
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Affiliation(s)
- Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand; Departments of Surgery, University of Auckland, Auckland, New Zealand; Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.
| | - Meredith L Borland
- Perth Children's Hospital, Perth, WA, Australia; Division of Emergency Medicine, School of Medicine, University of Western Australia, Perth, WA, Australia; Division of Paediatrics, School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Jeremy Furyk
- Emergency Department, The Townsville Hospital, Townsville, QLD, Australia; College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
| | - Megan Bonisch
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | | | - Susan Donath
- Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Kate L Francis
- Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Cynthia Sharpe
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - A Simon Harvey
- Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Royal Children's Hospital, Melbourne, VIC, Australia
| | - Andrew Davidson
- Murdoch Children's Research Institute, Parkville, VIC, Australia; Royal Children's Hospital, Melbourne, VIC, Australia
| | - Simon Craig
- Monash Medical Centre, Melbourne, VIC, Australia; Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Natalie Phillips
- Queensland Children's Hospital, Brisbane, QLD, Australia; Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
| | - Shane George
- Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia; Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia; School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Arjun Rao
- Sydney Children's Hospital, Randwick, NSW, Australia; School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Michael Zhang
- Emergency Department, John Hunter Hospital, Newcastle, NSW, Australia
| | - Amit Kochar
- Emergency Department, Women's and Children's Hospital, Adelaide, SA, Australia
| | | | - Ed Oakley
- Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Royal Children's Hospital, Melbourne, VIC, Australia
| | - Franz E Babl
- Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Royal Children's Hospital, Melbourne, VIC, Australia
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Kim MJ, Yum MS, Yeh HR, Ko TS, Lim HS. Pharmacokinetic and Pharmacodynamic Evaluation of Intravenous Levetiracetam in Children With Epilepsy. J Clin Pharmacol 2018; 58:1586-1596. [PMID: 30052270 DOI: 10.1002/jcph.1282] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 06/18/2018] [Indexed: 11/08/2022]
Abstract
This study aimed to evaluate the safety and tolerability of intravenous (IV) levetiracetam (LEV) as a monotherapy in children aged 1 month-16 years and to explore the pharmacokinetics (PK) of IV LEV and the time to seizure after IV then oral administration of LEV in pediatric children with epilepsy. Children diagnosed with acute unprovoked seizures requiring in-hospital IV LEV administration were included. After administration, the clinical seizure outcomes, side effects, and the Korean-Child Behavior Checklist were monitored and the PK and repeated time to seizure were analyzed via modeling using NONMEM software. Overall, 37 children with epilepsy were enrolled and underwent a PK analysis (median age, 4.6 years; median weight, 18.0 kg). Nine children (24.3%) had seizure recurrence during the follow-up period (median, 3.8 months) and 5 children (13.5%) experienced LEV-associated adverse events such as irritability (n = 2; 5.4%) and somnolence (n = 3; 8.1%). The plasma LEV concentrations after IV LEV were best described by a one-compartment linear PK model. Only body weight was associated with both the clearance and volume of distribution of LEV. The Weibull distribution model described the time to seizure recurrence well; no statistically significant predictor for the time to seizure was identified. Therefore, IV LEV was a well-tolerated and effective alternative in children with acute unprovoked seizures, and models for the PK and time to repeated seizure recurrence after LEV were successfully developed. In particular, the current use of a weight-based IV LEV dosing regimen in pediatric children is practical.
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Affiliation(s)
- Min-Jee Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Ryun Yeh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Sung Ko
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeong-Seok Lim
- Department of Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Singh K, Aggarwal A, Faridi MMA, Sharma S. IV Levetiracetam versus IV Phenytoin in Childhood Seizures: A Randomized Controlled Trial. J Pediatr Neurosci 2018. [PMID: 30090128 DOI: 10.4103/jpn.jpn-126-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To compare the efficacy of IV phenytoin and IV levetiracetam in acute seizures. DESIGN Randomized controlled trial. SETTING Tertiary care hospital, November 2012 to April 2014. PATIENTS 100 children aged 3-12 yrs of age presenting with acute seizures. INTERVENTION Participants randomly received either IV phenytoin 20 mg/kg (n = 50) or IV levetiracetam 30 mg/kg (n = 50). Patients who were had seizures at presentation received IV diazepam prior to these drugs. OUTCOME MEASURES Primary: Absence of seizure activity within next 24 hrs.Secondary: Stopping of clinical seizure activity within 20 mins of first intervention, change in cardiorespiratory parameters, and achievement of therapeutic drug levels. RESULTS Two groups were comparable in patient characteristics and seizure type (P > 0.05). Of the 100 children, 3 in levetiracetam and 2 in phenytoin group had a repeat seizure in 24 hrs, efficacy was comparable (94% vs 96%, P > 0.05). Of these, 18 (36%) in phenytoin and 12 (24%) in levetiracetam group received diazepam. Sedation time was 178.80 ±97.534 mins in phenytoin and 145.50 ±105.208 mins in levetiracetam group (P = 0.346). Changes in cardiorespiratory parameters were similar in both groups except a lower diastolic blood pressure with phenytoin (P = 0.023). Therapeutic drug levels were achieved in 38 (76%) children both at 4 and 24 hrs with phenytoin, compared to 50 (100%) and 48 (98%) at 1 and 24 hrs with levetiracetam (P < 0.05). CONCLUSION Intravenous levetiracetam and phenytoin have similar efficacy in preventing seizure recurrences for 24 hrs in children 3-12 years presenting with acute seizures.
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Affiliation(s)
- Kanika Singh
- Department of Paediatrics, University College of Medical Sciences and GTB Hospital, Delhi - 110095 India
| | - Anju Aggarwal
- Department of Paediatrics, University College of Medical Sciences and GTB Hospital, Delhi - 110095 India
| | - M M A Faridi
- Department of Paediatrics, University College of Medical Sciences and GTB Hospital, Delhi - 110095 India
| | - Sangeeta Sharma
- Department of Neuropsychopharmacology, Institute of Human Behaviour and Allied Sciences Delhi - 110095 India
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Jenjirattithigarn N, Worachat N, Horsuwan S, Puangpetch A, Prempunpong C, Khongkhatithum C, Thampratankul L, Prommas S, Visudtibhan A, Sukasem C. Determination of plasma Levetiracetam level by Liquid Chromatography-Tandem Mass Spectrometry (LC-MS-MS) and its application in pharmacokinetics studies in neonates. J Chromatogr B Analyt Technol Biomed Life Sci 2018; 1085:13-20. [PMID: 29626789 DOI: 10.1016/j.jchromb.2018.03.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 03/05/2018] [Accepted: 03/24/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Levetiracetam (LEV) is an antiepileptic drug which has good safety and efficacy in neonatal seizure (NS), a common incident in neonates with weight <1500 g. The pharmacokinetics for LEV in neonatal populations is yet to be clearly understood. In this study, we developed and validated a method for determination of LEV in plasma by liquid chromatography tandem mass spectrometry for the purpose of pharmacokinetic study. METHODS Plasma LEV was spiked with Lamivudine as internal standard before extraction by C18 solid-phase extraction (SPE) cartridge. Chromatography was performed using isocratic elution with mobile phase A: B (10: 90) for 2.0 min with flow rate 0.4 mL/min. The mobile phase was composed of 0.1% formic acid in 10.0 mM ammonium acetate (A) and 100% methanol (B). The injection volume was 1.0 μL and the total run time was 2.0 min. Multiple reaction monitoring (MRM) with electro spray in positive mode was used. The mass transition for LEV was 171.2/126.0 and 230.0/112.0 for IS with retention time of 0.73 and 0.72 min, respectively. RESULTS A calibration curve range from 0.50-80.0 μg/mL was obtained with a correlation coefficient >0.99 in the quadratic model. Precision and accuracy was within the acceptable range and the intra- and inter-day %CV for three concentrations of QCs were <10%. CONCLUSION This method was reliable, accurate and applicable for LEV pharmacokinetic study in neonates with seizure.
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Affiliation(s)
- Nuttawut Jenjirattithigarn
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand
| | - Nattha Worachat
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Bangkok 10400, Thailand
| | - Suchawadee Horsuwan
- Division of Neurology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Bangkok 10400, Thailand
| | - Apichaya Puangpetch
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand
| | - Chatchay Prempunpong
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Bangkok 10400, Thailand
| | - Chaiyos Khongkhatithum
- Division of Neurology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Bangkok 10400, Thailand
| | - Lunliya Thampratankul
- Division of Neurology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Bangkok 10400, Thailand
| | - Santirat Prommas
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand
| | - Anannit Visudtibhan
- Division of Neurology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Bangkok 10400, Thailand
| | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC), Ramathibodi Hospital, Bangkok, Thailand.
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Singh K, Aggarwal A, Faridi MMA, Sharma S. IV Levetiracetam versus IV Phenytoin in Childhood Seizures: A Randomized Controlled Trial. J Pediatr Neurosci 2018; 13:158-164. [PMID: 30090128 PMCID: PMC6057176 DOI: 10.4103/jpn.jpn_126_17] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objectives: To compare the efficacy of IV phenytoin and IV levetiracetam in acute seizures. Design: Randomized controlled trial. Setting: Tertiary care hospital, November 2012 to April 2014. Patients: 100 children aged 3–12 yrs of age presenting with acute seizures. Intervention: Participants randomly received either IV phenytoin 20 mg/kg (n = 50) or IV levetiracetam 30 mg/kg (n = 50). Patients who were had seizures at presentation received IV diazepam prior to these drugs. Outcome Measures: Primary: Absence of seizure activity within next 24 hrs. Secondary: Stopping of clinical seizure activity within 20 mins of first intervention, change in cardiorespiratory parameters, and achievement of therapeutic drug levels. Results: Two groups were comparable in patient characteristics and seizure type (P > 0.05). Of the 100 children, 3 in levetiracetam and 2 in phenytoin group had a repeat seizure in 24 hrs, efficacy was comparable (94% vs 96%, P > 0.05). Of these, 18 (36%) in phenytoin and 12 (24%) in levetiracetam group received diazepam. Sedation time was 178.80 ±97.534 mins in phenytoin and 145.50 ±105.208 mins in levetiracetam group (P = 0.346). Changes in cardiorespiratory parameters were similar in both groups except a lower diastolic blood pressure with phenytoin (P = 0.023). Therapeutic drug levels were achieved in 38 (76%) children both at 4 and 24 hrs with phenytoin, compared to 50 (100%) and 48 (98%) at 1 and 24 hrs with levetiracetam (P < 0.05). Conclusion: Intravenous levetiracetam and phenytoin have similar efficacy in preventing seizure recurrences for 24 hrs in children 3–12 years presenting with acute seizures.
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Affiliation(s)
- Kanika Singh
- Department of Paediatrics, University College of Medical Sciences and GTB Hospital, Delhi - 110095 India
| | - Anju Aggarwal
- Department of Paediatrics, University College of Medical Sciences and GTB Hospital, Delhi - 110095 India
| | - M M A Faridi
- Department of Paediatrics, University College of Medical Sciences and GTB Hospital, Delhi - 110095 India
| | - Sangeeta Sharma
- Department of Neuropsychopharmacology, Institute of Human Behaviour and Allied Sciences Delhi - 110095 India
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12
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Dalziel SR, Furyk J, Bonisch M, Oakley E, Borland M, Neutze J, Donath S, Sharpe C, Harvey S, Davidson A, Craig S, Phillips N, George S, Rao A, Cheng N, Zhang M, Sinn K, Kochar A, Brabyn C, Babl FE. A multicentre randomised controlled trial of levetiracetam versus phenytoin for convulsive status epilepticus in children (protocol): Convulsive Status Epilepticus Paediatric Trial (ConSEPT) - a PREDICT study. BMC Pediatr 2017. [PMID: 28641582 PMCID: PMC5480418 DOI: 10.1186/s12887-017-0887-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Convulsive status epilepticus (CSE) is the most common life-threatening childhood neurological emergency. Despite this, there is a lack of high quality evidence supporting medication use after first line benzodiazepines, with current treatment protocols based solely on non-experimental evidence and expert opinion. The current standard of care, phenytoin, is only 60% effective, and associated with considerable adverse effects. A newer anti-convulsant, levetiracetam, can be given faster, is potentially more efficacious, with a more tolerable side effect profile. The primary aim of the study presented in this protocol is to determine whether intravenous (IV) levetiracetam or IV phenytoin is the better second line treatment for the emergency management of CSE in children. Methods/Design 200 children aged between 3 months and 16 years presenting to 13 emergency departments in Australia and New Zealand with CSE, that has failed to stop with first line benzodiazepines, will be enrolled into this multicentre open randomised controlled trial. Participants will be randomised to 40 mg/kg IV levetiracetam infusion over 5 min or 20 mg/kg IV phenytoin infusion over 20 min. The primary outcome for the study is clinical cessation of seizure activity five minutes following the completion of the infusion of the study medication. Blinded confirmation of the primary outcome will occur with the primary outcome assessment being video recorded and assessed by a primary outcome assessment team blinded to treatment allocation. Secondary outcomes include: Clinical cessation of seizure activity at two hours; Time to clinical seizure cessation; Need for rapid sequence induction; Intensive care unit (ICU) admission; Serious adverse events; Length of Hospital/ICU stay; Health care costs; Seizure status/death at one-month post discharge. Discussion This paper presents the background, rationale, and design for a randomised controlled trial comparing levetiracetam to phenytoin in children presenting with CSE in whom benzodiazepines have failed. This study will provide the first high quality evidence for management of paediatric CSE post first-line benzodiazepines. Trial registration Prospectively registered with the Australian and New Zealand Clinical Trial Registry (ANZCTR): ACTRN12615000129583 (11/2/2015). UTN U1111–1144-5272. ConSEPT protocol version 4 (12/12/2014).
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Affiliation(s)
- Stuart R Dalziel
- Starship Children's Hospital, Private Bag 92024, Auckland, 1142, New Zealand. .,Liggins Institute, University of Auckland, Auckland, New Zealand.
| | - Jeremy Furyk
- The Townsville Hospital, Townsville, Queensland, Australia.,James Cook University, Townsville, Queensland, Australia
| | - Megan Bonisch
- Starship Children's Hospital, Private Bag 92024, Auckland, 1142, New Zealand
| | - Ed Oakley
- Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Victoria, Australia
| | | | | | - Susan Donath
- Murdoch Childrens Research Institute, Victoria, Australia
| | - Cynthia Sharpe
- Starship Children's Hospital, Private Bag 92024, Auckland, 1142, New Zealand
| | - Simon Harvey
- Royal Children's Hospital, Melbourne, Victoria, Australia
| | | | | | - Natalie Phillips
- Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Shane George
- Gold Coast University Hospital, Southport, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia.,Bond University, Gold Coast, Queensland, Australia
| | - Arjun Rao
- Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Nicholas Cheng
- Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Michael Zhang
- John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Kam Sinn
- Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Amit Kochar
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | | | - Franz E Babl
- Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Victoria, Australia
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13
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Ostahowski PJ, Kannan N, Wainwright MS, Qiu Q, Mink RB, Groner JI, Bell MJ, Giza CC, Zatzick DF, Ellenbogen RG, Boyle LN, Mitchell PH, Vavilala MS. Variation in seizure prophylaxis in severe pediatric traumatic brain injury. J Neurosurg Pediatr 2016; 18:499-506. [PMID: 27258588 DOI: 10.3171/2016.4.peds1698] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Posttraumatic seizure is a major complication following traumatic brain injury (TBI). The aim of this study was to determine the variation in seizure prophylaxis in select pediatric trauma centers. The authors hypothesized that there would be wide variation in seizure prophylaxis selection and use, within and between pediatric trauma centers. METHODS In this retrospective multicenter cohort study including 5 regional pediatric trauma centers affiliated with academic medical centers, the authors examined data from 236 children (age < 18 years) with severe TBI (admission Glasgow Coma Scale score ≤ 8, ICD-9 diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head Abbreviated Injury Scale score ≥ 3) who received tracheal intubation for ≥ 48 hours in the ICU between 2007 and 2011. RESULTS Of 236 patients, 187 (79%) received seizure prophylaxis. In 2 of the 5 centers, 100% of the patients received seizure prophylaxis medication. Use of seizure prophylaxis was associated with younger patient age (p < 0.001), inflicted TBI (p < 0.001), subdural hematoma (p = 0.02), cerebral infarction (p < 0.001), and use of electroencephalography (p = 0.023), but not higher Injury Severity Score. In 63% cases in which seizure prophylaxis was used, the patients were given the first medication within 24 hours of injury, and 50% of the patients received the first dose in the prehospital or emergency department setting. Initial seizure prophylaxis was most commonly with fosphenytoin (47%), followed by phenytoin (40%). CONCLUSIONS While fosphenytoin was the most commonly used medication for seizure prophylaxis, there was large variation within and between trauma centers with respect to timing and choice of seizure prophylaxis in severe pediatric TBI. The heterogeneity in seizure prophylaxis use may explain the previously observed lack of relationship between seizure prophylaxis and outcomes.
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Affiliation(s)
- Paige J Ostahowski
- Medical Student Research Training Program, University of Washington School of Medicine
| | | | - Mark S Wainwright
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois
| | | | - Richard B Mink
- Department of Pediatrics, Harbor-UCLA and Los Angeles BioMedical Research Institute, Torrance
| | - Jonathan I Groner
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio; and
| | - Michael J Bell
- Department of Critical Care Medicine, University of Pittsburgh, Pennsylvania
| | - Christopher C Giza
- Department of Neurosurgery and.,Division of Pediatric Neurology, Mattel Children's Hospital, UCLA, Los Angeles, California
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14
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Zelano J, Ben-Menachem E. Treating epileptic emergencies - pharmacological advances. Expert Opin Pharmacother 2016; 17:2227-2234. [PMID: 27686410 DOI: 10.1080/14656566.2016.1241236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Epileptic emergencies are frequently encountered and include ictal events as status epilepticus or seizure clusters, and non-ictal situations like postictal psychosis or acute drug side effects. The aim of this review was to describe recent pharmacological advances in the treatment of epileptic emergencies. Areas covered: Based on clinically relevant questions, a literature search was performed. The search showed that most pharmacological advances have been made in management of status epilepticus, where substantial literature has accumulated on several AEDs with potentially less side-effects than the traditional choices. The use of these drugs; valproate, levetiracetam, and lacosamide, was therefore made the main focus of this review. Pharmacological advances in treatment of other epileptic emergencies were scarce, and were therefore covered more briefly in the Expert Opinion section. Expert opinion: This section outlines our current practice in management of status epilepticus and seizures clusters. Our opinion is that valproate is an equal alternative as second line treatment to fosphenytoin, with levetiracetam considered a good choice in frail and elderly patients. Due to the lack of literature, lacosamide is used mainly as a 2nd line drug after the failure of valproate, fosphenytoin and levetiracetam. Our review underlines the need for more research in management of epileptic emergencies.
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Affiliation(s)
- Johan Zelano
- a Department of Clinical Neuroscience and Department of Neurology, Sahlgrenska Academy , University of Gothenburg, Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Elinor Ben-Menachem
- a Department of Clinical Neuroscience and Department of Neurology, Sahlgrenska Academy , University of Gothenburg, Sahlgrenska University Hospital , Gothenburg , Sweden
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15
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İşgüder R, Güzel O, Ceylan G, Yılmaz Ü, Ağın H. A Comparison of Intravenous Levetiracetam and Valproate for the Treatment of Refractory Status Epilepticus in Children. J Child Neurol 2016; 31:1120-6. [PMID: 27080042 DOI: 10.1177/0883073816641187] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/03/2016] [Indexed: 12/21/2022]
Abstract
Because of the lack of studies comparing the efficacy and safety of levetiracetam and valproate before the induction of general anesthesia in the treatment of convulsive refractory status epilepticus in children, we aimed to compare the effectiveness of these antiepileptic drugs in patients with convulsive status epilepticus admitted to the Pediatric Intensive Care Unit between 2011 and 2014. Forty-six (59%) of the 78 patients received levetiracetam, and 32 (41%) received valproate for the treatment of refractory status epilepticus. The response rate was not significantly different between the 2 groups. Although no adverse event was noted in patients who received levetiracetam, 4 (12.5%) patients in the valproate group experienced liver dysfunction (P = .025). According to our results, levetiracetam and valproate may be used in the treatment of refractory status epilepticus before the induction of general anesthesia. Levetiracetam appears as effective as valproate, and also safer.
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Affiliation(s)
- Rana İşgüder
- Department of Pediatric Intensive Care Unit, Dr Behçet Uz Children's Hospital, Izmir, Turkey
| | - Orkide Güzel
- Department of Pediatric Neurology, Dr Behçet Uz Children's Hospital, Izmir, Turkey
| | - Gökhan Ceylan
- Department of Pediatric Intensive Care Unit, Dr Behçet Uz Children's Hospital, Izmir, Turkey
| | - Ünsal Yılmaz
- Department of Pediatric Neurology, Dr Behçet Uz Children's Hospital, Izmir, Turkey
| | - Hasan Ağın
- Department of Pediatric Intensive Care Unit, Dr Behçet Uz Children's Hospital, Izmir, Turkey
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16
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Incecik F, Horoz OO, Herguner OM, Yıldızdas D, Besen S, Tolunay I, Altunbasak S. Intravenous levetiracetam in critically ill children. Ann Indian Acad Neurol 2016; 19:79-82. [PMID: 27011634 PMCID: PMC4782558 DOI: 10.4103/0972-2327.167702] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: To report the effectiveness and safety of intravenous (IV) levetiracetam (LEV) in the treatment of critically ill children with acute repetitive seizures and status epilepticus (SE) in a children's hospital. Materials and Methods: We retrospectively analyzed data from children treated with IV LEV. Results: The mean age of the 108 children was 69.39 ± 46.14 months (1-192 months). There were 58 (53.1%) males and 50 (46.8%) females. LEV load dose was 28.33 ± 4.60 mg/kg/dose (10-40 mg/kg). Out of these 108 patients, LEV terminated seizures in 79 (73.1%). No serious adverse effects were observed but agitation and aggression were developed in two patients, and mild erythematous rash and urticaria developed in one patient. Conclusion: Antiepileptic treatment of critically ill children with IV LEV seems to be effective and safe. Further study is needed to elucidate the role of IV LEV in critically ill children.
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Affiliation(s)
- Faruk Incecik
- Department of Pediatric Neurology, Cukurova University, Adana, Turkey
| | - Ozden O Horoz
- Department of Pediatric Intensive Care Unit, Cukurova University, Adana, Turkey
| | - Ozlem M Herguner
- Department of Pediatric Neurology, Cukurova University, Adana, Turkey
| | - Dincer Yıldızdas
- Department of Pediatric Intensive Care Unit, Cukurova University, Adana, Turkey
| | - Seyda Besen
- Department of Pediatric Neurology, Cukurova University, Adana, Turkey
| | - Ilknur Tolunay
- Department of Pediatric Intensive Care Unit, Cukurova University, Adana, Turkey
| | - Sakir Altunbasak
- Department of Pediatric Neurology, Cukurova University, Adana, Turkey
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17
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Lee YJ, Yum MS, Kim EH, Ko TS. Intravenous levetiracetam versus phenobarbital in children with status epilepticus or acute repetitive seizures. KOREAN JOURNAL OF PEDIATRICS 2016; 59:35-9. [PMID: 26893602 PMCID: PMC4753198 DOI: 10.3345/kjp.2016.59.1.35] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 07/06/2015] [Accepted: 07/15/2015] [Indexed: 12/11/2022]
Abstract
Purpose This study compared the efficacy and tolerability of intravenous (i.v.) phenobarbital (PHB) and i.v. levetiracetam (LEV) in children with status epilepticus (SE) or acute repetitive seizure (ARS). Methods The medical records of children (age range, 1 month to 15 years) treated with i.v. PHB or LEV for SE or ARS at our single tertiary center were retrospectively reviewed. Seizure termination was defined as seizure cessation within 30 minutes of infusion completion and no recurrence within 24 hours. Information on the demographic variables, electroencephalography and magnetic resonance imaging findings, previous antiepileptic medications, and adverse events after drug infusion was obtained. Results The records of 88 patients with SE or ARS (median age, 18 months; 50 treated with PHB and 38 with LEV) were reviewed. The median initial dose of i.v. PHB was 20 mg/kg (range, 10–20 mg/kg) and that of i.v. LEV was 30 mg/kg (range, 20–30 mg/kg). Seizure termination occurred in 57.9% of patients treated with i.v. LEV (22 of 38) and 74.0% treated with i.v. PHB (37 of 50) (P=0.111). The factor associated with seizure termination was the type of event (SE vs. ARS) in each group. Adverse effects were reported in 13.2% of patients treated with i.v. LEV (5 of 38; n=4, aggressive behavior and n=1, vomiting), and 28.0% of patients treated with i.v. PHB (14 of 50). Conclusion Intravenous LEV was efficacious and safe in children with ARS or SE. Further evaluation is needed to determine the most effective and best-tolerated loading dose of i.v. LEV.
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Affiliation(s)
- Yun-Jeong Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Mi-Sun Yum
- Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Eun-Hee Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Tae-Sung Ko
- Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea
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18
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Glauser T, Shinnar S, Gloss D, Alldredge B, Arya R, Bainbridge J, Bare M, Bleck T, Dodson WE, Garrity L, Jagoda A, Lowenstein D, Pellock J, Riviello J, Sloan E, Treiman DM. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr 2016; 16:48-61. [PMID: 26900382 PMCID: PMC4749120 DOI: 10.5698/1535-7597-16.1.48] [Citation(s) in RCA: 697] [Impact Index Per Article: 87.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
CONTEXT The optimal pharmacologic treatment for early convulsive status epilepticus is unclear. OBJECTIVE To analyze efficacy, tolerability and safety data for anticonvulsant treatment of children and adults with convulsive status epilepticus and use this analysis to develop an evidence-based treatment algorithm. DATA SOURCES Structured literature review using MEDLINE, Embase, Current Contents, and Cochrane library supplemented with article reference lists. STUDY SELECTION Randomized controlled trials of anticonvulsant treatment for seizures lasting longer than 5 minutes. DATA EXTRACTION Individual studies were rated using predefined criteria and these results were used to form recommendations, conclusions, and an evidence-based treatment algorithm. RESULTS A total of 38 randomized controlled trials were identified, rated and contributed to the assessment. Only four trials were considered to have class I evidence of efficacy. Two studies were rated as class II and the remaining 32 were judged to have class III evidence. In adults with convulsive status epilepticus, intramuscular midazolam, intravenous lorazepam, intravenous diazepam and intravenous phenobarbital are established as efficacious as initial therapy (Level A). Intramuscular midazolam has superior effectiveness compared to intravenous lorazepam in adults with convulsive status epilepticus without established intravenous access (Level A). In children, intravenous lorazepam and intravenous diazepam are established as efficacious at stopping seizures lasting at least 5 minutes (Level A) while rectal diazepam, intramuscular midazolam, intranasal midazolam, and buccal midazolam are probably effective (Level B). No significant difference in effectiveness has been demonstrated between intravenous lorazepam and intravenous diazepam in adults or children with convulsive status epilepticus (Level A). Respiratory and cardiac symptoms are the most commonly encountered treatment-emergent adverse events associated with intravenous anticonvulsant drug administration in adults with convulsive status epilepticus (Level A). The rate of respiratory depression in patients with convulsive status epilepticus treated with benzodiazepines is lower than in patients with convulsive status epilepticus treated with placebo indicating that respiratory problems are an important consequence of untreated convulsive status epilepticus (Level A). When both are available, fosphenytoin is preferred over phenytoin based on tolerability but phenytoin is an acceptable alternative (Level A). In adults, compared to the first therapy, the second therapy is less effective while the third therapy is substantially less effective (Level A). In children, the second therapy appears less effective and there are no data about third therapy efficacy (Level C). The evidence was synthesized into a treatment algorithm. CONCLUSIONS Despite the paucity of well-designed randomized controlled trials, practical conclusions and an integrated treatment algorithm for the treatment of convulsive status epilepticus across the age spectrum (infants through adults) can be constructed. Multicenter, multinational efforts are needed to design, conduct and analyze additional randomized controlled trials that can answer the many outstanding clinically relevant questions identified in this guideline.
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Affiliation(s)
- Tracy Glauser
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shlomo Shinnar
- Departments of Neurology, Pediatrics, and Epidemiology and Population Health, and the Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | | | - Brian Alldredge
- School of Pharmacy, University of California, San Francisco, CA
| | - Ravindra Arya
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jacquelyn Bainbridge
- Department of Clinical Pharmacy, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Mary Bare
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Thomas Bleck
- Departments of Neurological Sciences, Neurosurgery, Medicine, and Anesthesiology, Rush University Medical Center, Chicago, IL
| | - W. Edwin Dodson
- Departments of Neurology and Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Lisa Garrity
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andy Jagoda
- Department of Emergency Medicine, Mount Sinai Hospital, Mount Sinai School of Medicine, New York, NY
| | - Daniel Lowenstein
- Department of Neurology, University of California, San Francisco, CA
| | - John Pellock
- Division of Pediatric Neurology, Virginia Commonwealth University, Richmond, VA
| | | | - Edward Sloan
- Department of Emergency Medicine, University of Illinois at Chicago, Chicago, IL
| | - David M. Treiman
- Division of Neurology, Barrow Neurological Institute, Phoenix, AZ
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19
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Alford EL, Wheless JW, Phelps SJ. Treatment of Generalized Convulsive Status Epilepticus in Pediatric Patients. J Pediatr Pharmacol Ther 2015; 20:260-89. [PMID: 26380568 PMCID: PMC4557718 DOI: 10.5863/1551-6776-20.4.260] [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] [Indexed: 11/11/2022]
Abstract
Generalized convulsive status epilepticus (GCSE) is one of the most common neurologic emergencies and can be associated with significant morbidity and mortality if not treated promptly and aggressively. Management of GCSE is staged and generally involves the use of life support measures, identification and management of underlying causes, and rapid initiation of anticonvulsants. The purpose of this article is to review and evaluate published reports regarding the treatment of impending, established, refractory, and super-refractory GCSE in pediatric patients.
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Affiliation(s)
- Elizabeth L. Alford
- Department of Clinical Pharmacy, College of Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
- Center for Pediatric Pharmacokinetics and Therapeutics, Memphis, Tennessee
| | - James W. Wheless
- Departments of Pediatrics, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
- Pediatric Neurology, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
- Le Bonheur Neuroscience Center and Comprehensive Epilepsy Program, Memphis, Tennessee
| | - Stephanie J. Phelps
- Department of Clinical Pharmacy, College of Pharmacy, The University of Tennessee Health Science Center, Memphis, Tennessee
- Center for Pediatric Pharmacokinetics and Therapeutics, Memphis, Tennessee
- Departments of Pediatrics, College of Medicine, The University of Tennessee Health Science Center, Memphis, Tennessee
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20
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Intravenous levetiracetam in Thai children and adolescents with status epilepticus and acute repetitive seizures. Eur J Paediatr Neurol 2015; 19:429-34. [PMID: 25800343 DOI: 10.1016/j.ejpn.2015.02.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 01/08/2015] [Accepted: 02/21/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Intravenous levetiracetam is an option for treatment of status epilepticus (SE) and acute repetitive seizures (ARS). However, there have been relatively few studies with children and adolescents. Also, an appropriate dosage has yet to be determined. AIM This study investigated the safety and the efficacy of levetiracetam for intravenous treatment of convulsive status epilepticus and acute repetitive seizures in children and adolescents. METHOD Retrospectively, the study reviewed the medical records of 19 male and 31 female patients under 18 years of age who had received intravenous levetiracetam treatment either for acute repetitive seizures or for convulsive status epilepticus. The patients were admitted between April 1st, 2010 and December 31st, 2011 to the Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand. Data were collected on underlying illnesses, etiology of seizures, indication for levetiracetam therapy, initial dosage, rate of infusion, untoward effects during infusion and emerged complications. Efficacy of treatment was defined as the termination of seizure within 30 min of completing levetiracetam infusion and no seizure recurrence within 6 h of initial treatment. RESULTS The age range of the 50 patients was from one day to 18 years (mean 79.6 months). The analysis included 52 episodes of 34 acute repetitive seizures (63.4%) and 18 convulsive status epilepticus (34.6%). Infusion rates ranged from 2 to 66 mg/kg/min (mean 29.6). Cessation of seizure was obtained in 59.6% of 52 episodes. Patients with underlying drug resistant epilepsy did not respond to levetiracetam therapy as well as patients with other etiology of seizures. There were no adverse drug reactions or untoward effects observed during the therapy. CONCLUSION Intravenous administration of levetiracetam is safe and effective for treatment of acute repetitive seizures and convulsive status epilepticus in children and adolescents. Failure of treatment may be related to underlying drug resistant epilepsy. Further study of appropriate initial dosage and pharmacokinetic variations in the patients is needed as possible explanation of the unresponsiveness.
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Ueda R, Saito Y, Ohno K, Maruta K, Matsunami K, Saiki Y, Sokota T, Sugihara S, Nishimura Y, Tamasaki A, Narita A, Imamura A, Maegaki Y. Effect of levetiracetam in acute encephalitis with refractory, repetitive partial seizures during acute and chronic phase. Brain Dev 2015; 37:471-7. [PMID: 25174548 DOI: 10.1016/j.braindev.2014.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/05/2014] [Accepted: 08/07/2014] [Indexed: 10/24/2022]
Abstract
AIM To clarify the effect of levetiracetam (LEV) for acute and chronic seizure control in acute encephalitis with refractory, repetitive partial seizures (AERRPS). METHODS We retrospectively reviewed the clinical course of six AERRPS cases treated with LEV, and explored the acute phase termination by withdrawal from barbiturate-induced coma under artificial ventilation, and the reduction in seizure frequency during the chronic phase. LEV was administrated orally or via nasogastric tubes as an add-on agent during acute (n=3; age 8-10 years) and chronic (n=3; age 19-30 years) AERRPS. RESULTS In the acute phase, administration of LEV (50-60 mg/kg/d) in combination with phenobarbital (n=3; peak 57.9-76.1 μg/ml) and potassium bromide (n=2; 30-36 mg/kg/d)) resulted in successful reduction of intravenous barbiturate dosage and withdrawal from artificial ventilation. In the chronic phase, seizure frequency reduced by >75% for 5-18 months with LEV 750-1500 mg/d. CONCLUSION LEV may affect seizure control in AERRPS, particularly during the chronic phase, through its unique action of inhibition of excitatory neurotransmitter release. The regimen of oral barbiturate, potassium bromide and LEV would be worth for trial during the acute phase of AERRPS.
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Affiliation(s)
- Riyo Ueda
- Division of Child Neurology, Institute of Neurological Sciences, Faculty of Medicine, Tottori Univesity, Yonago, Japan
| | - Yoshiaki Saito
- Division of Child Neurology, Institute of Neurological Sciences, Faculty of Medicine, Tottori Univesity, Yonago, Japan
| | - Koyo Ohno
- Division of Child Neurology, Institute of Neurological Sciences, Faculty of Medicine, Tottori Univesity, Yonago, Japan
| | - Kanako Maruta
- Department of Pediatrics, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Kunihiro Matsunami
- Department of Pediatrics, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Yusuke Saiki
- Division of Child Neurology, Institute of Neurological Sciences, Faculty of Medicine, Tottori Univesity, Yonago, Japan
| | - Tatsuyuki Sokota
- Division of Child Neurology, Institute of Neurological Sciences, Faculty of Medicine, Tottori Univesity, Yonago, Japan
| | - Susumu Sugihara
- Division of Child Neurology, Institute of Neurological Sciences, Faculty of Medicine, Tottori Univesity, Yonago, Japan
| | - Yoko Nishimura
- Division of Child Neurology, Institute of Neurological Sciences, Faculty of Medicine, Tottori Univesity, Yonago, Japan
| | - Akiko Tamasaki
- Division of Child Neurology, Institute of Neurological Sciences, Faculty of Medicine, Tottori Univesity, Yonago, Japan
| | - Aya Narita
- Division of Child Neurology, Institute of Neurological Sciences, Faculty of Medicine, Tottori Univesity, Yonago, Japan
| | - Atsushi Imamura
- Department of Pediatrics, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Yoshihiro Maegaki
- Division of Child Neurology, Institute of Neurological Sciences, Faculty of Medicine, Tottori Univesity, Yonago, Japan.
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Abstract
Status epilepticus (SE) describes persistent or recurring seizures without a return to baseline mental status and is a common neurologic emergency. SE can occur in the context of epilepsy or may be symptomatic of a wide range of underlying etiologies. The clinician's aim is to rapidly institute care that simultaneously stabilizes the patient medically, identifies and manages any precipitant conditions, and terminates seizures. Seizure management involves "emergent" treatment with benzodiazepines followed by "urgent" therapy with other antiseizure medications. If seizures persist, then refractory SE is diagnosed and management options include additional antiseizure medications or infusions of midazolam or pentobarbital. This article reviews the management of pediatric SE and refractory SE.
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Cheng L, Lei S, Chen SH, Hong Z, Yang TH, Li L, Chen F, Li HX, Zhou D, Li JM. Pretreatment with intravenous levetiracetam in the rhesus monkey Coriaria lactone-induced status epilepticus model. J Neurol Sci 2014; 348:111-20. [PMID: 25579413 DOI: 10.1016/j.jns.2014.11.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 11/08/2014] [Accepted: 11/11/2014] [Indexed: 02/05/2023]
Abstract
PURPOSE To investigate the antiepileptic and protective effects of intravenous levetiracetam (iv LEV) in the rhesus monkey model of acute status epilepticus (SE). METHODS Thirty minutes before intraperitoneal induction of SE by Coriaria lactone (CL), rhesus monkeys were treated with LEV (15 or 150 mg/kg) delivered intravenously as a single bolus. CL dose and epileptic behavior were recorded. Electroencephalography (EEG) was performed before and during the experiment. All rhesus monkeys were killed after 1-month video monitoring and processed for pathological investigation of neuronal injury, terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) staining, and glial fibrillary acidic protein (GFAP) staining. RESULTS No animal exhibited spontaneous seizures during 1-month video monitoring. Development of acute SE was significantly inhibited in the group given 150 mg/kg LEV, compared with controls and the 15 mg/kg LEV group. Delayed latency, reduction of SE duration, decreased cumulative time of tonic convulsions, slight severity of SE, and a high CL induction dose were observed in the high LEV dose group (p<0.05). The EEG showed less frequent epileptic discharges in the group administered with 150 mg/kg LEV. Hematoxylin and eosin (H&E) staining, ultrastructural examination, TUNEL and GFAP staining revealed serious damage, including neuron loss, swollen mitochondrion, and strong positivity for TUNEL in the hippocampus and thalamus of controls, whereas moderate damage in the group administered with 15 mg/kg LEV, and very mild damage in the 150 mg/kg LEV group. Gliosis was found in the hippocampus of controls, not in the LEV groups and normal rhesus monkey. CONCLUSION The study supports the antiepileptic and protective effect of pretreatment with intravenous LEV in rhesus monkey model with SE.
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Affiliation(s)
- Lan Cheng
- Department of Neurology, West China Hospital, Sichuan University, PR China
| | - Song Lei
- Department of Pathology, West China Hospital, Sichuan University, PR China
| | - Si-Han Chen
- Department of Neurology, West China Hospital, Sichuan University, PR China
| | - Zhen Hong
- Department of Neurology, West China Hospital, Sichuan University, PR China
| | - Tian-Hua Yang
- Department of Neurology, West China Hospital, Sichuan University, PR China
| | - Li Li
- Laboratory of Transplant, West China Hospital, Sichuan University, PR China
| | - Fei Chen
- Laboratory of Transplant, West China Hospital, Sichuan University, PR China
| | - Hong-Xia Li
- National Chengdu Center for Safety Evaluation of Traditional Chinese Medicine, West China Hospital, Sichuan University, PR China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, PR China.
| | - Jin-Mei Li
- Department of Neurology, West China Hospital, Sichuan University, PR China.
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İşgüder R, Güzel O, Ağın H, Yılmaz Ü, Akarcan SE, Celik T, Ünalp A. Efficacy and safety of IV levetiracetam in children with acute repetitive seizures. Pediatr Neurol 2014; 51:688-95. [PMID: 25172096 DOI: 10.1016/j.pediatrneurol.2014.07.021] [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] [Received: 05/02/2014] [Revised: 07/11/2014] [Accepted: 07/13/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Levetiracetam has been proven to be effective in both partial and generalized seizures in children. However, few studies have reported its efficacy in the treatment of acute repetitive seizures. We aimed to investigate the efficacy and safety of levetiracetam in children with acute repetitive seizures. METHODS The medical records of children from the age of 1 month-18 years who received levetiracetam because of acute repetitive seizures in the pediatric intensive care unit between 2010 and 2013 were reviewed retrospectively. RESULTS Of the 133 patients, levetiracetam terminated seizures in 104 (78.2%). Side effects such as agitation and aggression were observed in three patients (2.2%). The likelihood of treatment failure was increased by four times by younger age at seizure onset; by six times in the individuals with neurological abnormalities; and by 22 times in the patients with West syndrome. The patients who used levetiracetam as the first treatment option for acute repetitive seizures had a longer duration of epilepsy, a higher rate of neurological abnormality, and a higher proportion of medically resistant epilepsy compared with the individuals who used levetiracetam as an add-on treatment to the other intravenous antiepileptic drugs. However, no differences were detected between these two groups in terms of treatment response. CONCLUSIONS Intravenous levetiracetam appears to be effective and safe in the treatment of acute repetitive seizures. Randomized clinical trials are needed to determine whether intravenous levetiracetam may replace other antiepileptic drugs as the first-line therapy in the management of acute repetitive seizures.
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Affiliation(s)
- Rana İşgüder
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Children's Hospital, Izmir, Turkey.
| | - Orkide Güzel
- Department of Pediatric Neurology, Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Hasan Ağın
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Ünsal Yılmaz
- Department of Pediatric Neurology, Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Sanem Eren Akarcan
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Tanju Celik
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Aycan Ünalp
- Department of Pediatric Neurology, Dr. Behçet Uz Children's Hospital, Izmir, Turkey
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25
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Effectiveness of intravenous levetiracetam as an adjunctive treatment in pediatric refractory status epilepticus. Pediatr Emerg Care 2014; 30:525-8. [PMID: 25062293 DOI: 10.1097/pec.0000000000000183] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Intravenous levetiracetam (LEV) has been shown to be effective and safe in treating adults with refractory status epilepticus (SE). We sought to investigate the efficacy and safety of intravenous LEV for pediatric patients with refractory SE. METHODS We performed a retrospective medical-record review of pediatric patients who were treated with intravenous LEV for refractory SE. Clinical information regarding age, sex, seizure type, and underlying neurological status was collected. We evaluated other anticonvulsants that were used prior to administration of intravenous LEV and assessed loading dose, response to treatment, and any adverse events from intravenous LEV administration. RESULTS Fourteen patients (8 boys and 6 girls) received intravenous LEV for the treatment of refractory SE. The mean age of the patients was 4.4 ± 5.5 years (range, 4 days to 14.6 years). Ten of the patients were neurologically healthy prior to the refractory SE, and the other 4 had been previously diagnosed with epilepsy. The mean loading dose of intravenous LEV was 26 ± 4.6 mg/kg (range, 20-30 mg/kg). Seizure termination occurred in 6 (43%) of the 14 patients. In particular, 4 (57%) of the 7 patients younger than 2 years showed seizure termination. No immediate adverse events occurred during or after infusions. CONCLUSIONS The current study demonstrated that the adjunctive use of intravenous LEV was effective and well tolerated in pediatric patients with refractory SE, even in patients younger than 2 years. Intravenous LEV should be considered as an effective and safe treatment option for refractory SE in pediatric patients.
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Özkale Y, Özkale M, Saygi S, Erol I. Long-term accidental overdose of levetiracetam in an infant. J Child Neurol 2014; 29:959-61. [PMID: 23520362 DOI: 10.1177/0883073813480560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 02/01/2013] [Indexed: 11/16/2022]
Abstract
Levetiracetam is one of the new anticonvulsant drugs that has a high therapeutic index and potential antiepileptogenic effects. Herein, we report a patient with multidrug refractory epilepsy and Ohtahara syndrome who was accidentally administered 300 mg/kg/d for 35 days by her mother. To our knowledge, there are only a few cases of accidental overdose of levetiracetam in pediatric patients reported in the literature, and this case study is the first to report such a high and long-term dose in an infant who showed no adverse effects.
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Affiliation(s)
- Yasemin Özkale
- Department of Pediatrics, Baskent University Faculty of Medicine, Adana, Turkey
| | - Murat Özkale
- Department of Pediatrics, Baskent University Faculty of Medicine, Adana, Turkey
| | - Semra Saygi
- Division of Child Neurology, Baskent University Faculty of Medicine, Adana, Turkey
| | - Ilknur Erol
- Division of Child Neurology, Baskent University Faculty of Medicine, Adana, Turkey
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Wright C, Downing J, Mungall D, Khan O, Williams A, Fonkem E, Garrett D, Aceves J, Kirmani B. Clinical pharmacology and pharmacokinetics of levetiracetam. Front Neurol 2013; 4:192. [PMID: 24363651 PMCID: PMC3850169 DOI: 10.3389/fneur.2013.00192] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 11/11/2013] [Indexed: 11/26/2022] Open
Abstract
Status epilepticus and acute repetitive seizures still pose a management challenge despite the recent advances in the field of epilepsy. Parenteral formulations of old anticonvulsants are still a cornerstone in acute seizure management and are approved by the FDA. Intravenous levetiracetam (IV LEV), a second generation anticonvulsant, is approved by the FDA as an adjunctive treatment in patients 16 years or older when oral administration is not available. Data have shown that it has a unique mechanism of action, linear pharmacokinetics and no known drug interactions with other anticonvulsants. In this paper, we will review the current literature about the pharmacology and pharmacokinetics of IV LEV and the safety profile of this new anticonvulsant in acute seizure management of both adults and children.
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Affiliation(s)
- Chanin Wright
- Division of Pharmacy, Department of Pediatrics, Scott & White Hospital and Texas A&M Health Science Center College of Medicine , Temple, TX , USA
| | - Jana Downing
- Division of Pharmacy, Department of Pediatrics, Scott & White Hospital and Texas A&M Health Science Center College of Medicine , Temple, TX , USA
| | - Diana Mungall
- Texas A&M Health Science Center College of Medicine , Temple, TX , USA
| | - Owais Khan
- Division of Neonatology, Department of Pediatrics, University of Chicago Medical Center , Chicago, IL , USA
| | - Amanda Williams
- Division of Pharmacy, Department of Pediatrics, Scott & White Hospital and Texas A&M Health Science Center College of Medicine , Temple, TX , USA
| | - Ekokobe Fonkem
- Department of Neurology, Scott & White Neuroscience Institute and Texas A&M Health Science Center College of Medicine , Temple, TX , USA
| | | | - Jose Aceves
- Division of Pediatric Neurology, Department of Pediatrics, Scott & White Hospital and Texas A&M Health Science Center College of Medicine , Temple, TX , USA
| | - Batool Kirmani
- Epilepsy Center, Department of Neurology, Scott & White Neuroscience Institute and Texas A&M Health Science Center College of Medicine , Temple, TX , USA
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28
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Role of intravenous levetiracetam for acute seizure management in preterm neonates. Pediatr Neurol 2013; 49:340-3. [PMID: 23921284 DOI: 10.1016/j.pediatrneurol.2013.05.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 05/13/2013] [Accepted: 05/24/2013] [Indexed: 01/02/2023]
Abstract
BACKGROUND Neonatal seizures are common in the first month of life and may impair neurodevelopmental outcome. Current antiepileptic drugs used in the treatment of neonatal seizures have limited efficacy and undesirable side effects. Intravenous levetiracetam is increasingly being used in the neonatal period to treat seizures. Presently, insufficient data about the efficacy and safety of intravenous levetiracetam in preterm neonates exist. METHODS We retrospectively analyzed data from preterm neonates who were treated with intravenous levetiracetam at our institution between January 2007 and December 2011. Data were acquired from review of our institution's electronic medical record regarding patients who were treated with intravenous levetiracetam during the neonatal period (0 to 28 days) and were born at preterm gestation (<37 weeks). RESULTS Twelve patients received a levetiracetam load of 25 to 50 mg/kg for neonatal seizures. Nine of 11 patients (82%) reached seizure cessation within 24 hours of receiving levetiracetam. No serious side effects were evident. Seven patients (59%) were discharged on oral levetiracetam alone, four patients (33%) were discharged on no oral antiepileptic drug, and one patient (8%) was discharged on levetiracetam and phenobarbital. Eleven of 12 patients were followed up to 6 months after receiving intravenous levetiracetam. Of these, six patients (55%) had achieved seizure freedom and been completely weaned off of all antiepileptic drugs. Three patients (27%) had achieved seizure freedom while still on oral levetiracetam. CONCLUSIONS Intravenous levetiracetam appears to be efficacious for seizure management in preterm neonates.
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29
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Weinstock A, Ruiz M, Gerard D, Toublanc N, Stockis A, Farooq O, Dilley D, Karmon Y, Elgie MJ, Schiemann-Delgado J. Prospective Open-Label, Single-Arm, Multicenter, Safety, Tolerability, and Pharmacokinetic Studies of Intravenous Levetiracetam in Children With Epilepsy. J Child Neurol 2013; 28:1423-1429. [PMID: 23533164 DOI: 10.1177/0883073813480241] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Levetiracetam given via intravenous administration has been shown to be an effective alternative in adults with epilepsy when oral administration is not feasible. This study was a prospective single-arm, multicenter study to assess tolerability, safety, and pharmacokinetics of intravenous levetiracetam in children with epilepsy. Children with epilepsy ages 1 month to 16 years requiring intravenous levetiracetam were enrolled. Assessments included vital signs, electrocardiogram, hematology, chemistry, plasma concentrations of antiepileptic medications, weight, physical/neurological examinations, and pharmacokinetics. A total of 52 patients were enrolled. Mild to moderate treatment-emergent adverse events occurred in 63%, the most frequent being pyrexia and dry mouth. Most other treatment-emergent adverse events were considered unrelated to intravenous levetiracetam administration. Therefore, intravenous levetiracetam in the acute setting was overall well tolerated in children 1 month to 16 years.
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Affiliation(s)
- Arie Weinstock
- 1State University of New York at Buffalo, Buffalo, NY, USA
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30
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Capovilla G, Beccaria F, Beghi E, Minicucci F, Sartori S, Vecchi M. Treatment of convulsive status epilepticus in childhood: Recommendations of the Italian League Against Epilepsy. Epilepsia 2013; 54 Suppl 7:23-34. [DOI: 10.1111/epi.12307] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Giuseppe Capovilla
- Child Neuropsychiatry Department; Epilepsy Center; C. Poma Hospital; Mantua Italy
| | - Francesca Beccaria
- Child Neuropsychiatry Department; Epilepsy Center; C. Poma Hospital; Mantua Italy
| | - Ettore Beghi
- Department of Neuroscience; IRCCS-Institute of Pharmacological Research “Mario Negri”; Milan Italy
| | - Fabio Minicucci
- Clinical Neurophysiology; San Raffaele Hospital; Milan Italy
| | - Stefano Sartori
- Pediatric Neurology and Clinical Neurophysiology Unit; Department of Pediatrics; University of Padova; Padova Italy
| | - Marilena Vecchi
- Pediatric Neurology and Clinical Neurophysiology Unit; Department of Pediatrics; University of Padova; Padova Italy
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31
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Mendoza-Torreblanca JG, Vanoye-Carlo A, Phillips-Farfán BV, Carmona-Aparicio L, Gómez-Lira G. Synaptic vesicle protein 2A: basic facts and role in synaptic function. Eur J Neurosci 2013; 38:3529-39. [DOI: 10.1111/ejn.12360] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Revised: 08/09/2013] [Accepted: 08/17/2013] [Indexed: 10/26/2022]
Affiliation(s)
| | | | | | | | - Gisela Gómez-Lira
- Department of Pharmacobiology; Centro de Investigación y Estudios Avanzados del Instituto Politécnico Nacional; Calzada de los Tenorios 235 Col. Granjas Coapa C.P. 14330 D. F., Mexico
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32
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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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Aceves J, Khan O, Mungall D, Fonkem E, Wright C, Wenner A, Kirmani B. Efficacy and tolerability of intravenous levetiracetam in childrens. Front Neurol 2013; 4:120. [PMID: 23966977 PMCID: PMC3743038 DOI: 10.3389/fneur.2013.00120] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 08/02/2013] [Indexed: 11/13/2022] Open
Abstract
Intractable epilepsy in children poses a serious medical challenge. Acute repetitive seizures and status epilepticus leads to frequent emergency room visits and hospital admissions. Delay of treatment may lead to resistance to the first-line anticonvulsant therapies. It has been shown that these children continue to remain intractable even after acute seizure management with approved Food and Drug Administration (FDA) agents. Intravenous levetiracetam, a second-generation anticonvulsant was approved by the FDA in 2006 in patients 16 years and older as an alternative when oral treatment is not an option. Data have been published showing that intravenous levetiracetam is safe and efficacious, and can be used in an acute inpatient setting. This current review will discuss the recent data about the safety and tolerability of intravenous levetiracetam in children and neonates, and emphasize the need for a larger prospective multicenter trial to prove the efficacy of this agent in acute seizure management.
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Affiliation(s)
- Jose Aceves
- Department of Pediatrics, Division of Pediatric Neurology, Texas A&M Health Science Center College of Medicine, Scott & White Hospital , Temple, TX , USA
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34
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Cormier J, Chu CJ. Safety and efficacy of levetiracetam for the treatment of partial onset seizures in children from one month of age. Neuropsychiatr Dis Treat 2013; 9:295-306. [PMID: 23458993 PMCID: PMC3582481 DOI: 10.2147/ndt.s30224] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Epilepsy is a common neurological disorder in the pediatric population, affecting up to one percent of children, and for which the mainstay of treatment is anticonvulsant medication. Despite the frequent use of anticonvulsant drugs, remarkably little is known about the safety and efficacy of most of these medications in the pediatric epilepsy population. Of 34 anticonvulsants currently approved for use by the US Food and Drug Administration (FDA), only 13 have been approved for use in children. Although infants and young children are disproportionately affected by epilepsy, there are currently only three anticonvulsant medications that have been specifically evaluated and approved for use in children younger than 2 years of age. In 2012, the FDA approved levetiracetam as an adjunctive treatment for partial onset seizures in infants and children from one month of age. Here we review the available data on levetiracetam in the pediatric epilepsy population. We first discuss the pharmacological profile of levetiracetam, including its mechanism of action, formulations and dosing, and pharmacokinetics in children. We then review the available efficacy, safety, and tolerability data in children from one month of age with partial onset seizures. We conclude that the current data leading to the approval of levetiracetam for use in infants and children with partial onset seizures is encouraging, although more work needs to be done before definitive conclusions can be drawn about the efficacy of levetiracetam across different pediatric age groups.
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Affiliation(s)
- Justine Cormier
- Massachusetts General Hospital, Department of Neurology, Programs in Child Neurology and Neurophysiology, Boston, MA, USA
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35
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Intravenous levetiracetam in acute repetitive seizures and status epilepticus in children: Experience from a children's hospital. Seizure 2012; 21:529-34. [DOI: 10.1016/j.seizure.2012.05.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 05/16/2012] [Accepted: 05/18/2012] [Indexed: 11/22/2022] Open
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Fuller KL, Wang YY, Cook MJ, Murphy MA, D'Souza WJ. Tolerability, safety, and side effects of levetiracetam versus phenytoin in intravenous and total prophylactic regimen among craniotomy patients: a prospective randomized study. Epilepsia 2012; 54:45-57. [PMID: 22738092 DOI: 10.1111/j.1528-1167.2012.03563.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE Practical choice in parenteral antiepileptic drugs (AEDs) remains limited despite formulation of newer intravenous agents and requirements of special patient groups. This study aims to compare the tolerability, safety, and side effect profiles of levetiracetam (LEV) against the standard agent phenytoin (PHT) when given intravenously and in total regimen for seizure prophylaxis in a neurosurgical setting. METHODS This prospective, randomized, single-center study with appropriate blinding comprised evaluation pertaining to intravenous use 3 days following craniotomy and at discharge, and to total intravenous-plus-oral AED regimen at 90 days. Primary tolerability end points were discontinuation because of side effect and first side effect. Safety combined end point was major side effect or seizure. Seizure occurrence and side effect profiles were compared as secondary outcomes. KEY FINDINGS Of 81 patients randomized, 74 (36 LEV, 38 PHT) received parenteral AEDs. No significant difference attributable to intravenous use was found between LEV and PHT in discontinuation because of side effect (LEV 1/36, PHT 2/38, p = 1.00) or number of patients with side effect (LEV 1/36, PHT 4/38, p = 0.36). No significant difference was found between LEV and PHT total intravenous-plus-oral regimen in discontinuation because of side effect (hazard ratio [HR] 0.78, 95% confidence interval [CI] 0.21-2.92, p = 0.72) or number of patients with side effect (HR 1.51, 95% CI 0.77-2.98, p = 0.22). More patients assigned PHT reached the undesirable clinical end point for safety of major side effect or seizure (HR 0.09, 95% CI 0.01-0.70, p = 0.002). Seizures occurred only in patients assigned PHT (n = 6, p = 0.01). Although not significant, trends were observed for major side effect in more patients assigned PHT (p = 0.08) and mild side effect in more assigned LEV (p = 0.09). SIGNIFICANCE Both LEV and PHT are well-tolerated perioperatively in parenteral preparation, and in total intravenous-plus-oral prophylactic regimen. Comparative safety and differing side effect profile of intravenous LEV supports use as an alternative to intravenous PHT.
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Affiliation(s)
- Karen L Fuller
- Centre for Clinical Neurosciences and Neurological Research, St Vincent's Hospital, Melbourne, Victoria, Australia.
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Jain V, Harvey AS. Treatment of refractory tonic status epilepticus with intravenous lacosamide. Epilepsia 2012; 53:761-2. [DOI: 10.1111/j.1528-1167.2012.03419.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Current standard treatment of established status epilepticus after failure of benzodiazepines is intravenous phenytoin/fosphenytoin, phenobarbital, or valproate. Since 2006 two new antiseizure drugs have become available as intravenous formulation: levetiracetam (2006) and lacosamide (2008). Both drugs have been taken up very rapidly by the clinicians to treat acute seizures and status epilepticus, despite lack of evidence from randomized controlled trials. The favorable pharmacokinetic profile and the good tolerability, especially the lack of sedating effects of both drugs make them promising potential alternatives to the standard antiseizure drugs. Future randomized controlled trials are needed to inform clinicians better about the best choice of treatment in established status epilepticus. The experimental evidence as well as the current clinical experience with levetiracetam and lacosamide are summarized in this review.
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Affiliation(s)
- Eugen Trinka
- Department of Neurology, Paracelsus Medical University, Ignaz Harrer Strasse 79, Salzburg, Austria.
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Abstract
OPINION STATEMENT Antiepileptic drugs (AEDs) are the mainstay of treatment for recurrent seizures. Uncontrolled seizures may cause medical, developmental, and psychological disturbances. The medical practitioner should thus strive to eliminate or minimize seizures. Treatment advances in epilepsy include 1) identification of the basic mechanisms of epilepsy and action of AEDs, 2) the introduction of new AEDs, and 3) the use of neurostimulation, including vagus nerve stimulation. Treatment with AEDs involves balancing each AED's efficacy against its side effects. In some patients, effective AEDs must be discontinued because of intolerable side effects. Although all AEDs have a proven efficacy, the choice of AEDs should be based on better efficacy for individual seizure types or epilepsy syndromes. Side effects also differ from drug to drug and must be taken into account. This article focuses on studies and expert opinion consensus to guide the choice of AEDs.
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Höfler J, Unterberger I, Dobesberger J, Kuchukhidze G, Walser G, Trinka E. Intravenous lacosamide in status epilepticus and seizure clusters. Epilepsia 2011; 52:e148-52. [PMID: 21801171 DOI: 10.1111/j.1528-1167.2011.03204.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Status epilepticus (SE) and seizure clusters (SC) represent neurologic emergencies with a case fatality rate up to 34%, depending on cause and comorbidity. As SE becomes more refractory to treatment over time, appropriate medication is important. This study aimed to investigate efficacy and tolerability of intravenous (IV) lacosamide (LCM) in treatment of SC and SE. Data of patients with SE or SC who were treated with IV LCM between December 2009 and February 2011 in two Austrian centers were analyzed retrospectively. Clinical information was extracted from patients' charts. Forty-eight patients (26f/22m) aged median 62 years (range 17-95 years) were identified. Thirty-five percent of patients (17 of 48) had SC and 65% (31 of 48) had SE. SE was nonconvulsive in 10 (32%), convulsive in 11 (36%), and focal in 10 (32%) patients. SE was acute symptomatic in six (20%) and remote symptomatic in 11 (35%) patients. Fourteen (45%) had preexisting epilepsy. Median initial bolus dose was 200 mg (range 200-400 mg) in patients with SE and 200 mg in patients with SC. Maximum infusion rate was 60 mg/min. Cessation was observed in 42 patients (88%). Success rate in patients with SE receiving LCM as first or second drug was 100% (8 of 8), as third drug 81% (11 of 15), and as fourth or later drug 75% (6 of 8). There were no side effects observed except for pruritus and skin rash in two patients. These data support use of IV LCM as a potential alternative to standard antiepileptic drugs for acute treatment of seizure emergency situations, although randomized controlled studies are needed.
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Affiliation(s)
- Julia Höfler
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Salzburg, Austria
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Use of intravenous levetiracetam for management of acute seizures in neonates. Pediatr Neurol 2011; 44:265-9. [PMID: 21397167 DOI: 10.1016/j.pediatrneurol.2010.11.005] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 10/11/2010] [Accepted: 11/10/2010] [Indexed: 01/02/2023]
Abstract
Antiepileptic drugs used for the treatment of neonatal seizures have limited efficacy and undesirable side effects, leading to increased off-label use in neonates. Intravenous levetiracetam became available in August 2006 for use in patients above 16 years of age. Insufficient data are available about the efficacy and safety of intravenous levetiracetam in neonates. Data captured from our institution's electronic medical records were retrospectively analyzed for neonates treated with intravenous levetiracetam between January 2007 and December 2009. Data were acquired by reviewing our electronic medical records. Twenty-two patients received a levetiracetam load of 10-50 mg/kg for neonatal seizures. Nineteen of 22 patients (86%) demonstrated immediate seizure cessation at 1 hour. Seven of 22 patients (32%) achieved complete seizure cessation after administration of the loading dose, 14 (64%) achieved seizure cessation by 24 hours, 19 (86%) by 48 hours, and all 22 (100%) by 72 hours. No serious side effects were evident. Nineteen patients (86%) were discharged on oral levetiracetam, and only two patients (9%) were discharged with an additional oral antiepileptic drug. Intravenous levetiracetam can be used as monotherapy and adjunctively in acute seizure management during the neonatal period.
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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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Visudtibhan A, Bhudhisawadi K, Vaewpanich J, Chulavatnatol S, Kaojareon S. Pharmacokinetics and clinical application of intravenous valproate in Thai epileptic children. Brain Dev 2011; 33:189-94. [PMID: 20444563 DOI: 10.1016/j.braindev.2010.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2010] [Revised: 04/09/2010] [Accepted: 04/09/2010] [Indexed: 11/27/2022]
Abstract
Roles of intravenous administration of valproate in status epilepticus and serial seizures are documented in adults and children. Pharmacokinetic parameters are necessary to predict the optimum therapeutic level after administration. A cross-sectional study to determine the pharmacokinetic parameters and safety of intravenous valproate for future application was conducted in Thai children from January to December 2008. There were eleven children, age-range 1-15 years (mean age 9.5 years) enrolled. Valproate of 15-20 mg/kg was administrated intravenously at the rate of 3 mg/kg/min, followed by 6 mg/kg every 6 h. Valproate level was determined prior to the initial dose and at ½, 1, 2, 4, 5, and 6 h postdose. Complete blood count, serum ammonia, and liver function tests were collected prior to the initial dose and at 6 h. Median loading dose was 19 mg/kg (range 15-20.5 mg/kg). Median maximum concentration at 30 min after infusion was 98.8 mcg/mL (range 67-161 mcg/mL). Median volume of distribution was 0.20 L/kg (range 0.15-0.53 L/kg). Median half-life was 9.5 h (range 4.4-24.2 h). Median clearance was 0.02 L/h/kg (range 0.01-0.05 L/h/kg). Six hours after initial dose, eight children did not have recurrent seizure. One child had brief seizure at 20 min after initial dose. Seizure recurred in two children at 4th and 5th hour. Asymptomatic transient elevation of serum ammonia was observed in two children. Volume of distribution of 0.20 L/kg could be applied for initial intravenous administration with a favorable efficacy.
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Affiliation(s)
- Anannit Visudtibhan
- Division of Neurology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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Ramantani G, Ikonomidou C, Walter B, Rating D, Dinger J. Levetiracetam: safety and efficacy in neonatal seizures. Eur J Paediatr Neurol 2011; 15:1-7. [PMID: 21094062 DOI: 10.1016/j.ejpn.2010.10.003] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Revised: 09/10/2010] [Accepted: 10/26/2010] [Indexed: 01/02/2023]
Abstract
PURPOSE Neonatal seizures are common, especially in prematurity. Phenobarbital (PB) currently represents the antiepileptic drug (AED) of choice, despite being related to increased neuronal apoptosis in animal models and cognitive impairment in human subjects. Levetiracetam (LEV) may have a more favorable profile since it does not cause neuronal apoptosis in infant rodents. METHODS In a prospective feasibility study, LEV was applied as first-line treatment in 38 newborns with EEG-confirmed seizures, after ruling out hypoglycemia, hypocalcaemia, hypomagnesaemia and pyridoxin dependency. Initial intravenous doses of 10 mg/kg LEV were gradually increased to 30 mg/kg over 3 days with a further titration to 45-60 mg/kg at the end of the week. Acute intervention with up to 2 intravenous doses of PB 20 mg/kg was tolerated during LEV titration. LEV was switched to oral as soon as the infants' condition allowed. Based on clinical observation, EEG tracings (aEEG/routine EEGs), and lab data, drug safety and anticonvulsant efficacy were assessed over 12 months. RESULTS In 19 newborns a single PB dose of 20 mg/kg was administered, while 3 newborns received 2 PB doses. 30 infants were seizure free under LEV at the end of the first week and 27 remained seizure free at four weeks, while EEGs markedly improved in 24 patients at 4 weeks. In 19 cases, LEV was discontinued after 2-4 weeks, while 7 infants received LEV up to 3 months. No severe adverse effects were observed. CONCLUSIONS These results illustrate the safety of LEV treatment in neonatal seizures, including prematurity and suggest LEV anticonvulsant efficacy. Additional PB treatment admittedly constitutes a methodological shortcoming due to the prolonged anticonvulsive efficacy of PB. Double blind prospective controlled studies and long-term evaluation of cognitive outcome are called for.
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Affiliation(s)
- Georgia Ramantani
- Department of Pediatric Neurology, University Children's Hospital Dresden, Fetscherstrasse 74, 01307 Dresden, Germany.
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Abend NS, Gutierrez-Colina AM, Dlugos DJ. Medical treatment of pediatric status epilepticus. Semin Pediatr Neurol 2010; 17:169-75. [PMID: 20727486 DOI: 10.1016/j.spen.2010.06.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Status epilepticus (SE) is a common pediatric neurologic emergency that refers to a prolonged seizure or recurrent seizures without a return to baseline mental status between seizures. Appropriate treatment strategies are necessary to prevent prolonged SE and its associated morbidity and mortality. This review discusses the importance of a rapid and organized management approach, reviews data related to commonly utilized medications including benzodiazepines, phenytoin, phenobarbital, valproate sodium, and levetiracetam, and then provides a sample SE management algorithm.
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Affiliation(s)
- Nicholas S Abend
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Reiter PD, Huff AD, Knupp KG, Valuck RJ. Intravenous levetiracetam in the management of acute seizures in children. Pediatr Neurol 2010; 43:117-21. [PMID: 20610122 DOI: 10.1016/j.pediatrneurol.2010.03.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Revised: 11/12/2009] [Accepted: 03/31/2010] [Indexed: 11/19/2022]
Abstract
Levetiracetam may be effective in children with acute seizures or status epilepticus. We performed a retrospective chart review of children who received intravenous levetiracetam within 30 minutes of a seizure. Seventy-three patients during a 2-year study period met our inclusion criteria. The mean (+/- S.D.) age and weight of the patients were 5.59 +/- 5.6 years (range, 1 day to 17.8 years) and 23.1 +/- 21 kg (range, 1.97-97 kg), respectively. Patients received a mean (+/- S.D.) levetiracetam dose of 29.4 +/- 13.5 mg/kg. Most children (n = 49, or 67%) received additional antiepileptic drugs to abort their seizure. Overall, the mean (+/- S.D.) total (abortive plus chronic) number of concomitant antiepileptic drugs used by the population was 2.53 +/- 1.7 (1.07 +/- 0.98 as additional abortive therapy, and 1.42 +/- 1.29 as chronic therapy). Most patients received levetiracetam for serial seizures (79%), whereas 12% and 8% manifested a single seizure or status epilepticus, respectively. Clinical effectiveness at 1, 12, 24, 48, and 72 hours after the initial levetiracetam dose constituted the primary study outcome. Eighty-nine percent of patients remained seizure-free at 1 hour. This rate decreased at each evaluation time point. Most patients (71%) were placed on maintenance levetiracetam within 24 hours of their loading dose. The predictive ability of patient and drug regimen variables in outcomes was poor. Only the number of concomitant antiepileptic drugs consistently predicted outcomes. Levetiracetam was well tolerated at the doses studied, and appears most effective in single seizure events.
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Affiliation(s)
- Pamela D Reiter
- Department of Pharmacy, Center for Pediatric Medicine, Children's Hospital, Aurora, Colorado 80045, USA.
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Ng YT, Hastriter EV, Cardenas JF, Khoury EM, Chapman KE. Intravenous levetiracetam in children with seizures: a prospective safety study. J Child Neurol 2010; 25:551-5. [PMID: 20413804 DOI: 10.1177/0883073809348795] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In 2006, intravenous levetiracetam received US Food and Drug Administration (FDA) approval for adjunctive treatment of partial onset seizures in adults with epilepsy, 16 years or older. We have established the safety, tolerability, and dosage of intravenous levetiracetam in children. This prospective study included 30 children (6 months to <15 years of age). Patients were administered a single dose of intravenous levetiracetam (50 mg/kg, maximal dose 2500 mg) over 15 minutes. A blood level of levetiracetam was performed 10 minutes after the infusion. The treated children's average age was 6.3 years (range 0.5-14.8 years). The mean levetiracetam level was 83.3 microg/mL (range 47-128 microg/mL). There were no serious adverse reactions. Minor reactions included sleepiness, fatigue, and restlessness. An apparent decrease in seizure frequency across all seizure types was noted. The dose of 50 mg/kg was well tolerated by the patients and is a safe, appropriate loading dose.
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Affiliation(s)
- Yu-tze Ng
- Department of Pediatric Neurology, Barrow Neurological Institute, Phoenix, Arizona 85013, USA.
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Abstract
Children with Angelman syndrome have an increased risk of developing a nonconvulsive status epilepticus. Although the urgency to treat nonconvulsive status epilepticus depends on the underlying illness, most clinicians and authors agree that treatment should be focused to rapidly terminate this condition. Until now, the use of levetiracetam to treat nonconvulsive status epilepticus in children is based only on some case reports. Our case further supports this treatment regime for a subgroup of children with a special risk of nonconvulsive status epilepticus and developmental delay.
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Affiliation(s)
- Peter Weber
- Division of Neuropediatrics and Developmental Medicine, University Children's Hospital Basel, Basel, Switzerland.
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Depositario-Cabacar DT, Peters JM, Pong AW, Roth J, Rotenberg A, Riviello JJ, Takeoka M. High-dose intravenous levetiracetam for acute seizure exacerbation in children with intractable epilepsy. Epilepsia 2010; 51:1319-22. [DOI: 10.1111/j.1528-1167.2010.02519.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fürwentsches A, Bussmann C, Ramantani G, Ebinger F, Philippi H, Pöschl J, Schubert S, Rating D, Bast T. Levetiracetam in the treatment of neonatal seizures: a pilot study. Seizure 2010; 19:185-9. [PMID: 20133173 DOI: 10.1016/j.seizure.2010.01.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Revised: 01/05/2010] [Accepted: 01/07/2010] [Indexed: 01/02/2023] Open
Abstract
PURPOSE At present, neonatal seizures are usually treated with Phenobarbital (PB) despite the limited efficacy and the potential risk this treatment holds for the developing brain. We report here a prospective pilot feasibility study on the use of Levetiracetam as monotherapy in the treatment of neonatal seizures. METHODS Six newborns (body weight>2000 g, gestational age>30 weeks) presenting with neonatal seizures were enrolled. Patients whose seizures were caused by electrolyte disturbances or hypoglycemia, or whose seizures did respond to pyridoxine were excluded. Patients previously treated with other antiepileptic drugs (AEDs), with the exception of single PB doses before and during titration, were excluded. LEV was administered orally, increasing the dose by 10mg/(kg day) over 3 days. Endpoint was the need of any additional AEDs (or PB) after day 3, or 3 months of LEV treatment. A decision regarding further treatment was made on an individual basis and follow-up was documented up to 8 months of age. RESULTS No severe adverse effects were observed. Mild sedation was reported in one infant. All six patients treated with oral LEV became seizure free within 6 days. Five patients remained seizure free after 3 months with ongoing LEV monotherapy. One infant developed pharmacoresistant epilepsy. Seizures relapsed later in the clinical course of two more patients, one of whom was no longer under LEV therapy. DISCUSSION Results from our small patient group indicate that LEV may be an alternative therapeutic option in neonatal seizures.
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