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Rectal use of levetiracetam: best practice report for a stepwise approach for sustainable off-label decision making and treatment. Int J Clin Pharm 2023:10.1007/s11096-023-01539-3. [PMID: 36753020 DOI: 10.1007/s11096-023-01539-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/09/2023] [Indexed: 02/09/2023]
Abstract
Off-label drug use is common practice in palliative care. It may pose a risk to the patient and benefit should outweigh harm. A decision and documentation aid for off-label use was developed to support practitioners in clinical practice off-label use. Using the example of the rectal administration of levetiracetam in three patient cases, the utilisation and benefits of the decision and documentation aid are presented and discussed. The rectal administration of levetiracetam clearly is an experimental treatment approach with little underlying evidence. To support and document the decision-making process for or against such an off-label use in clinical practice, it is helpful to have a structured approach in order to make this data comprehensible for a later point in time. Off-label use may be a permissible treatment alternative without underlying evidence, provided it takes place in a well-planned and well-monitored therapeutic setting and the benefits outweigh the potential risks.
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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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Vossler DG, Bainbridge JL, Boggs JG, Novotny EJ, Loddenkemper T, Faught E, Amengual-Gual M, Fischer SN, Gloss DS, Olson DM, Towne AR, Naritoku D, Welty TE. Treatment of Refractory Convulsive Status Epilepticus: A Comprehensive Review by the American Epilepsy Society Treatments Committee. Epilepsy Curr 2020; 20:245-264. [PMID: 32822230 PMCID: PMC7576920 DOI: 10.1177/1535759720928269] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose: Established tonic–clonic status epilepticus (SE) does not stop in one-third
of patients when treated with an intravenous (IV) benzodiazepine bolus
followed by a loading dose of a second antiseizure medication (ASM). These
patients have refractory status epilepticus (RSE) and a high risk of
morbidity and death. For patients with convulsive refractory status
epilepticus (CRSE), we sought to determine the strength of evidence for 8
parenteral ASMs used as third-line treatment in stopping clinical CRSE. Methods: A structured literature search (MEDLINE, Embase, CENTRAL, CINAHL) was
performed to identify original studies on the treatment of CRSE in children
and adults using IV brivaracetam, ketamine, lacosamide, levetiracetam (LEV),
midazolam (MDZ), pentobarbital (PTB; and thiopental), propofol (PRO), and
valproic acid (VPA). Adrenocorticotropic hormone (ACTH), corticosteroids,
intravenous immunoglobulin (IVIg), magnesium sulfate, and pyridoxine were
added to determine the effectiveness in treating hard-to-control seizures in
special circumstances. Studies were evaluated by predefined criteria and
were classified by strength of evidence in stopping clinical CRSE (either as
the last ASM added or compared to another ASM) according to the 2017
American Academy of Neurology process. Results: No studies exist on the use of ACTH, corticosteroids, or IVIg for the
treatment of CRSE. Small series and case reports exist on the use of these
agents in the treatment of RSE of suspected immune etiology, severe
epileptic encephalopathies, and rare epilepsy syndromes. For adults with
CRSE, insufficient evidence exists on the effectiveness of brivaracetam
(level U; 4 class IV studies). For children and adults with CRSE,
insufficient evidence exists on the effectiveness of ketamine (level U; 25
class IV studies). For children and adults with CRSE, it is possible that
lacosamide is effective at stopping RSE (level C; 2 class III, 14 class IV
studies). For children with CRSE, insufficient evidence exists that LEV and
VPA are equally effective (level U, 1 class III study). For adults with
CRSE, insufficient evidence exists to support the effectiveness of LEV
(level U; 2 class IV studies). Magnesium sulfate may be effective in the
treatment of eclampsia, but there are only case reports of its use for CRSE.
For children with CRSE, insufficient evidence exists to support either that
MDZ and diazepam infusions are equally effective (level U; 1 class III
study) or that MDZ infusion and PTB are equally effective (level U; 1 class
III study). For adults with CRSE, insufficient evidence exists to support
either that MDZ infusion and PRO are equally effective (level U; 1 class III
study) or that low-dose and high-dose MDZ infusions are equally effective
(level U; 1 class III study). For children and adults with CRSE,
insufficient evidence exists to support that MDZ is effective as the last
drug added (level U; 29 class IV studies). For adults with CRSE,
insufficient evidence exists to support that PTB and PRO are equally
effective (level U; 1 class III study). For adults and children with CRSE,
insufficient evidence exists to support that PTB is effective as the last
ASM added (level U; 42 class IV studies). For CRSE, insufficient evidence
exists to support that PRO is effective as the last ASM used (level U; 26
class IV studies). No pediatric-only studies exist on the use of PRO for
CRSE, and many guidelines do not recommend its use in children aged <16
years. Pyridoxine-dependent and pyridoxine-responsive epilepsies should be
considered in children presenting between birth and age 3 years with
refractory seizures and no imaging lesion or other acquired cause of
seizures. For children with CRSE, insufficient evidence exists that VPA and
diazepam infusion are equally effective (level U, 1 class III study). No
class I to III studies have been reported in adults treated with VPA for
CRSE. In comparison, for children and adults with established convulsive SE
(ie, not RSE), after an initial benzodiazepine, it is likely that loading
doses of LEV 60 mg/kg, VPA 40 mg/kg, and fosphenytoin 20 mg PE/kg are
equally effective at stopping SE (level B, 1 class I study). Conclusions: Mostly insufficient evidence exists on the efficacy of stopping clinical CRSE
using brivaracetam, lacosamide, LEV, valproate, ketamine, MDZ, PTB, and PRO
either as the last ASM or compared to others of these drugs.
Adrenocorticotropic hormone, IVIg, corticosteroids, magnesium sulfate, and
pyridoxine have been used in special situations but have not been studied
for CRSE. For the treatment of established convulsive SE (ie, not RSE), LEV,
VPA, and fosphenytoin are likely equally effective, but whether this is also
true for CRSE is unknown. Triple-masked, randomized controlled trials are
needed to compare the effectiveness of parenteral anesthetizing and
nonanesthetizing ASMs in the treatment of CRSE.
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Affiliation(s)
| | - Jacquelyn L Bainbridge
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | | | - Edward J Novotny
- 384632University of Washington, Seattle, WA, USA.,Seattle Children's Center for Integrative Brain Research, Seattle, WA, USA
| | | | | | | | - Sarah N Fischer
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - David S Gloss
- Charleston Area Medical Center, Charleston, West Virginia, VA, USA
| | | | - Alan R Towne
- 6889Virginia Commonwealth University, Richmond, VA, USA
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Cao Y, He X, Zhao L, He Y, Wang S, Zhang T, Jiang J. Efficacy and safety of Levetiracetam as adjunctive treatment in children with focal onset seizures: A systematic review and meta-analysis. Epilepsy Res 2019; 153:40-48. [DOI: 10.1016/j.eplepsyres.2019.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/16/2019] [Accepted: 04/01/2019] [Indexed: 01/20/2023]
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Muramatsu K, Sawaura N, Ogata T, Makioka N, Tomita K, Motojima T, Ida K, Hazama K, Arakawa H. Efficacy and tolerability of levetiracetam for pediatric refractory epilepsy. Brain Dev 2017; 39:231-235. [PMID: 27745925 DOI: 10.1016/j.braindev.2016.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 09/07/2016] [Accepted: 09/21/2016] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Levetiracetam has a high tolerability and is effective against various seizure types and epilepsy syndromes. However, no study has specifically evaluated the efficacy of levetiracetam in children with refractory epilepsy based on magnetic resonance imaging (MRI) findings and the presence of intellectual disability (ID). METHODS We retrospectively evaluated levetiracetam efficacy and safety in 49 pediatric patients who met the following inclusion criteria: (1) diagnosis of refractory epilepsy with first-line antiepileptic (AED) treatment ⩾2years, (2) younger than 20years old, and (3) received oral levetiracetam treatment for ⩾6months. We assessed the relationships of these outcomes with MRI findings and ID status. RESULTS Eighteen (37%) patients achieved a ⩾50% reduction in seizure frequency, and the majority (78%) had no remarkable side effects. Twenty-two (45%) patients had previously been treated with more than seven antiepileptic drugs prior to levetiracetam. Among 18 patients who achieved a ⩾50% reduction in seizure frequency, 13 and 5 had negative and positive MRI findings, and 9 and 9 had and did not have ID, respectively. CONCLUSIONS Our findings suggest that even for intractable pediatric cases with symptomatic etiology (i.e., MRI lesion and ID), levetiracetam has favorable efficacy for refractory epilepsy with tolerable adverse effects.
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Affiliation(s)
- Kazuhiro Muramatsu
- Department of Pediatrics, Gunma University Graduate School of Medicine, Gunma, Japan; Department of Pediatrics, Maebashi Red Cross Hospital, Gunma, Japan.
| | - Noriko Sawaura
- Department of Pediatrics, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Tomomi Ogata
- Department of Pediatrics, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Nishiki Makioka
- Department of Pediatrics, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Keiko Tomita
- Department of Pediatrics, Gunma University Graduate School of Medicine, Gunma, Japan; Department of Pediatrics, JCHO Gunma Chuo Hospital, Gunma, Japan
| | - Toshino Motojima
- Department of Pediatrics, Gunma University Graduate School of Medicine, Gunma, Japan; Department of Pediatrics, Motojima General Hospital, Gunma, Japan
| | - Kuniko Ida
- Department of Pediatrics, Gunma University Graduate School of Medicine, Gunma, Japan; Department of Pediatrics, Isesaki Municipal Hospital, Gunma, Japan
| | - Kyoko Hazama
- Department of Pediatrics, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hirokazu Arakawa
- Department of Pediatrics, Gunma University Graduate School of Medicine, Gunma, Japan
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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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Smith DM, McGinnis EL, Walleigh DJ, Abend NS. Management of Status Epilepticus in Children. J Clin Med 2016; 5:jcm5040047. [PMID: 27089373 PMCID: PMC4850470 DOI: 10.3390/jcm5040047] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 04/02/2016] [Accepted: 04/07/2016] [Indexed: 01/04/2023] Open
Abstract
Status epilepticus is a common pediatric neurological emergency. Management includes prompt administration of appropriately selected anti-seizure medications, identification and treatment of seizure precipitant(s), as well as identification and management of associated systemic complications. This review discusses the definitions, classification, epidemiology and management of status epilepticus and refractory status epilepticus in children.
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Affiliation(s)
- Douglas M Smith
- Departments of Neurology and Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Emily L McGinnis
- Departments of Neurology and Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Diana J Walleigh
- Departments of Neurology and Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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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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Zheng F, Du C, Wang X. Levetiracetam for the treatment of status epilepticus. Expert Rev Neurother 2015; 15:1113-21. [DOI: 10.1586/14737175.2015.1088785] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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10
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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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Wang X, Jin J, Chen R. Combination drug therapy for the treatment of status epilepticus. Expert Rev Neurother 2015; 15:639-54. [DOI: 10.1586/14737175.2015.1045881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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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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Lang N, Esser W, Evers S, Kellinghaus C, Nguento A, Schlegel U, Gaida B, Gburek-Augustat J, Altenmüller DM, Burghaus L, Hoffmann F, Fiedler B, Bast T, Rehfeld T, Happe S, Seitz RJ, Boor R, Stephani U. Intravenous levetiracetam in clinical practice--Results from an independent registry. Seizure 2015; 29:109-13. [PMID: 26076852 DOI: 10.1016/j.seizure.2015.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 03/06/2015] [Accepted: 03/26/2015] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Most common clinical studies with antiepileptic drugs do not reflect medical everyday practice due to their strict in- and exclusion criteria and specifications of treatment regimens. Here we present a large non-interventional registry with the intention to evaluate the spectrum of applications in daily use and the efficacy and tolerability of intravenously given levetiracetam (LEV-iv). METHODS In a prospective approach of 17 neurological and neuropediatric centres in Germany LEV-iv treated patients of all ages were included over a period of 10 months. The observational period was 10 days with daily documentation of LEV-iv administration, type and frequency of seizures, currently used drugs and doses, and adverse events (AEs). In addition, treatment efficacy and tolerability were assessed by patients and physicians at study end as well as practicability of LEV-iv using a five-step scale. RESULTS In 95 patients LEV-iv was administered, 93 were included into the analysis. The median LEV-iv dose was 1500 mg (range 110-6000 mg) per day. Median age was 66 years (range 0.7-90.3 years). The majority of patients (n=70, 75%) suffered from status epilepticus (SE, n=55, 59%) and acute seizure clusters (n=15, 16%). Of those with SE, 41 patients (75%) had SE for the first time. Acute seizure clusters and SE terminated in 83% after LEV-iv administration. A total of 29 adverse events were reported in 17 of the 95 patients from the safety set. Ten of these were at least possibly related to LEV-iv treatment. Slight decrease of blood pressure during the infusion (3 patients each) was captured most frequently. No serious side effect was observed. Physicians rated the efficacy and tolerability of LEV-iv treatment as good or very good in 78% and 82% of the cases, respectively. CONCLUSION In this large observational study of everyday practise the use of LEV-iv exhibited a remarkable good response and tolerability in patients with acute onset seizures (mostly SE). Further randomized controlled studies, like the established status epilepticus trial (ESET) are needed to confirm these findings.
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Affiliation(s)
- N Lang
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - W Esser
- Department of Neurology, Städtisches Klinikum, Karlsruhe, Germany
| | - S Evers
- Department of Neurology, Lindenbrunn Hospital, Coppenbrügge, Germany
| | - C Kellinghaus
- Department of Neurology, Klinikum, Osnabrück, Germany
| | - A Nguento
- Department of Neurology, Asklepios Klinikum Uckermark, Schwedt, Germany
| | - U Schlegel
- Department of Neurology, Ruhr University, Bochum, Germany
| | - B Gaida
- Department of Neurology, University Hospital, Greifswald, Germany
| | - J Gburek-Augustat
- Department of Neuropediatrics, University Hospital, Tübingen, Germany
| | | | - L Burghaus
- Department of Neurology, University Hospital, Köln, Germany
| | - F Hoffmann
- Department of Neurology, Krankenhaus Martha-Maria, Halle, Germany
| | - B Fiedler
- Department of Neuropediatrics, University Hospital, Münster, Germany
| | - T Bast
- University Children's Hopsital, Heidelberg, Germany
| | - T Rehfeld
- Department of Neurology, Dietrich Bonhoeffer Klinikum, Neubrandenburg, Germany
| | - S Happe
- Department of Neurology, Klinik Maria Frieden, Telgte, Germany
| | - R J Seitz
- Department of Neurology, University Hospital, Düsseldorf, Germany
| | - R Boor
- Northern German Epilepsy Centre for Children and Adolescents, Raisdorf, Germany
| | - U Stephani
- Department of Neuropediatrics, University Hospital Schleswig-Holstein, Kiel, Germany.
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Redecker J, Wittstock M, Benecke R, Rösche J. Efficacy of perampanel in refractory nonconvulsive status epilepticus and simple partial status epilepticus. Epilepsy Behav 2015; 45:176-9. [PMID: 25819947 DOI: 10.1016/j.yebeh.2015.01.036] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 01/27/2015] [Accepted: 01/28/2015] [Indexed: 12/24/2022]
Abstract
We provide some evidence concerning the efficacy of perampanel (PER) in refractory status epilepticus (SE). We retroactively identified patients with SE treated in our department by searching for the term "status epilepticus" in the electronic archive of medical records. We present and analyze in this paper the subset of data of the patients treated with PER. We analyzed ten episodes of SE in nine patients. At the first administration, PER was given in a dosage of 6mg to most of our patients (7 of 10). On average, PER was administered as the 6th antiepileptic drug (AED) (range: 2-10). Depending on the criterion for efficacy, PER appears effective for the termination of SE in 2 to 6 (of 10) episodes. Unfortunately, safety data for the administration of PER with loading doses needed for the treatment of SE are lacking. Because of this, PER should be used very carefully in refractory SE and only after first-line treatment options have failed.
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Affiliation(s)
- Juliane Redecker
- Klinik und Poliklinik für Neurologie, Universität Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany.
| | - Matthias Wittstock
- Klinik und Poliklinik für Neurologie, Universität Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany.
| | - Reiner Benecke
- Klinik und Poliklinik für Neurologie, Universität Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany.
| | - Johannes Rösche
- Klinik und Poliklinik für Neurologie, Universität Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany.
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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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Abstract
Several new antiepileptic drugs (AED's) have been approved by the FDA in the last 2 decades. The newer AED's score over the older ones, in terms of improved tolerability, safety, improved pharmacokinetics and lower drug-drug interactions. However, efficacy may not be significantly higher. This article reviews the newer antiepileptics approved in the pediatric age group and the evidence for or against their clinical use.
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Kim HJ, Kim SH, Kang HC, Lee JS, Chung HJ, Kim HD. Adjunctive levetiracetam treatment in pediatric Lennox-Gastaut syndrome. Pediatr Neurol 2014; 51:527-31. [PMID: 25266616 DOI: 10.1016/j.pediatrneurol.2014.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 06/03/2014] [Accepted: 06/07/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Our aim was to investigate the efficacy and tolerability of levetiracetam as an add-on treatment in pediatric patients with Lennox-Gastaut syndrome. METHODS The study was an open-label, multicenter, observational clinical trial of levetiracetam as an add-on treatment in Lennox-Gastaut syndrome. Fifty-five patients aged 1.1-18.6 years (mean, 10.0 years) were enrolled. The study included a 4-8-week titration period and an 8-week maintenance period. The maintenance dose of levetiracetam was 20-80 mg/kg/day, according to its effectiveness and tolerability. The primary end point was reduction in seizure frequency, and related variables were also evaluated. RESULTS Among 55 patents, 51 patients (92.7%) completed the study. Thirty-two patients (58.2%) experienced a more than 50% reduction in seizure frequency, and 15 patients (27.3%) became seizure free. A reduction in seizure frequency of more than 50% was observed in 21 of 36 patients (58.3%) with convulsive seizures, 7 of 12 patients (58.3%) with drop attacks, 2 of 4 patients (50.0%) with myoclonic seizures, and 2 of 3 patients (66.7%) with epileptic spasms. Overall, 34.5% of patients reported adverse events. None of the adverse events were life threatening, and the most common adverse event was hyperactivity (12.7%). CONCLUSIONS This study suggests that levetiracetam is a safe and effective treatment in pediatric patients with Lennox-Gastaut syndrome.
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Affiliation(s)
- Hyo Jeong Kim
- Department of Pediatrics, Konyang University College of Medicine, Daejeon, Korea
| | - Shin Hye Kim
- Department of Pediatrics, Kwandong University College of Medicine, Goyang, Korea
| | - Hoon-Chul Kang
- Division of Pediatric Neurology, Pediatric Epilepsy Clinics, Severance Children's Hospital, Epilepsy Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Soo Lee
- Division of Pediatric Neurology, Pediatric Epilepsy Clinics, Severance Children's Hospital, Epilepsy Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Jung Chung
- Department of Pediatrics, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | - Heung Dong Kim
- Division of Pediatric Neurology, Pediatric Epilepsy Clinics, Severance Children's Hospital, Epilepsy Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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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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Singh SP, Agarwal S, Faulkner M. Refractory status epilepticus. Ann Indian Acad Neurol 2014; 17:S32-6. [PMID: 24791086 PMCID: PMC4001215 DOI: 10.4103/0972-2327.128647] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 12/09/2013] [Accepted: 12/09/2013] [Indexed: 12/18/2022] Open
Abstract
Refractory status epilepticus is a potentially life-threatening medical emergency. It requires early diagnosis and treatment. There is a lack of consensus upon its semantic definition of whether it is status epilepticus that continues despite treatment with benzodiazepine and one antiepileptic medication (AED), i.e., Lorazepam + phenytoin. Others regard refractory status epilepticus as failure of benzodiazepine and 2 antiepileptic medications, i.e., Lorazepam + phenytoin + phenobarb. Up to 30% patients in SE fail to respond to two antiepileptic drugs (AEDs) and 15% continue to have seizure activity despite use of three drugs. Mechanisms that have made the treatment even more challenging are GABA-R that is internalized during status epilepticus and upregulation of multidrug transporter proteins. All patients of refractory status epilepticus require continuous EEG monitoring. There are three main agents used in the treatment of RSE. These include pentobarbital or thiopental, midazolam and propofol. RSE was shown to result in mortality in 35% cases, 39.13% of patients were left with severe neurological deficits, while another 13% had mild neurological deficits.
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Affiliation(s)
- Sanjay P Singh
- Department of Neurology, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Shubhi Agarwal
- Department of Neurology, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - M Faulkner
- Department of Neurology, Creighton University School of Medicine, Omaha, Nebraska, USA
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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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Abstract
Seizure is a common presenting complaint for patients in the pediatric emergency department (PED) setting. In some cases, protocols are in place on how to manage this group of patients, for example, a patient with a simple febrile seizure already back to baseline or a patient with known epilepsy already back to baseline. However, many scenarios present dilemmas for physicians in the PED, specifically patients with status epilepticus (SE). Unfortunately, there is not a national SE protocol, and hospital-specific guidelines may or may not exist. Current practices are constantly changing because new medications arise, and more information is gathered regarding existing medications and guidelines. Here we will review the basics about first-time afebrile seizures presenting to the PED and common treatments specific to seizure types. We will then review SE management basics and medical therapy, including both older and newer agents and their routes of administration for both the prehospital and the hospital setting.
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22
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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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Francesca SB. Estado epiléptico, consideraciones sobre manejo y tratamiento. REVISTA MÉDICA CLÍNICA LAS CONDES 2013. [DOI: 10.1016/s0716-8640(13)70247-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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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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25
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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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Das bewusstseinsgestörte Kind. Monatsschr Kinderheilkd 2013. [DOI: 10.1007/s00112-013-2929-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, Laroche SM, Riviello JJ, Shutter L, Sperling MR, Treiman DM, Vespa PM. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17:3-23. [PMID: 22528274 DOI: 10.1007/s12028-012-9695-z] [Citation(s) in RCA: 1003] [Impact Index Per Article: 83.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Status epilepticus (SE) treatment strategies vary substantially from one institution to another due to the lack of data to support one treatment over another. To provide guidance for the acute treatment of SE in critically ill patients, the Neurocritical Care Society organized a writing committee to evaluate the literature and develop an evidence-based and expert consensus practice guideline. Literature searches were conducted using PubMed and studies meeting the criteria established by the writing committee were evaluated. Recommendations were developed based on the literature using standardized assessment methods from the American Heart Association and Grading of Recommendations Assessment, Development, and Evaluation systems, as well as expert opinion when sufficient data were lacking.
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Affiliation(s)
- Gretchen M Brophy
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Medical College of Virginia Campus, 410 N. 12th Street, P.O. Box 980533, Richmond, VA 23298-0533, USA.
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Mastrangelo M, Celato A. Diagnostic work-up and therapeutic options in management of pediatric status epilepticus. World J Pediatr 2012; 8:109-15. [PMID: 22573420 DOI: 10.1007/s12519-012-0348-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 02/06/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Status epilepticus (SE) is a life-threatening neurologic disorder comprising prolonged and unremitting crisis, and two or more series of seizures without complete intercritical recovery. DATA SOURCES We reviewed the literature through a Pubmed/Medline research using key words including status epilepticus, antiepileptic drugs and children, in order to revise and compare international/national protocols and to examine pediatric guidelines in SE management. RESULTS Neurologic impairment and SE etiology seem to be the most independent risks for mortality. A deep semiologic evaluation is essential to addressing diagnostic work-up. Ematochemical parameters, plasma levels of antiepileptic drugs and clinically oriented toxic/metabolic screening should be mandatory for investigating both causes and effects of SE. Electroencephalography is clearly helpful to characterize focal from generalized SE and to distinguish epileptic events from pseudoseizures, and it is deal to find nonconvulsive SE. Neuroimaging techniques could detect epileptogenic lesions (such as cortical malformations, tumors, demyelinating disorders or strokes) but are common in practice to find negative or controversial results. Pharmacologic management can be essentially arranged in three stages: benzodiazepines for early SE (lasting less than 30 minutes), phenytoin/fosphenytoin, phenobarbital, valproate, levetiracetam or lacosamide for established SE (30-90 minutes), and anesthetics for refractory SE (more than 90 minutes). CONCLUSIONS Status epilepticus is the most common neurologic emergency in childhood. A systematic diagnostic work-up and a three steps based therapeutic approach is required at this age.
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Affiliation(s)
- Mario Mastrangelo
- Department of Pediatrics, Child Neurology and Psychiatry, La Sapienza-University of Rome, Rome, Italy.
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Affiliation(s)
- Felix Rosenow
- Department of Neurology, Philipps-University Marburg, Marburg, Germany.
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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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Akyildiz BN, Kumandaş S. Treatment of pediatric refractory status epilepticus with topiramate. Childs Nerv Syst 2011; 27:1425-30. [PMID: 21442269 DOI: 10.1007/s00381-011-1432-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Accepted: 03/07/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We evaluated a topiramate (TPM) regimen for treating refractory status epilepticus in the largest pediatric series, reported to date. METHODS Fourteen patients received TPM via the nasogastric route. Initially, all patients received TPM as a 5 mg/kg loading dose followed by 5 mg/kg/day in two doses as maintenance. Thereafter, patients were divided into three groups based on the response to TPM therapy and seizure cessation time (full responder, partial responder, and nonresponder). Four patients received only thiopental, two received thiopental, and high-dose midazolam, one received thiopental, high-dose midazolam, and propofol, two received only propofol, one received propofol, and high-dose midazolam and four patients were on a high-dose midazolam infusion. RESULTS The median time to seizure cessation was 5.5 h (range 2-48 h). Nine patients were full responders, three were partial responders, and two were nonresponders At follow-up, six patients were weaned successfully from thiopental, two patients from high-dose midazolam and three patients from propofol. Three patients developed mild metabolic acidosis during TPM theraphy. CONCLUSIONS Most of the patients responded to this treatment which was well tolerated. So we recommended its use for terminating refractory status epilepticus in children.
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Affiliation(s)
- Başak Nur Akyildiz
- Department of Pediatric Intensive Care, Erciyes University Faculty of Medicine, Talas Yolu, Melikgazi, Kayseri, Turkey.
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Therapie des Status epilepticus. Monatsschr Kinderheilkd 2011. [DOI: 10.1007/s00112-011-2393-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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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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Schreiber JM, Gaillard WD. Treatment of Refractory Status Epilepticus in Childhood. Curr Neurol Neurosci Rep 2010; 11:195-204. [DOI: 10.1007/s11910-010-0170-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
This review discusses the medical management of pediatric refractory status epilepticus, defined here as persistent seizures of any type after the administration of 2 appropriate anticonvulsants. The use of both nonanesthetic and anesthetic anticonvulsants is discussed along with the relative strengths and weaknesses of each agent. Appropriate treatment goals and the use of electroencephalographic monitoring are described as are reasonable treatment algorithms. Finally, ethical considerations are briefly discussed in the context of available outcome data.
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Affiliation(s)
- James Owens
- Department of Pediatrics and Neurology, Baylor College of Medicine, Houston, TX, USA.
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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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Blonk MI, van der Nagel BC, Smit LS, Mathot RA. Quantification of levetiracetam in plasma of neonates by ultra performance liquid chromatography–tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2010; 878:675-81. [DOI: 10.1016/j.jchromb.2010.01.037] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2009] [Revised: 01/15/2010] [Accepted: 01/24/2010] [Indexed: 10/19/2022]
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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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Levetiracetam has a time- and stimulation-dependent effect on synaptic transmission. Seizure 2009; 18:615-9. [PMID: 19651528 DOI: 10.1016/j.seizure.2009.07.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Revised: 06/08/2009] [Accepted: 07/10/2009] [Indexed: 11/23/2022] Open
Abstract
We recently reported that rodent hippocampal slices incubated with levetiracetam for 3h had altered responses to repetitive stimulation and reduced neurotransmitter release. However, our experiments failed to determine the actual time course of diminished transmission in individual slices followed over time. We have now been able to record from the same slices for up to 3h to determine the latency of the levetiracetam effect after the onset of exposure. Within 30 min of levetiracetam exposure, the later field potentials of a burst were reduced. Between 60 and 180 min the relative size of later field potentials remained stable. Similar time-dependent reductions were not seen in control slices or in slices exposed to the inactive levetiracetam isomer UCB L060. These new results establish a clear time dependence of the levetiracetam effect, even in vitro, and are best explained by levetiracetam acting within neurons to alter synaptic vesicle release.
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