Rhabdomyolysis in a Hospitalized 16-Year-Old Boy: A Rarely Reported Underlying Cause

Rhabdomyolysis associated with newer-generation anti-seizure medications (ASMs): a real-world retrospective and pharmacovigilance study

Objective: Rhabdomyolysis is a potentially fatal adverse reaction mostly triggered by certain medications. Few real-world studies have shown a clear association between newer-generation anti-seizure medications (ASMs) and rhabdomyolysis. We sought to quantify the risk and evaluate the clinical features and management of rhabdomyolysis associated with newer-generation ASMs. Methods: Data were retrieved from the US FDA Adverse Event Reporting System database (FAERS) from 2018 to 2022 on newer-generation ASMs to identify rhabdomyolysis events, and disproportionality analyses were conducted by estimating the reporting odds ratios (RORs) and corresponding 95% confidence intervals (CIs). Furthermore, case reports from 2012 to 31 December 2022 on newer-generation ASMs-induced rhabdomyolysis were retrieved for retrospective analysis. Results: A total of 1,130 rhabdomyolysis reports from the FAERS database were considered. Levetiracetam had the greatest proportion and the highest positive signal values of rhabdomyolysis. The RORs (95% CIs) for newer-generation ASMs were, in descending order, levetiracetam 8.01 (7.26-8.84), lamotrigine 3.78 (3.25-4.40), oxcarbazepine 3.47 (2.53-4.75), pregabalin 2.75 (2.43-3.12), lacosamide 1.85 (1.29-2.65), topiramate 1.64 (1.25-2.15), and gabapentin 1.32 (1.13-1.55). Twenty-six case reports showed evidence of rhabdomyolysis, and levetiracetam (65.4%) was the most frequently reported agent. The median age was 32 years; typical initial symptoms included muscle weakness (34.8%), myalgia (34.8%), backache (17.4%), fatigue (13.0%) and leg pain (8.7%). The median time to onset of rhabdomyolysis was 2 days. All cases had elevated creatine phosphokinase (CPK), and some cases were accompanied by elevated creatinine (57.1%) and myoglobinuria (53.8%). Cessation of ASMs could lead to complete clinical remission. The median time for creatine phosphokinase (CPK) normalization was 8 days. Conclusion: This study identified 7 newer-generation ASMs with significant rhabdomyolysis reporting associations. Prescribers should be more aware of this risk and teach patients to recognize rhabdomyolysis signs/symptoms early.

Suspected Levetiracetam-Induced Acute Rhabdomyolysis in a Patient With Retinoblastoma: A Case Report and Literature Review

Rhabdomyolysis is a condition characterized by the destruction of the skeletal muscle and the release of its content into the circulation, and it can cause acute kidney injury (AKI). There are numerous causes for the development of this condition, and some of them are rare. Levetiracetam, an antiepileptic agent, has been speculated as a rare possibility for the development of rhabdomyolysis. In this report, we highlight a case of a 36-year-old gentleman with retinoblastoma since childhood, who was maintained on levetiracetam for two years for epilepsy. He was brought to our hospital with a history of generalized fatigue and unwitnessed seizure. Upon further investigations, he was found to have severe rhabdomyolysis and AKI that required renal replacement therapy. Levetiracetam was suspected as a culprit and therefore was discontinued with gradual improvement of renal function over a few months.

Suspected Levetiracetam-Induced Rhabdomyolysis: A Case Report and Literature Review

Patient: Male, 22-year-old

Final Diagnosis: Rhabdomyolysis

Symptoms: Creatine-kinase elevation

Medication: —

Clinical Procedure: —

Specialty: General and Internal Medicine

Acute Kidney Injury Caused by Levetiracetam in a Patient With Status Epilepticus

Levetiracetam is a widely used, effective and usually well-tolerated anti-epileptic medicine. It is mostly excreted by kidneys and requires dose adjustment according to the glomerular filtration rate. Very few case reports have been published in the literature about levetiracetam causing acute kidney injury (AKI). We present a case of a 26-year-old male with a seizure disorder on levetiracetam, presented with status epilepticus requiring intubation for airway protection. He received 4 g of intravenous levetiracetam as a loading dose and continued with a maintenance dose of 750 mg intravenous every 12 hours. He had signs of AKI on day two and creatinine eventually reached a maximum level of 12.2 mg/dL. His kidney function improved to his new baseline in a period of 30 days without requiring renal replacement therapy. He did not have significant rhabdomyolysis and his kidney function started improving right after his anti-epileptic therapy was switched to valproic acid pointing towards levetiracetam as the primary cause of kidney injury. Clinicians should be aware that levetiracetam can cause AKI on patients with a seizure disorder, especially when administered in high doses. Kidney function should be monitored closely and patients should be treated aggressively with intravenous fluids when they have any signs of rhabdomyolysis to prevent further kidney damage.

Levetiracetam Treatment-Associated Acute Rhabdomyolysis in an Adolescent

Etiology of rhabdomyolysis includes hereditary muscle enzyme deficiencies, trauma, viral infections, excessive exercise, hypothyroidism, and medications such as colchicine, lithium, and statins. Several studies have reported that various antiepileptic drugs may induce rhabdomyolysis. Levetiracetam is one of the antiepileptic drugs implicated in the etiology of rhabdomyolysis. Herein, we present a case of rhabdomyolysis in an adolescent treated with levetiracetam. We wanted to draw attention to the increasing trend of levetiracetam-associated rhabdomyolysis frequency in pediatric patients.

Rhabdomyolysis: a rare adverse effect of levetiracetam

A 62-year-old previously healthy male was admitted with new onset generalised tonic-clonic seizures. Treatment was initiated with the antiepileptic levetiracetam and he had no further episodes of seizures. Creatine kinase (CPK) level was 1812 IU/L 12-hour postadmission. Despite good hydration, his CPK levels continued to rise dramatically and reached a level of 19 000 IU/L on day 5. This rise was unexplained as he did not have any further seizures and had a normal renal function. In the absence of other risk factors, the rare possibility of levetiracetam being responsible for the disproportionately high CPK was considered. Within 12 hours of withdrawal of levetiracetam, there was a downward trend in the CPK levels, with a 10-fold decrease in CPK levels over the next 4 days. This is only the ninth case reported in literature regarding this rare and potentially serious adverse effect of levetiracetam.

Population-Based Study of Risk of AKI with Levetiracetam

BACKGROUND AND OBJECTIVES

Regulatory agencies warn about the risk of AKI with levetiracetam use on the basis of information from case reports. We conducted this study to determine whether new levetiracetam use versus nonuse is associated with a higher risk of AKI.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This was a population-based retrospective cohort study of adults with epilepsy in Ontario, Canada. Patients who received a new outpatient prescription for levetiracetam between January 1, 2004 and March 1, 2017 were matched to two nonusers on stage of CKD, recorded seizure in the prior 90 days, and logit of a propensity score for levetiracetam use. The primary outcome was a hospital encounter (emergency department visit or hospitalization) with AKI within 30 days of cohort entry. Secondary outcomes were AKI within 180 days and change in the concentration of serum creatinine. We assessed the primary outcome using health care diagnosis codes. We evaluated the change in the concentration of serum creatinine in a subpopulation with laboratory measurements.

RESULTS

We matched 3980 levetiracetam users to 7960 nonusers (mean age 55 years, 51% women). Levetiracetam use was not significantly associated with a higher risk of AKI within 30 days (13 [0.33%] events in levetiracetam users and 21 [0.26%] events in nonusers [odds ratio, 1.24; 95% confidence interval, 0.62 to 2.47]). Similarly, there was no significant association with AKI within 180 days (odds ratio, 0.70; 95% confidence interval, 0.43 to 1.13). The change in the concentration of serum creatinine did not significantly differ between levetiracetam users and nonusers.

CONCLUSIONS

In this population-based study levetiracetam use was not associated with a higher risk of AKI.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_12_11_Yau_Podcast.mp3.

Rhabdomyolysis: A Rare Adverse Effect of Levetiracetam

Levetiracetam is an anti-epileptic that works at the synapse and binds synapse vesicle protein 2A, thereby controlling the release of neurotransmitters. Its side effects mainly include somnolence, headache, fatigue, dizziness, vomiting, and behavioral alterations. Rhabdomyolysis is a rare adverse effect of levetiracetam. The underlying pathophysiology of this adverse effect is unknown. Our patient is a 42-year-old male who was brought to the hospital with a complaint of generalized tonic-clonic seizures and urinary incontinence. His symptoms were caused by hyponatremia. Levetiracetam was started for seizure prevention along with management for hyponatremia. His creatine phosphokinase levels increased on the third day of admission to 30,000 U/L. Four days after the discontinuation of levetiracetam and with the institution of supportive therapy, the patient's rhabdomyolysis resolved.