Abstracts

Levetiracetam (LVT) is currently licensed for adjunctive treatment of partial seizures in adults. Literature suggests both pediatric potential and possible efficacy in a wider range of seizures. Anecdotal evidence suggests it is well tolerated. People with intellectual disabilities (ID) are at special risk of developing refractory epilepsy (RE) often of symptomatic/cryptogenic generalized type, with difficult to treat myoclonic, atonic, tonic and atypical absence seizures. We report our experience using LVT in a specialist epilepsy service for people with ID. LVT was added to the treatment of 64 people with ID and RE, aged 9-54 years, with follow-up 0.5 - 4 years. 64% were male. [gt]70% had cryptogenic/symptomatic generalized epilepsies. Co-medications were mainly valproate, lamotrigine and topiramate, less frequently gabapentin, carbamazepine or phenytoin. Dose titration was monitored by community-based epilepsy specialist nurses. Adverse events were regularly monitored using a standardized checklist. Seizure frequency was monitored by carers and patients using standardized recording formats individually designed for each patient[apos]s seizure type. A favorable response led to attempt at reduction of concomitant medication. Where there was no response, or if carers or patients were concerned about adverse effects, LVT was withdrawn. Complete seizure control was obtained in 11% of this very refractory group. Most achieved reduction in seizure frequency between 40-80%. There was frequently a change to milder, shorter seizures. Improvement was seen in some patients with tonic seizures (often notoriously difficult to treat). Further analysis of seizure frequency was limited because in this naturalistic study there were occasionally other factors such as concomitant withdrawal of carbamazepine in patients with myoclonus. A dose-related mood change responded to slower dose escalation in one case. LVT was withdrawn in 4 cases where it was ineffective and in 2 because of behavioral change. In both latter cases it was successfully re-introduced with good results using slower dose escalation. The original problem was attributed to paradoxical normalization. LVT seems generally well tolerated in people with ID, including children. As reported elsewhere it shows efficacy in generalized as well as partial seizure types. In this population it is recommended that slow dose escalation is used. It is important to consider other causes for the emergence of behavioral changes than purely drug-induced effects, such as paradoxical normalization. In such cases re-challenge with more appropriate dose escalation may be successful. Our practice supports the value of community-based specialist nurse monitoring of dose regimes and adverse events.