Abstracts

Rationale: Patients with brain injury have an increased risk of seizures, which may be especially detrimental in the acute care setting. Phenytoin is often considered the agent of choice for seizure prophylaxis because of its availability in both parenteral and oral forms. However, the prophylactic use of phenytoin is associated with the need for frequent monitoring of drug levels, as well as the possibility of drug interactions and adverse events. Newer antiepileptic drugs such as levetiracetam are associated with a more favorable safety profile and do not require monitoring of levels. The purpose of this analysis was to determine the cost difference associated with the use of levetiracetam vs. phenytoin for routine seizure prophylaxis in a neurocritical care unit at a large teaching hospital. Methods: All patients admitted to the Duke University Hospital neurocritical care unit from 2/2/07 to 3/1/07 who received anticonvulsant prophylaxis with either phenytoin, fosphenytoin or levetiracetam were reviewed. Data was compiled on a daily basis from the medication administration record, the corresponding pharmacy medication system report, and the physician order entry system, and the costs associated with drug administration and blood level monitoring was recorded. Results: 54 patients received seizure prophylaxis for various indications: intracranial hemorrhage (29.4%), seizure disorder (15%), craniotomy (39%) or other (16.6%). There were a total of 118 patient days on phenytoin or fosphenytoin (51 patient days on intravenous therapy and 78 days on enteral therapy) and 195 patient days on levetiracetam (23 intravenous and 179 enteral). Although the direct cost of medication per patient-day was similar between groups ($12.59 for phenytoin vs. $12.49 for levetiracetam), the total treatment costs were substantially lower in the levetiracetam group ($17.02 per patient-day in the levetiracetam group vs. $92.78 per patient-day in the phenytoin group). The increased costs associated with phenytoin were primarily associated with the need for monitoring, which included free and total drug levels, and determination of albumin ($80.20 per patient-day).Conclusions: The cost data in this analysis show that levetiracetam is a more cost effective option than phenytoin for seizure prophylaxis in patients with acute brain injury. The major cost difference was related to the amount spent on serum levels and monitoring for each drug. With the approval of intravenous levetiracetam, there are increased options for antiepileptic drug prophylaxis in the critically ill population. Further studies are needed to assess the role of levetiracetam in the prophylaxis and treatment of patients with acute brain injury.