Abstracts

Rationale: Levetiracetam (LEV) is one of the newer antiepileptic drugs (AED) that is widely used nowadays as an add-on treatment for refractory epilepsy in many countries. High efficacy, relative rapidity of action and very mild adverse effect profile of oral LEV has been shown in many clinical trials. Recently, intravenous (IV) LEV was introduced to the market, which can be used for acute inpatient treatment of refractory epilepsy where there are limitations for use of traditional rescue AED. However, very limited data is available on use of IV LEV for the treatment of repetitive seizures or status epilepticus (SE) in hospitalized patients.Methods: We analyzed seizure suppressing effect and rapidity of onset of action of IV LEV in 6 patients with non-convulsive SE (Table). Patients 1 and 3 had characteristic repetitive generalized polyspike-wave discharges on EEG, consistent with idiopathic generalized epilepsy. Other 4 patients had partial SE. Patients 1-4 had known history of seizures and were on some type of AED prior to development of the status; patients 5 and 6 had no prior history of epilepsy. In all cases IV LEV was infused over 10 min after electrographic confirmation of SE, with continuation of video-EEG monitoring for at least 12 hours after normalization of EEG.Results: In five patients (1, 2, 3, 5, 6) a single dose of 1 gram IV LEV was sufficient to terminate SE within first 45 min after drug administration. Patient 4 required additional 1 gram of IV LEV 30 min after initial dose for adequate seizure control. Five patients (1-4, 6) were continued on maintanance oral LEV therapy with the daily dose titrated to complete suppression of interictal epileptiform discharges on EEG. They all remained seizure-free on one month follow-up evaluation. Patient 5 was continued on 1 gram of scheduled IV LEV twice daily, and had no recurrence of epileptiform activity on EEG after initial termination of SE. Unfortunately, she had end-stage chronic pulmonary disease and died at the hospital on day 4 after admission due to acute respiratory failure (withdrawal of care was requested by the family). None of six patients had significant side effects from IV LEV administration. Minor side effects included transient somnolence (in 3 patients) and headache (in 1 patient) shortly after LEV infusion.Conclusions: These cases show dramatic response to IV LEV with prompt resolution of electrographic seizures after drug administration in patients with non-convulsive SE. Although in most cases of chronic refractory epilepsy, rapid onset of action is not always essential, it may have a clear advantage in patients who experience frequent seizures or are in status. Due to its high efficacy in most seizure types, remarkable rapidity of action and proven safety profile, LEV seems a very attractive choice of AED in these situations. However, carefully conducted randomized, controlled clinical trials needed to standardize indications for use of IV LEV in hospitalized patients, which may in time allow incorporating it into clinically vlidated protocol for acute treatment of non-convulsive SE.