Rationale:
In 2016, the American Epilepsy Society (AES) proposed a tiered algorithm for the treatment of convulsive status epilepticus. This algorithm recommends that if first line benzodiazepines fail, patients should receive a weight based dose of a second-tier anti-seizure medication consisting of levetiracetam, fosphenytoin, or valproic acid.
1 The Established Status Epilepticus Treatment Trial (ESETT) trial, showed that the three second tier agents are equally effective in terms of seizure cessation, specifically utilizing levetiracetam 60 mg/kg.
1 Although there are well established guidelines, it is common that providers give a non-weight-based dose of levetiracetam for patients presenting in convulsive status epilepticus.
This is a retrospective analysis of patients presenting in convulsive status epilepticus to our institution since the initiation of the status epilepticus algorithm to evaluate if non-weight-based dosing of intravenous (IV) levetiracetam 1,000 mg leads to increased morbidity and mortality as compared to recommended weight-based IV 60 mg/kg dosing used in the ESETT trial. It is hypothesized that weight-based dosing of levetiracetam demonstrates more favorable outcomes.
Methods:
The study evaluated patients who presented in convulsive status epilepticus that received IV levetiracetam 1,000 mg. The primary outcome was cessation of status epilepticus after the administration of 1,000 mg of levetiracetam. Secondary outcomes are the need for admission to ICU, length of intensive care unit (ICU) stay, length of hospitalization, length of long-term electroencephalogram (EEG) monitoring, intubation, and mortality. The primary outcome and some of the secondary outcomes were then compared to those measured in the ESETT trial levetiracetam group that received weight-based dosing as treatment for convulsive status epilepticus.
Results:
Of 636 charts obtained and reviewed, 42 had received 1,000 mg. Of the 42 patients, 13 patients (30.9%) had seizure cessation after administration of levetiracetam 1,000 mg, as compared to 68 of 145 patients (47%) who received weight-based dosing in the ESETT trial. There was no significant difference in the primary outcome. There was a significant difference when comparing the secondary outcome of the number of patients intubated between the two groups. The number of patients admitted to the ICU did not demonstrate a significant difference.
Conclusions:
There was no statistically significant difference when comparing the rates of seizure cessation in those who received levetiracetam 1,000 mg in our study and those who received weight-based 60 mg/kg dosing in the ESETT trial. However, the trend did favor the weight-based dosing for high rates of seizure cessation with 47% in the ESETT trial compared to 30.9% of those given 1,000 mg in our study.
Reference: 1. Kapur, J., Elm, J., Chamberlain, J., et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. The New England Journal of Medicine, 2019. 381(22): p2103-2013.
Funding: None