Brief CommunicationDeterminants of success in the use of oral levetiracetam in status epilepticus☆
Introduction
Status epilepticus (SE) represents an emergency neurological condition with an important clinical impact; its treatment is traditionally based on administration of older-generation antiepileptic drugs (AEDs) such as benzodiazepines, phenytoin, valproate, and phenobarbital, with the subsequent option of coma induction with an appropriate agent [1].
In this context, investigation of newer AEDs has received little attention, and no head-to-head comparisons are available to date. Topiramate has been reported to be effective in small case series of children [2] and adults [3] with SE. We recently reported the use of levetiracetam (LEV) in adults with SE [4]. This drug appears promising in this setting, especially owing to its wide spectrum of action [5], favorable pharmacokinetic profile [6], and the possibility of rapid titration.
However, to date, it is unknown whether particular subgroups of patients may be more suitable for this treatment, and whether a dose–response relationship exists. Furthermore, as for other newer AEDs, LEV bioavailability after administration through a nasogastric tube in comatose patients with impaired gastrointestinal motility has not been assessed. The objective of this observational study was to analyze the effects of LEV in adult patients with SE, including the effects after administration of LEV through a nasogastric tube.
Section snippets
Methods
We screened a retrospective SE database of two tertiary referral hospitals in Boston (Brigham & Women’s Hospital, Massachusetts General Hospital; January 2000–April 2004) [4] and a prospective SE database of consecutive patients treated for SE at our institution (July 2004–July 2005). The primary investigator (A.O.R.) had no influence on the prescription of AEDs. SE was defined in both series as ongoing seizures or seizures without recovery of consciousness or baseline clinical condition for at
Results
In the retrospective series, 8 of 68 subjects fulfilled the inclusion criteria (12%); in the prospective series, 15 of 30 were included (50%).
Among the resulting group of 23 subjects, 10 (43%) were women, mean age was 59.5 (±17.7), an acute etiology was found in 10 (43%), all had localization-related seizures, and 7 (30%) were on LEV treatment at the beginning of their SE episode. Nine subjects (39%) had refractory SE, defined as requiring coma induction according to the treating clinician; all
Discussion
Analysis of this ambispective series suggests that LEV may represent a useful alternative in SE if administered early in the course of the illness. Furthermore, it suggests that escalation of the dose beyond 3000 mg/day provides no additional benefit if a response does not occur at lower dosage.
We assume that a response within 72 hours would suggest a causal relationship, but this assumption is impossible to formally prove. As in our previous study [4], we found that a response to LEV was always
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This study was supported by UCB, Smyrna (GA), USA. Dr. Rossetti is supported by the Swiss National Science Foundation and the SICPA Foundation, Prilly, Switzerland.