Levetiracetam versus Phenytoin as Seizure Prophylaxis in Severe Traumatic Brain Injury

Jones, Kristen E.; Puccio, Ava M.; Harshman, Kathy J.; Falcione, Bonnie A.; Benedict, Neal; Jankowitz, Brian T.; Fischer, Michael; Okonkwo, David O.

doi:10.1227/01.neu.0000333495.50604.5b

Cited by 20 publications

(30 citation statements)

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“…52 One small study evaluating the use of levetiracetam compared with phenytoin for early seizure prophylaxis after TBI suggested that levetiracetam was associated with more electroencephalographic abnormalities. 48 Although the investigators did not perform pharmacokinetics with levetiracetam or measure Cl cr in this study, the results raise the question as to whether levetiracetam was inadvertently underdosed (500 mg every 12 hrs was the standard levetiracetam dose). Further studies are needed to better define the role of levetiracetam and similar anticonvulsant agents for seizure prophylaxis and treatment of status epilepticus.…”

Section: Implications Of Arcmentioning

confidence: 87%

“…The evidence supporting the use of levetiracetam in patients with TBI for early seizure prophylaxis or in patients with status epilepticus is generally low quality or underpowered. [48][49][50][51] In addition, the failure rate for therapies in these indications is relatively high and may be difficult to detect, even with agents where therapeutic drug monitoring and individualization of dosing are standard. 52 One small study evaluating the use of levetiracetam compared with phenytoin for early seizure prophylaxis after TBI suggested that levetiracetam was associated with more electroencephalographic abnormalities.…”

Section: Implications Of Arcmentioning

confidence: 99%

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Augmented Renal Clearance

2019

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Augmented renal clearance (ARC) is a phenomenon in critically ill patients characterized by increased creatinine clearance and elimination of renally eliminated medications. Patients with severe neurologic injury, sepsis, trauma, and burns have been consistently identified as at risk of ARC, with mean creatinine clearances ranging from 170 ml/minute to more than 300 ml/minute. Several potential mechanisms may contribute to the occurrence of ARC including endogenous responses to increased metabolism and solute production, alterations in neurohormonal balance, and therapeutic maneuvers such as fluid resuscitation. Augmented renal clearance is associated with suboptimal exposure to critical medications, including β‐lactams and vancomycin, increasing the risk of treatment failure. Although definitive screening tools are not yet known, critical care pharmacists must be vigilant in recognizing when ARC may be a contributing factor affecting expected treatment outcomes in individual patients. Optimizing dosing strategies in critically ill patients with ARC remains a goal of continued research. The current review discusses the clinical characteristics and methods of identifying patients at risk of ARC, potential mechanisms for ARC, and describes pharmacotherapy dosing considerations in patients with ARC.

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Section: Implications Of Arcmentioning

confidence: 87%

Section: Implications Of Arcmentioning

confidence: 99%

Augmented Renal Clearance

2019

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“…To reduce this risk, seizure prophylaxis with empirical AEDs has been proposed as part of the management of a variety of neurosurgical diseases, including traumatic brain injury, [28][29][30] subarachnoid hemorrhage, 22,36 and CNS neoplasms. 15,18,19,[24][25][26]31,32 The results of such a management strategy have been mixed. For example, Class 1 evidence suggests that patients with a variety of traumatic intracranial mass lesions are protected from seizures with routine AED prophylaxis.…”

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confidence: 99%

Postoperative seizures following the resection of convexity meningiomas: are prophylactic anticonvulsants indicated?

Sughrue

Rutkowski

Chang

et al. 2011

JNS

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“…There have been several examples of successful clinical trials focused on one issue, one symptom, or one subdomain at a time, conducted in specific TBI subpopulations most likely to benefit. These trials have shown the following: Phenytoin and levetiracetam reduce early seizures in adults with acute, moderate‐to‐severe TBI Amantadine hastens recovery of consciousness for adults with subacute, very severe TBI …”

Section: Examples Of Domain‐specific Candidate Treatments For Tbimentioning

confidence: 99%

How do you treat traumatic brain injury? One symptom at a time

Brody

Chan

Cizza

2019

Annals of Neurology

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How Do You Treat Traumatic Brain Injury?One Symptom at a Time W hen General Creighton Adams was asked how to tackle a difficult problem, he reputedly answered, "When eating an elephant, take one bite at a time." In our view, the problem of treating traumatic brain injury (TBI) should be addressed the same way, one symptom or subdomain at a time. In this editorial, we will make the case for the approach and lay the outline for a path forward.TBI is no longer a silent pandemic. Military health systems, sports organizations, and the general public are clamoring for answers. We have very few solutions based on solid scientific evidence; most of what we do is based on "clinical experience," which has been defined as "making the same mistakes with increasing confidence over an impressive number of years." 1 So, what are our options?We could keep doing large, acute phase clinical trials in moderate-to-severe TBI with broad inclusion criteria and global outcome measures, hoping to find a "magic bullet." Unfortunately, this has not worked in the past, despite substantial effort and expense. [2][3][4] We could focus all of our efforts on prevention. Certainly, car safety, better helmets, and balance training are worthy endeavors, but an exclusive focus on prevention would leave the millions of patients with chronic symptoms and deficits in the lurch.We could slump into nihilism. Nothing will ever fix the "squashed bug" or "unscramble the egg." For us, this is not an option. Our patients demand more.We could double down on basic science research, looking long and hard in the laboratory for the magic bullet that will cure TBI. Clearly, basic science is important and should continue. In the domain of cancer treatment, finer and finer pathophysiological subdivisions punctuated by occasional breakthrough discoveries have led to effective treatments for a few specific cancers. 5 However, substantial progress in cancer has mainly come from systematically trying a lot of ideas in a lot of clinical trials to figure out empirically what works and what does not. [6][7][8] Fortunately, a few bright sparks have been spotted. There have been several examples of successful clinical trials focused on one issue, one symptom, or one subdomain at a time, conducted in specific TBI subpopulations most likely to benefit. These trials have shown the following:

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Levetiracetam versus Phenytoin as Seizure Prophylaxis in Severe Traumatic Brain Injury

Cited by 20 publications

References 0 publications

Augmented Renal Clearance

Augmented Renal Clearance

Postoperative seizures following the resection of convexity meningiomas: are prophylactic anticonvulsants indicated?

How do you treat traumatic brain injury? One symptom at a time

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