Recurrent seizures in a levetiracetam-treated patient after subarachnoid hemorrhage: A matter of enhanced renal function?

Drust, Andreas; Luchtmann, Michael; Firsching, Raimund; Tröger, Uwe; Martens‐Lobenhoffer, Jens; Bode‐Böger, Stefanie M.

doi:10.1016/j.yebeh.2011.12.016

Cited by 6 publications

(6 citation statements)

References 10 publications

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“…Furthermore, Monte Carlo simulation suggested that a daily dose of 4 g or more of levetiracetam would be necessary to achieve a trough concentration greater than 6 μg/ml. Two case reports (aneurysmal SAH and TBI) also demonstrated low levetiracetam concentrations associated with ARC . Lastly, more recent research in patients with TBI, many of whom exhibited ARC, suggested that a standard “1 g every 12 hours” dose did not consistently achieve levetiracetam concentrations within the normally desired range .…”

Section: Identifying Patients At Risk For Arcmentioning

confidence: 95%

“…Two case reports (aneurysmal SAH and TBI) also demonstrated low levetiracetam concentrations associated with ARC. 64,65 Lastly, more recent research in patients with TBI, many of whom exhibited ARC, suggested that a standard "1 g every 12 hours" dose did not consistently achieve levetiracetam concentrations within the normally desired range. 66 However, safety has not been rigorously studied in these pharmacokinetic analyses, so it is unknown if empirically increasing levetiracetam doses to reach pharmacokinetic targets will lead to an increase in adverse events.…”

Section: Dosing Considerationsmentioning

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: Identifying Patients At Risk For Arcmentioning

confidence: 95%

Section: Dosing Considerationsmentioning

confidence: 99%

Augmented Renal Clearance

2019

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“…Augmented renal clearance (ARC), defined as a creatinine clearance (CrCl) exceeding 130 ml/min, has been reported in patients with an SAH, given the young age at onset 49 50 Levetiracetam renal clearance has been reported to be directly related to creatinine clearance in SAH, resulting in a need for higher than regular doses to achieve seizure control in patients with ARC 45 .…”

Section: Discussionmentioning

confidence: 99%

“…In addition, the regimen least likely to achieve levels within the reference range was 500 mg IV Q12H. Furthermore, Drust et al 49 reported an SAH patient who required a total levetiracetam daily dose of 4 g to maintain therapeutic levels and remain seizure-free. This has been attributed to the patient’s ARC (CrCl ~ 160 mL/min).…”

Section: Discussionmentioning

confidence: 99%

“…Augmented renal clearance (ARC), defined as a creatinine clearance (CrCl) exceeding 130 ml/min, has been reported in patients with an SAH, given the young age at onset. 49,50 Levetiracetam renal clearance has been reported to be directly related to creatinine clearance in SAH, resulting in a need for higher than regular doses to achieve seizure control in patients with ARC. 45 A Monte Carlo simulation conducted by Spencer et al 45 based on pharmacokinetic data obtained from 12 patients (10 of whom had an SAH) showed that the regimen most likely to achieve serum levetiracetam levels within the suggested reference range (6-20 μg/mL) was 1000 mg IV Q8H.…”

Section: Levetiracetam Dosing and Monitoringmentioning

confidence: 99%

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Seizures and Choice of Antiepileptic Drugs Following Subarachnoid Hemorrhage: A Review

Mahmoud

Buxton

2017

Can. J. Neurol. Sci.

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Seizures are important complications following a subarachnoid hemorrhage (SAH). The evidence for the use of antiepileptic drugs (AEDs) in treatment and prevention of those seizures is conflicting. The purpose of this review is to provide an up-to-date evidence summary of the incidence and outcomes of seizures following an SAH as well as the use of different AEDs post-SAH in order to evaluate the need for seizure prophylaxis, the choice of AEDs, and their dosing considerations in SAH patients. A literature search of PubMed, Medline, Embase, and the Cochrane Library was performed. A total of 37 studies were reviewed, mostly observational. Definitions of seizures in temporal relation to initial hemorrhage were variable. Similarly, the rates of seizures varied in the literature, ranging from 0 to 31%. Given the reported adverse outcomes associated with AED usage, seizure prophylaxis is not warranted. Levetiracetam appears to be better tolerated than phenytoin in SAH patients, though further research is needed. Higher initial dosing of levetiracetam might be required due to its enhanced clearance in SAH patients. In conclusion, there is a lack of quality evidence to definitively recommend the use of one AED over another. Further prospective research comparing the use of different AEDs in patients with an SAH is needed.

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