Levetiracetam


  Issues for Surgery


Precipitation of rebound seizures or status epilepticus if omitted.


  Advice in the Perioperative period


Elective and Emergency Surgery
Continue.

Patients should be advised to take their regular medications on the day of surgery1, 2, 3.

Abrupt withdrawal of any anticonvulsant drug should be avoided1.

Confirm with the patient if they need to be maintained on a specific manufacturer’s product (see Further Information).

Post-operative Advice

Regular dosing of the patient’s usual oral medication should be re-established as early as possible post-operatively2, 3.

If patients are unable to take their regular oral medication post-operatively, consider using the intravenous route. The intravenous dose and frequency should be the same as the established oral dose1.

Monitor renal function. The use of levetiracetam has been very rarely associated with acute kidney injury (AKI)4.


  Interaction(s) with Common Anaesthetic Agents


For general information regarding the use of anaesthetic agents in patients with epilepsy – see Antiepileptics – A General Overview.

Central Nervous System (CNS) Depression (also see under Interaction(s) with other Common Medicines used in the Perioperative Period)

Levetiracetam has minor to moderate CNS depressant effects. Whilst the clinical significance is unclear caution is recommended when administering any other agent that may have additive CNS depressant effects such as1:-

  • benzodiazepines
  • inhalational anaesthetics and intravenous anaesthetics
  • local anaesthetics
  • opioids*

*NB: Tramadol should be avoided in patients with a history of epilepsy due to an increase in seizure risk1.

(Consult British National Formulary for available drugs in each class)


  Interaction(s) with other Common Medicines used in the Perioperative Period


For general information regarding the use of antiemetics in patients with epilepsy – see Antiepileptics – A General Overview.

CNS Depression (also see under Interaction(s) with Common Anaesthetic Agents for information on opioids)

Levetiracetam has minor to moderate CNS depressant effects. Whilst the clinical significance is unclear caution is recommended when administering antiemetics that may have additive CNS depressant effects such as cyclizine, droperidol and prochlorperazine*1.

*NB: see ‘Antiepileptics – A General Overview

Laxatives

There have been isolated reports of decreased levetiracetam efficacy when the osmotic laxative macrogol has been concomitantly administered with oral levetiracetam. Macrogol should not be taken for one hour before and for one hour after taking oral levetiracetam4.


  Further Information


MHRA/CHM Advice: Antiepileptic Drugs: updated advice on switching between different manufacturer’s products for a particular drug (November 2017)1

Levetiracetam is a category 3 antiepileptic, hence it is usually unnecessary to ensure that patients are maintained on a specific manufacturer’s product as therapeutic equivalence can be assumed. However, other factors are important when considering if switching is appropriate such as patient anxiety, risk of confusion or dosing errors. (For more information see Antiepileptics – A General Overview).


  References


  1. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press http://www.medicinescomplete.com [Accessed 30th June 2019]
  2. Perks A, Cheema S, Mohanraj R. Anaesthesia and epilepsy. BJA: British Journal of Anaesthesia. 2012; 108(4):562-571
  3. Carter EL, Adapa RM. Adult epilepsy and anaesthesia. BJA Education. 2015; 15(3):111-117
  4. Summary of Product Characteristics – Keppra® (levetiracetam) 1000 mg film-coated tablets. UCB Pharma Limited. Accessed via www.medicines.org.uk 01/07/2019 [date of revision of the text April 2019]