Add-on levetiracetam in children and adolescents with refractory epilepsy: results of an open-label multi-centre study

The Effect of Levetiracetam and Valproic Acid Treatment on Anger and Attention Deficit Hyperactivity Disorder Clinical Features in Children and Adolescents with Epilepsy: A Prospective Study

BACKGROUND AND OBJECTIVE

Antiseizure medications (ASMs) can potentially trigger psychobehavioral adverse events associated with the onset or exacerbation of psychiatric symptoms such as irritability, aggression, and hyperactivity. The objective of this study was to evaluate the effects of levetiracetam and valproic acid on changes in clinical features of anger, attention deficit hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD). The purpose was to furnish guidance on rational drug selection in children and adolescents with epilepsy to minimize psychiatric comorbidity in the treatment of epilepsy.

METHOD

This was a prospective, observational, cohort study involving treatment-naïve children aged 7-18 years with newly diagnosed generalized or focal epilepsy who were prescribed levetiracetam or valproic acid as monotherapy for a 6-month period and regularly followed up. Psychiatric assessment was conducted at the time of the new epilepsy diagnosis and at the six-month follow-up. These assessments were performed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children Current and Lifetime Version (DSM-5), a structured psychiatric interview, as well as the State-Trait Anger Expression Style Inventory and Turgay DSM-IV Based Disruptive Behaviour Disorders Screening and Rating Scale. Anger subscores, ADHD symptoms, change in diagnosis, focal and generalized epilepsy groups, continuous seizures and seizure-free periods before and 6 months after treatment with valproic acid and levetiracetam were compared.

RESULTS

A total of 50 children, 25 in the valproic acid group and 25 in the levetiracetam group, with a mean age of 11.92 ± 3.08 years, were included in the study. There was a statistically significant increase in the ADHD subscale score post-treatment among patients receiving levetiracetam (p = 0.045) and valproic acid (p = 0.034) compared with pre-treatment. The change in both anger-in and anger-out expression scores with treatment was significantly higher in patients receiving levetiracetam (p = 0.035) compared with those receiving valproic acid (p = 0.026). Statistically, there was a significant difference in the diagnostic criteria of the levetiracetam group pre- and post-treatment (p = 0.026). The proportion of patients in whom the diagnostic criteria for ADHD+ODD were fulfilled increased from 16% before treatment to 48% after treatment, a statistically significant increase (p = 0.026).

CONCLUSION

This study found an increase in internalized anger features and ADHD symptom severity in children with epilepsy treated with valproic acid and levetiracetam. In those prescribed levetiracetam, there was a statistically significant rise in the proportion meeting the diagnostic criteria for ADHD + ODD. Our research is one of the first to prospectively examine the psychiatric assessment of children diagnosed with epilepsy. The remarkable results demonstrate changes in psychiatric diagnoses associated with the treatment of levetiracetam and valproic acid. Furthermore, a considerable rise in ADHD symptoms was observed in those treated with valproic acid.

A 5-Year Study of Antiseizure Medications (ASMs) Monitoring in Patients with Neuropsychiatric Disorders in an Italian Clinical Center

Despite receiving appropriate antiseizure medications (ASMs), a relevant percentage of neuropsychiatric patients do not benefit from this approach, and one reason is subtherapeutic ASMs plasma concentration (C(p)) due to improper drug adherence, interindividual pharmacokinetic differences, or metabolic interactions among different drugs. For these reasons, therapeutic drug monitoring (TDM) by measuring ASMs C(p) is an effective tool that improves pharmacological therapies in clinical practice. Based on these premises, in the present real-world study, we analyzed the C(p) of the most used ASMs in diverse medical conditions, which were assayed during the years 2018-2022 at the University Hospital of Pisa, including about 24,000 samples. This population was largely heterogeneous, and our database did not contain clinical information about the patients. The most used ASMs were Valproate (VPA: 54.5%) and Levetiracetam (LEV: 18.6%), followed by Oxcarbazepine (OxCBZ: 8.3%) and Carbamazepine (CBZ: 7.2%), whereas the associations LEV/VPA, Ethosuximide (ESM)/VPA, and CBZ/VPA were the most frequently proposed. In about 2/3 of assays, ASMs C(p) was in range, except for VPA, which was underdosed in almost half of the samples. Importantly, toxic levels of ASMs C(p) were found very rarely. For VPA, there was a decrease of mean C(p) across ages, from adolescents to older patients, while the C(p) of LEV, CBZ, OxCBZ, and Topiramate (TPM) showed a slight tendency to increase. When we compared females and males, we found that for VPA, the average age was higher for females, whereas women taking Lamotrigine (LTG) and OxCBZ were younger than men. Then, comparing ASMs used in neurologic and psychiatric disorders, based on the request form, it emerged that the mean C(p) of CBZ, OxCBZ, and LTG on samples collected in the Psychiatric Unit was lower compared to the Neurology and Child Neuropsychiatry Units. Finally, the ASMs subjected to multiple dosing starting from an initial subtherapeutic C(p) increased their level at different time points within a year, reaching the reference range for some of them. In conclusion, the present study suggests that TDM is widely applied to monitor ASMs C(p), finding many of them within the reference range, as a demonstration of its utility in clinical practice.

Cosmetic adverse effects of antiseizure medications; A systematic review

BACKGROUND

We systematically reviewed the existing literature on the cosmetic adverse effects of antiseizure medications (ASMs) in order to depict a clear picture of these unwanted side effects of ASMs with a particular attention to hair loss, hirsutism, acne, and gingival hyperplasia.

METHODS

This systematic review was prepared according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Scopus, MEDLINE, and Google Scholar from the inception to 25 March, 2021 were systematically searched. These key words (title/abstract) were used: "hair loss" OR "hirsutism" OR "acne" OR "gingival hyperplasia" AND "seizure" OR "epilepsy" OR "anriseizure" OR "antiepileptic". The exclusion criteria included: non-original studies, articles not in English, and animal studies.

RESULTS

The primary search yielded 3938 studies; 127 studies were related to the topic and were included in the current systematic review. The most robust evidence on cosmetic adverse effects of ASMs were related to phenytoin (causing gingival hyperplasia, hirsutism, and acne) and valproate (causing hair loss and hirsutism); however, many other ASMs were also implicated in causing these cosmetic adverse effects.

CONCLUSION

Antiseizure medications may be associated with various cosmetic adverse effects. Phenytoin and valproate are the most notorious ASMs in this regard; but, other ASMs have also been implicated in causing hair loss, hirsutism, acne, and gingival hyperplasia. Physicians should pay more attention to these significant adverse effects that may affect a patient's facial attractiveness, quality of life, and emotional state.

Effect of Levetiracetam Usage on Serum Creatine Phosphokinase Concentration in Patients with Epilepsy

Background:

Levetiracetam (LEV) is a widely used antiepileptic drug (AED) in the treatment of various type of seizures, including generalized epileptic seizure as well as focal seizures, and it is generally well tolerated. Common side effects of LEV are somnolence, asthenia, dizziness, mood changes, kidney dysfunction, minor infections, and thrombocytopenia. Recently, increased creatine phosphokinase (CPK) concentration or rhabdomyolysis after LEV administration has been reported. The goal of the study was to evaluate clinical risk factors associated with increased CPK concentration or rhabdomyolysis in LEV administration.

Materials and Methods:

One hundred and sixty children were enrolled. The risk factors were retrospectively analyzed.

Results:

Among the 160 patients, 84 (52.5%) were boys and 76 (47.5%) were girls, and the mean age was 85.95 ± 49.03 months (9–188 months). Of the 160 patients, 66 (41.3%) were treated with monotherapy, and 94 (58.8%) with polytherapy. We detected increased CPK concentration or rhabdomyolysis in three patients (1.9%). The CPK values of these three patients were 943, 1504, and 5046, respectively. No significant differences were observed in the serum CPK concentration between the patients treated with LEV.

Conclusion:

We detected that LEV may cause increased CPK concentration or rhabdomyolysis. When treating patients with LEV, clinicians should closely monitor serum CPK level. To the best of our knowledge, this is the first study of elevated CPK concentration or rhabdomyolysis associated with LEV therapy in children.

Efficacy and safety of Levetiracetam as adjunctive treatment in children with focal onset seizures: A systematic review and meta-analysis

OBJECTIVE

To assess the efficacy and safety of levetiracetam (LEV) as adjunctive treatment in children (0-18 years) with focal-onset seizures (FOS) with a larger dataset.

METHODS

A pooled analysis would be performed for prospective clinical trials and a meta-analysis for controlled studies. Retrospectives studies were also summarized using descriptive statistics.

RESULTS

Thirty-one articles (1763 patients) were identified, eighteen prospective self-controlled studies and thirteen retrospective studies. LEV was more effective than placebo, the pooled risk ratios (RRs) and 95% confidence intervals (CIs) for the 50% responder rate, seizure freedom rate and the median percentage reduction rate were 1.98 (1.49-2.63), 5.12 (2.09-12.51) and 3.19 (2.37-4.30), respectively. The overall response rates (ORRs) and 95% CIs were 56% (52%-60%), 14% (9%-19%) and 55% (31%-79%), respectively. For safety assessment, the pooled RRs and 95% CIs for the at least one treatment-emergent adverse events (TEAE) rate and at least one adverse drug reactions related (ADR-related) TEAE rate were 1.03 (0.94-1.13) and 1.45 (1.13-1.86) between two group. The ORRs and 95% CIs were 74% (54%-94%) and 48% (40%-55%). The adverse events significantly associated with LEV were somnolence 2.26 (95% CI 1.30-3.93) and hostility 2.33 (95% CI 1.15-4.70). The most frequency adverse events were pyrexia, headache, nervousness, upper respiratory tract and somnolence. The RRs for withdrawal rate or the ADR-related withdrawal rate were 0.77 (95% CI 0.44-1.38) and 0.91 (0.42-1.98), the ORRs were 17% (5%-28%) and 6% (4%-8%).

CONCLUSION

The meta-analysis suggested that add-on LEV can significantly reduce seizure frequency and fairly tolerated compared to placebo.

Usefulness of perampanel with concomitant levetiracetam for patients with drug-resistant epilepsy

PURPOSE

The purpose was to evaluate the efficacy of treatment and the occurrence of aggression-related adverse events among children receiving perampanel (PER) with concomitant levetiracetam (LEV).

METHODS

Patients were selected according to the following criteria: 1) between 12 and 18 years old; 2) seizures refractory to at least 2 first-line drugs; 3) at least 4 seizures a month before PER administration; and 4) at least 12 months of follow-up. Patients were subdivided into groups with and without LEV as concomitant treatment. PER was administered at a dose of 2 mg/day, increasing by 2 mg/day every 2 weeks up to 12 mg/day if seizures appeared. In comparison with the baseline seizure frequency, response to PER treatment was classified as follows: complete cessation (100% seizure control); response (≥50% reduction in seizures); and exacerbation (≥50% increase in seizures). Responders were identified as patients showing complete cessation or response.

RESULTS

The study group comprised 39 outpatients with a mean age of 13.7 years at enrollment. Responder status was seen in 13 of the 19 patients with LEV and 4 of the 20 patients without LEV. PER appeared significantly more effective in patients with LEV than in those without LEV (p = 0.0076). Seizure-free status was significantly more frequent among patients with LEV (47.4%) than among those without LEV (15.0% (p = 0.0407)). Aggression was present in 2 patients without LEV, but none with LEV.

CONCLUSION

The present study suggests the utility of PER with concomitant LEV for children with drug-resistant epilepsy.

Pyridoxine Add-On Treatment for the Control of Behavioral Adverse Effects Induced by Levetiracetam in Children: A Case-Control Prospective Study

BACKGROUND

Few studies on adult and pediatric patients have shown pyridoxine efficacy as additional therapy for those receiving levetiracetam (LEV) to prevent and mitigate behavioral adverse effects (BAEs).

OBJECTIVE

The aim of our study was to analyze the safety and efficacy of pyridoxine supplementation in the prevention of LEV adverse effects, including suicidal ideation.

METHODS

This randomized, case-control trial included patients receiving LEV as monotherapy treatment. Patients were subdivided into 2 groups, according to whether they were treated with LEV only (group 1) or LEV with supplemental pyridoxine (group 2).

RESULTS

In both cohorts, the most frequent BAEs were irritability/aggression followed by depression and confusion. Those patients (92%) who initiated pyridoxine after 1 month of LEV treatment did not need to change or suspend LEV ( P < 0.001), and BAE improved after 9.06 ± 3.05 days of pyridoxine supplementation. None of the patients complained of symptoms of pyridoxine toxicity, and no new adverse effects of LEV off-label were reported.

CONCLUSIONS

In our study, we found pyridoxine to be safe and effective in controlling LEV-induced BAEs in children.

Hallucination: A rare complication of levetiracetam theraphy

Levetiracetam is a new antiepileptic drug. In addition to epilepsy, it is also used for treating anxiety disorders and dystonia as well as tardive dyskinesia associated with the use of levodopa and neuroleptic drugs. Phenytoin therapy in a 10-year-old boy with convulsions was discontinued following cardiac rhythm impairment. The patient was then started on levetiracetam. However, visual and auditory hallucinations were observed on the 1st day of levetiracetam therapy. Levetiracetam was discontinued and replaced with sodium valproate, and the hallucinations resolved. The purpose of this report was to remind physicians that hallucinations are one of the rare complications of levetiracetam.

Safety of Levetiracetam in Paediatrics: A Systematic Review

Objective

To identify adverse events (AEs) associated with Levetiracetam (LEV) in children.

Methods

Databases EMBASE (1974-February 2015) and Medline (1946-February 2015) were searched for articles in which paediatric patients (≤18 years) received LEV treatment for epilepsy. All studies with reports on safety were included. Studies involving adults, mixed age population (i.e. children and adults) in which the paediatric subpopulation was not sufficiently described, were excluded. A meta-analysis of the RCTs was carried out and association between the commonly reported AEs or treatment discontinuation and the type of regimen (polytherapy or monotherapy) was determined using Chi² analysis.

Results

Sixty seven articles involving 3,174 paediatric patients were identified. A total of 1,913 AEs were reported across studies. The most common AEs were behavioural problems and somnolence, which accounted for 10.9% and 8.4% of all AEs in prospective studies. 21 prospective studies involving 1120 children stated the number of children experiencing AEs. 47% of these children experienced AEs. Significantly more children experienced AEs with polytherapy (64%) than monotherapy (22%) (p<0.001). Levetiracetam was discontinued in 4.5% of all children on polytherapy and 0.9% on monotherapy (p<0.001), the majority were due to behavioural problems.

Conclusion

Behavioural problems and somnolence were the most prevalent adverse events to LEV and the most common causes of treatment discontinuation. Children on polytherapy have a greater risk of adverse events than those receiving monotherapy.

Clinical features of long-term low-dose levetiracetam treatment for epilepsy

BACKGROUND

The aim of this study was to assess the rate of response to long-term low-dose levetiracetam (LEV) treatment and the clinical factors associated with response.

METHODS

The response to low-dose LEV of 43 patients with epilepsy (22 male, 21 female; age range, 5-39 years; median age, 13 years) was retrospectively assessed. Patients aged <15 years received <20 mg/kg/day LEV, whereas those aged ≥15 years received <1000 mg/day LEV. Clinical features were compared between responders to low-dose LEV, responders to the recommended dose, and non-responders.

RESULTS

Of the 43 patients who received low-dose LEV, 13 (30%) showed improvement, defined as seizure cessation or >75% seizure reduction over 6 months for patients with monthly, weekly, and daily seizures; and over 1 year for patients with yearly seizures. Efficacy was maintained for >1 year in 10 (77%) of the 13 patients. Long-term response to low-dose LEV was significantly associated with older age at onset and fewer previous treatments with ineffective anti-epileptic drugs. All patients showing long-term response to low-dose LEV developed only focal seizures.

CONCLUSIONS

Titration of LEV starting from a low dose may be effective in selected patients. Once patients respond to low-dose treatment, maintenance of the effective dosage may prolong response.

Correlation between efficacy of levetiracetam and serum levels among children with refractory epilepsy

BACKGROUND

Levetiracetam is used as adjunctive therapy in various types of seizures. Studies evaluating the effect of levetiracetam on children with refractory epilepsy are scarce. The aim of this study was to evaluate the correlation between serum concentration of levetiracetam and either efficacy or tolerability in children with refractory epilepsy, and to determine the value of levetiracetam blood level monitoring.

METHODS

Medical records of 50 children with refractory epilepsy treated with levetiracetam and regularly followed at Assaf Harofeh Medical Center were retrospectively reviewed. Trough serum levetiracetam concentration was determined using high-performance liquid chromatography and correlated with the administered dose and clinical report.

RESULTS

No correlation between levetiracetam serum levels and clinical efficacy, tolerability or administered dosage was found. The average dose of levetiracetam was 43.7 ± 20.0 (range 14-100) mg/kg/day and the average serum concentration was 16.0 ± 9.5 (range 2.5-38.5) μg/mL. Forty-five patients (95%) had more than a 50% reduction of seizure frequency, with 22 (44%) patients becoming seizure-free for at least 6 months. Adverse events related to levetiracetam were reported in 15 (30%) patients. No correlation between serum concentrations and adverse events was found. These results were not affected by gender, age, type of seizure, and other drugs.

CONCLUSIONS

Determination of serum concentration is not needed in all children treated with levetiracetam. Serum concentrations may be valuable either in patients with refractory epilepsy for compliance evaluation or in patients with satisfactory control of seizures for determination of their therapeutic baseline.

Levetiracetam Monotherapy in Children with Epilepsy: A Systematic Review

BACKGROUND

Levetiracetam, a second-generation anti-epileptic drug (AED) with a good efficacy and safety profile, is licensed as monotherapy for adults and children older than 16 years with focal seizures with or without secondary generalization. However, it is increasingly being used off-label in younger children.

OBJECTIVES

We critically reviewed the available evidence and discuss the present status of levetiracetam monotherapy in children 0-16 years old.

DATA SOURCES

We systematically searched the literature using PubMed, Web of Science and Embase up to August 2014 for articles on levetiracetam monotherapy in children. Keywords were levetiracetam, monotherapy and child*. The titles and abstracts of 532 articles were evaluated by AW, of which 480 were excluded. The full texts of the other 52 articles were assessed for relevance.

RESULTS

We covered one review, one opinion statement and 32 studies in this review, including four randomized controlled trials, ten open-label prospective studies, eight retrospective studies, and ten case reports. The formal evidence for levetiracetam monotherapy in children is minimal: it is potentially efficacious or effective as initial monotherapy in children with benign epilepsy with centrotemporal spikes. In all of the published studies, however, efficacy and tolerability of levetiracetam seemed to be good and comparable to other AEDs.

CONCLUSION

The data of 32 studies on levetiracetam monotherapy in children were insufficient to confirm that levetiracetam is effective as initial monotherapy for different types of seizures and/or epilepsy syndromes. There is still an urgent need for well designed trials to justify the widespread use of levetiracetam monotherapy in children of all ages.

Continuation rates of levetiracetam in children from the EULEVp cohort study

BACKGROUND

Since indication extension to children data regarding the effectiveness of levetiracetam in paediatric patients remains limited.

AIMS

Investigate the real-life effectiveness of levetiracetam in paediatric patients.

METHODS

Epileptic children (<16 years) who had initiated levetiracetam between 1 October 2006 and 31 March 2007 were included and followed for 1 year by hospital or non-hospital neurologists practising in France.

RESULTS

Among the 156 identified children, 147 were analysed: 51.7% were female, and mean (SD) age was 9.2 years (4.2). Most patients had either partial symptomatic (30.6%) or partial cryptogenic (26.5%) epilepsy, 92.5% experienced seizures during the 6 months preceding levetiracetam initiation, and 19.2% were on levetiracetam alone at initiation. One-year levetiracetam continuation rate was estimated to be 72.0% (95%CI [63.8; 78.6]). Of the 104 children continuing levetiracetam treatment at end of study, 31.7% were seizure-free during the last six months of follow-up, and 23.1% on levetiracetam alone. Discontinuation of levetiracetam (n = 41) was mainly for insufficient efficacy (58.5% of those concerned).

CONCLUSIONS

In real-life clinical practice important treatment retention and non-negligible reduction of seizure frequency may be expected.

Proposed guidelines for the management of nodding syndrome

Nodding Syndrome is a poorly understood neurologic disorder of unknown aetiology that affects children and adolescents in Africa. Recent studies have suggested that the head nods are due to atonic seizures and Nodding Syndrome may be classified as probably symptomatic generalised epilepsy. As part of the Ugandan Ministry of Health clinical management response, a multidisciplinary team developed a manual to guide the training of health workers with knowledge and skills to manage the patients. In the absence of a known cause, it was decided to offer symptomatic care. The objective is to relieve symptoms, offer primary and secondary prevention for disability and rehabilitation to improve function. Initial management focuses on the most urgent needs of the patient and the immediate family until 'stability' is achieved. The most important needs were considered as seizure control, management of behavioural and psychiatric difficulties, nursing care, nutritional and subsequently, physical and cognitive rehabilitation. This paper summarises the processes by which the proposed guidelines were developed and provides an outline of the specific treatments currently being provided for the patients.

Efficacy and safety of add-on levetiracetam in refractory childhood epilepsy

PURPOSE

The purpose of the present study was to evaluate the efficacy and safety of levetiracetam (LEV) in refractory epileptic children.

METHODS

The study group included 61 outpatients (7 generalized, 48 localization-related, 3 undetermined, 3 unclassified) aged between 16 months and 18 years. LEV was given twice daily at a total dose of 10 mg/kg/day. The final mean dose was 50.7 mg/kg/day. The mean number of prior anti-epileptic drugs was 5.2. The entire treatment period was more than 6 months after LEV administration.

RESULTS

Fifteen children (24.6%) became seizure-free for 6 months after starting LEV, and 18 (29.5%) had a seizure reduction of more than 50% for the entire 6 months. The response rate was 33/61 (54.1%). Responders included 2/3 of patients (66.7%) with epilepsy with continuous spikes and waves during slow sleep and 13/19 (68.4%) with frontal lobe epilepsy. The effective dosage of LEV in the responders demonstrated a wide range (mean, 46.1 mg/kg/day; range, 19.4-59.1 mg/kg/day), and showed bimodal distribution. Adverse events occurred in only two patients who did not require LEV discontinuation.

CONCLUSION

LEV represents an important addition to the treatments available for refractory epileptic children.

Levetiracetam in children, adolescents and young adults with intractable epilepsy: efficacy, tolerability and effect on electroencephalogram--a pilot study

Levetiracetam has been authorized for use in Israel as an add-on therapy for intractable epilepsy since May 2006. The aim of the present study was to document its effectiveness for this indication in children, adolescents, and young adults. The medical files of 78 patients aged 0.5-39 years (mean, 14.2 years) treated at our center for intractable epilepsy were reviewed. All received levetiracetam as add-on therapy following a failure to respond to at least 3 anti-epileptic drugs. Fifty-two patients (67%) had partial epilepsy and the remainder had primary generalized epilepsy. The epilepsy was symptomatic in 57%, cryptogenic in 27%, and idiopathic in 15%. Average age at first seizure was 4.1 years. In 45% of patients, the number of seizures was reduced by half with levetiracetam treatment; 11.5% of the cohort achieved complete remission. There was a statistically significant correlation between clinical seizure control and improvement in the electroencephalography findings (p = 0.0012). The drug was well tolerated, with a retention rate of 69% after one year. The most common adverse effects were irritability and impulsiveness, in 26.9% of patients. Severe behavioral side effects (psychosis, confusion) were experienced by 6.4%. In conclusion, levetiracetam is an effective and tolerable add-on agent for use in most epileptic children, adolescents, and young adults who fail to respond to at least 3 antiepileptic drugs and should be the treatment of choice in this setting. Despite the relatively high rate of behavioral side effects in this study, the retention rate at one year was high.

Safety and efficacy of levetiracetam for the treatment of partial onset seizures in children from one month of age

Epilepsy is a common neurological disorder in the pediatric population, affecting up to one percent of children, and for which the mainstay of treatment is anticonvulsant medication. Despite the frequent use of anticonvulsant drugs, remarkably little is known about the safety and efficacy of most of these medications in the pediatric epilepsy population. Of 34 anticonvulsants currently approved for use by the US Food and Drug Administration (FDA), only 13 have been approved for use in children. Although infants and young children are disproportionately affected by epilepsy, there are currently only three anticonvulsant medications that have been specifically evaluated and approved for use in children younger than 2 years of age. In 2012, the FDA approved levetiracetam as an adjunctive treatment for partial onset seizures in infants and children from one month of age. Here we review the available data on levetiracetam in the pediatric epilepsy population. We first discuss the pharmacological profile of levetiracetam, including its mechanism of action, formulations and dosing, and pharmacokinetics in children. We then review the available efficacy, safety, and tolerability data in children from one month of age with partial onset seizures. We conclude that the current data leading to the approval of levetiracetam for use in infants and children with partial onset seizures is encouraging, although more work needs to be done before definitive conclusions can be drawn about the efficacy of levetiracetam across different pediatric age groups.

The efficacy and side effects of levetiracetam on refractory epilepsy in children

Objective:

To evaluate the efficacy and tolerability of levetiracetam (LEV) add-on therapy in children with refractory epilepsy.

Materials and Methods:

We evaluated 102 children (56 boys, 46 girls, mean age 96.00 ± 31.15 months) with refractory epilepsy. Patients received LEV as add-on therapy. Changes in seizure frequency and adverse events were observed. Follow-up was conducted at least 6 months after treatment.

Results:

In total, 46 (45.1%) of the 102 children achieved more than 50% seizure frequency reduction, and 16 (15.6%) of these were seizure free. LEV reduced seizure frequency by at least 50% in 58.3% of patients with partial seizures, in 32.0% of patients with primary generalized seizures, and in 17.6% of patients with both partial and generalized seizures.

Conclusion:

Our results confirm that LEV, as add-on therapy, was effective in reducing seizure frequency in a variety of seizure types but seems most effective for partial-onset seizures. LEV was also well-tolerated in children.

Tsukamurella sp. E105 as a new biocatalyst for highly enantioselective hydrolysis of ethyl 2-(2-oxopyrrolidin-1-yl) butyrate

A new bacterial strain, E105, has been introduced as a biocatalyst for the enantioselective hydrolysis of ethyl (R,S)-2-(2-oxopyrrolidin-1-yl) butyrate, (R,S)-1, to (S)-2-(2-oxopyrrolidin-1-yl) butyric acid, (S)-2. This strain was isolated from 60 soil samples using (R,S)-1 as the sole carbon source. The isolate was identified as Tsukamurella tyrosinosolvens E105, based on its morphological characteristics, physiological tests, and 16S rDNA sequence analysis. The process of cell growth and hydrolase production for this strain was then investigated. The hydrolase activity reached its maximum after cultivation at 200 rpm and 30 °C for 36 h. Furthermore, the performance of the enantioselective hydrolysis of (R,S)-1 was studied. The optimal reaction temperature, initial pH, substrate concentration, and concentration of suspended cells were 30 °C, 6.8, 10 and 30 g/l (DCW), respectively. Under these conditions, a high conversion (>45 %) of the product (S)-2 with an excellent enantiomeric excess (ee) (>99 %), and a satisfied enantiomeric ratio (E) (>600) as well were obtained. This study showed that the bacterial isolate T. tyrosinosolvens E105 displayed a high enantioselectivity towards the hydrolysis of racemic ethyl 2-(2-oxopyrrolidin-1-yl) butyrate.

A long-term open-label extension study assessing cognition and behavior, tolerability, safety, and efficacy of adjunctive levetiracetam in children aged 4 to 16 years with partial-onset seizures

The objective of this study was to assess cognition and behavior in children (4-16 years; n = 103) with partial-onset seizures using the Leiter-R International Performance Scale and Achenbach Child Behavior Checklist. The study was a multicenter, open-label, noncomparative 48-week extension study (NCT00152516) of adjunctive levetiracetam (20-100 mg/kg/d, mean 50.2 mg/kg/d). Improvement from baseline in Leiter-R Memory Screen composite score at weeks 24 and 48 (mean [SD] change, +4.8 [12.6] and +4.5 [15.3]) was similar to changes observed with levetiracetam and placebo in a prior study. Child Behavior Checklist Syndrome scores improved from baseline at weeks 24 and 48 (total problems mean [SD] change, -9.3 [22.2] and -10.4 [23.4]). Adjunctive levetiracetam was well tolerated (most frequently reported central nervous system-related treatment-emergent adverse events: headache [24.3%], aggression [7.8%], irritability [7.8%]). Of the patients, 4.9% discontinued because of treatment-emergent adverse events. Levetiracetam provided good and sustained seizure control (median percentage reduction from baseline in partial-onset seizure frequency/wk during maintenance: 86.4%); 24.7% of patients had continuous seizure freedom from all seizure types for ≥40 weeks. In children, adjunctive levetiracetam was associated with long-term stability in cognitive functioning and improvement in emotional/behavioral functioning over time.

Levetiracetam Extended Release as Adjuvant Therapy for the Control of Partial-onset Seizures

Extended release (XR) formulation of levetiracetam (LEV) is approved by the Food and Drug Administration as an add-on to other antiepileptic drugs (AEDs) for adults with partial onset seizures. This is based on class-I evidence demonstrating significant seizure reduction in once daily dosing. Keppra-XR is marketed with the brand name of Keppra XR since 2008 (UCB Pharma). Its original immediate release (IR) formulation has been in the market since 2000. LEV has a unique molecular structure which is chemically unrelated to existing AEDs. The precise mechanism of action is unknown. Animal studies showed binding to synaptic vesicle protein SV2A, thought to be involved in modulating synaptic neurotransmitter release. LEV-IR is proven effective as adjunctive therapy for partial-onset seizures, primary generalized tonic-clonic seizures and myoclonic seizures. It was shown to be equivalent to carbamazepine as first-line treatment for partial-onset seizures. The extended release formulation added advantages such as better tolerance and increased compliance.

Levetiracetam in childhood epilepsy

Levetiracetam is an antiepileptic drug that has been shown to be effective in various types of seizures, both partial and generalized. Although it is not yet well established because of the small number of studies, levetiracetam as both add-on therapy and monotherapy can be considered as an alternative to valproic acid in some pediatric patients. We have reviewed the available data on the efficacy, tolerability, and safety of levetiracetam in children with epilepsy. The efficacy of levetiracetam as an adjunctive therapy and as monotherapy for generalized and partial childhood epilepsies and for some types of specific epileptic syndromes of infancy and childhood (such as juvenile myoclonic epilepsy, benign rolandic epilepsy, and Jeavon syndrome) has been demonstrated in some studies. Moreover, levetiracetam may be a valuable option for children with refractory epilepsy. The reported tolerability of levetiracetam and its safety profile are favorable. Among the side effects reported, behavioral changes and even psychotic reactions seem to occur more frequently in younger patients (under 4 years of age). The onset of signs/symptoms usually occurs early, even during the titration phase, and, in many cases, at a low dosage (<20 mg/kg/day). These side effects were always observed to be reversible after discontinuation of levetiracetam. In conclusion, results from clinical trials to date suggest that levetiracetam has a full spectrum of efficacy as well as a favorable safety profile, and this drug can be considered a valuable option in the treatment of epilepsy in pediatric patients.

Efficacy and safety of adjunctive levetiracetam therapy in pediatric intractable epilepsy

To investigate the efficacy and safety of levetiracetam adjunctive therapy in childhood intractable epilepsy, data were reviewed for 130 children who had >or=4 seizures per month, whose seizures were intractable to an initial >or=2 antiepileptic drugs, and who could be monitored for at least 6 months after levetiracetam add-on. Reduction in seizure frequency and related variables were investigated. Sixty-two of the 130 patients (48%) showed a seizure reduction of >or=50%, and 28 patients (22%) became seizure-free. A reduction in seizures by >or=50% was observed in 33/64 in children with partial seizures (52%) and in 29/66 children with generalized seizures (44%). Efficacy did not differ significantly among seizure types. Overall efficacy was unaffected by abnormalities evident from magnetic resonance imaging, by mental retardation, or by maintenance dose of levetiracetam. The mean maintenance dose of levetiracetam was 47.0mg/kg per day (S.D. = +/- 29.7), and mean follow-up duration was 13.4 months (S.D. =+/- 8.7). No demographic features differed significantly between patients with seizure freedom and without seizure remission. Levetiracetam was discontinued in 24 children at last visit (retention rate, 82%). The most common complaint was irritability (5%), and none of the adverse events were life threatening. In conclusion, levetiracetam adjunctive therapy is effective and safe for childhood intractable epilepsy.

Review of levetiracetam, with a focus on the extended release formulation, as adjuvant therapy in controlling partial-onset seizures

Levetiracetam is a second-generation antiepileptic drug (AED) with a unique chemical structure and mechanism of action. The extended release formulation of levetiracetam (Keppra XR(); UCB Pharma) was recently approved by the Food and Drug Administration for adjunctive therapy in the treatment of partial-onset seizures in patients 16 years of age and older with epilepsy. This approval is based on a double-blind, randomized, placebo-controlled, multicenter, multinational trial. Levetiracetam XR allows for once-daily dosing, which may increase compliance and, given the relatively constant plasma concentrations, may minimize concentration-related adverse effects. Levetiracetam's mode of action is not fully elucidated, but it has been found to target high-voltage, N-type calcium channels as well as the synaptic vesicle protein 2A (SV2A). Levetiracetam has nearly ideal pharmacokinetics. It is rapidly and almost completely absorbed after oral ingestion, is <10% protein-bound, demonstrates linear kinetics, is minimally metabolized through a pathway independent of the cytochrome P450 system, has no significant drug-drug interactions, and has a wide therapeutic index. The most common reported adverse events with levetiracetam XR were somnolence, irritability, dizziness, nausea, influenza, and nasopharyngitis. Levetiracetam XR provides an efficacious and well-tolerated treatment option for adjunctive therapy in the treatment of partial-onset seizures.

Levetiracetam in continuous spike waves during slow-wave sleep syndrome

We investigated the clinical characteristics of children with continuous spike waves during slow-wave sleep syndrome and their treatment response to levetiracetam. Five boys and one girl, diagnosed with epilepsy with continuous spike waves during slow-wave sleep syndrome, were enrolled. Their clinical characteristics, including neuroimaging findings, were reviewed. The signs related to continuous spike waves during slow-wave sleep included increased seizure frequency (6/6), impaired responsiveness (3/6), and psychomotor regression (2/6). Magnetic resonance imaging disclosed lissencephaly in one patient, and porencephaly of the left hemisphere in another. The number of antiepileptic drugs before the use of levetiracetam was 0-4 (mean +/- SD, 2.3 +/- 1.5). Five of 6 children demonstrated a good response to levetiracetam, whereas 2 (40%) underwent a relapse of electrical status epilepticus during sleep pattern on electroencephalograms 4 and 5 months after clinical improvement. Both were 5 years old. The most common presenting sign in children with continuous spike waves during slow-wave sleep syndrome is increasing seizure frequency. Levetiracetam is effective in treating children with continuous spike waves during slow-wave sleep syndrome. However, the relapse rate of continuous spike waves during slow-wave sleep syndrome remains high in young children.