Keppra Nursing Implications
Levetiracetam (Keppra) Nursing Pharmacology Guide
Levetiracetam, otherwise also known as the brand name Keppra, is a type of drug belonging to the drug class anticonvulsants. It is one of the medications administered to treat and decrease the occurrence of seizures. Other available brand names of levetiracetam include Keppra XR and Spritam.
Indications of Levetiracetam (Keppra)
Below are the indications and dosage considerations for the following conditions:
- For myoclonic seizures
- For partial-onset seizure utilized as adjunctive treatment
The dosage form and strengths of levetiracetam are as follows:
- Tablet, immediate-release (Keppra, generic): 250mg, 500mg, 750mg, 1 gram
- 3-D tablet, immediate-release (Spritam): 250mg, 500mg, 750mg, 1 gram
- Tablet, extended-release (Keppra XR): 500mg, 750mg
- Oral solution (Keppra, Generic): 100mg/ml
- Injectible solution: 5mg/ml, 10mg/ml, 15mg/ml, 100mg/ml
Pharmacology of Levetiracetam (Keppra)
- Mechanism of action
- The antiepileptic mechanism of levetiracetam is unknown.
- However, it is believed that levetiracetam acts by inhibiting the voltage-dependent N-type calcium channel through the binding of the drug to the synaptic proteins that adjusts the release of neurotransmitters in the body. This is achieved by the displacement of negative modulators which in turn will allow the transmission of Gamma-aminobutyric acid (GABA) – a natural anti-seizure compound made in the brain.
- Absorption – Levetiracetam has a bioavailability of 100%. It’s peak plasma time is 1 hour (for immediate release) and 4 hours(for extended release).
- Distribution – It is attracted to protein and is bounded to them less than 10% of the time.
- Metabolism – This drug is broken down through the hepatic enzymatic hydrolysis. It has inactive metabolites when processed in the liver.
- Elimination – Levetiracetam has a half-life of 6-8 hours and will typically be increased in the elderly or those with kidney disease. The total body clearance for this drug is around 0.96 ml/min/kg with a renal clearance of 0.6ml/min/kg and a 4ml/min/kg for metabolites. Pediatric clearances is usually higher at more than 40%. Levetiracetam is highly dialyzable and is primarily excreted 66% of the time through the urine.
Levetiracetam (Keppra) Dosing Considerations
The following are dosing considerations for patients with renal impairment in accordance with their creatinine clearance (CrCl):
Immediate release and intravenous form
- CrCl greater than 80 mL/min/1.73 m²: Dose adjustment not needed
- CrCl 50-80 mL/min/1.73 m²: 500-1000 mg orally every 12 hours
- CrCl 30-50 mL/min/1.73 m²: 250-750 mg orally every 12 hours
- CrCl less than 30 mL/min/1.73 m²: 250-500 mg orally every 12 hours
- Dialysis (conventional): 500-1000 mg orally once/day, THEN 250-500 mg supplemental dose after dialysis
Extended release tablets
- CrCl greater than 80 mL/min/1.73 m²: Dose adjustment not needed
- CrCl 50-80 mL/min/1.73 m²: 1000-2000 mg orally every 24 hours
- CrCl 30-50 mL/min/1.73 m²: 500-1500 mg orally every 24 hours
- CrCl less than 30 mL/min/1.73 m²: 500-1000 mg orally every 24 hours
- End-stage renal disease requiring hemodialysis: Immediate release formulation recommended
Drug Interactions with Levetiracetam (Keppra)
Drug interactions of levetiracetam (Keppra) are as follows:
- Increased toxicity levels. When some drugs used for thalassemia and levetiracetam (Keppra_ are used in conjunction, it may cause pharmacodynamic synergism wherein both of the drugs’ toxicity levels are increased. This pharmacodynamic synergism also happens with the use of levetiracetam and some drugs for nausea and vomiting and polycythemia vera.
2. For Close Monitoring
- Increased toxicity by sedation – When drugs for postpartum depression, tardive dyskinesia, general anesthetics, migraine, insomnia, antipsychotic medication, or anticonvulsant is used in conjunction with levetiracetam, it may cause a pharmacodynamic effect that increases sedation and somnolence.
- Increased toxicity – When drugs such as some kinase inhibitors (for certain lymphomas) and other anticonvulsants are used together with levetiracetam, it may cause increased toxicity levels in the blood by virtue of pharmacodynamic effect.
- Risk of hypoventilation, airway obstruction, desaturation, or apnea – Levetiracetam usage together with some barbiturates, alcohol, or other CNS depressants will add these effects to the patient.
- Decreased serum levels – Some drugs used for obesity will affect the effectiveness of levetiracetam by virtue of inhibition of gastrointestinal absorption of the drug. Some drugs used for hyperphosphatemia will also reduce the effectiveness of levetiracetam by increasing the elimination of the drug by the body.
3. Minor Drug Interactions
- Decreased levels of effectivity – Certain antipyretics and drugs for attention deficit hyperactivity disorder losses their effectivity when used with levetiracetam by virtue of increasing metabolism of the drug in the body.
- Pharmacodynamic antagonism – Some muscle relaxants and sage may have reduced effects when used in conjunction with levetiracetam.
- Unspecified interaction mechanism – Vitamin B7 and carnitine supplements losses their effectivity when used with levetiracetam by means of unspecified interaction mechanisms.
Side Effects Adverse Effects of Levetiracetam (Keppra)
Below are the adverse effects of levetiracetam (Keppra):
More than 10% of patients experience:
- Asthenia, or physical weakness and lack of energy
- Increased blood pressure
A small group of patients may experience the following side effects:
- Viral Infection
- Ataxia, or the presence of abnormal and awkward movements
- Paresthesia, or the unusual prickling and numbness experienced usually in the arms, legs or feet.
- Diplopia, or double vision
- Amblyopia, or lazy eye
The following adverse effects of levetiracetam (Keppra) must be checked:
- Abnormal hepatic function tests
- Dyskinesia, or the involuntary and awkward movement of the extremities and the body
- Decreased hematocrit
- Suicidal tendencies
- Bone marrow suppression
- Epidermal necrolysis
Other reported effects of levetiracetam (Keppra) include:
- Hepatic: Abnormal liver function tests, hepatic failure, hepatitis, pancreatitis
- Skin: Alopecia, erythema multiforme; drug rash with eosinophilia and systemic syndrome (DRESS)
- Neurologic: Choreoathetosis (the involuntary movement of the body), dyskinesia, worsening of seizures
- Hematology: Leukopenia, neutropenia, pancytopenia, thrombocytopenia, agranulocytosis
- Skeletomuscular: Muscle weakness
- Psychological: Panic attacks
- General: Weight loss, hyponatremia, acute kidney injury, anaphylaxis and angioedema
Contraindications of Levetiracetam
Levetiracetam (Keppra) is contraindicated to patients with previous hypersensitivity to the drug. Caution should be exercised when using levetiracetam (Keppra) on the following:
- Patients are advised of symptom monitoring because somnolence and asthenia may occur within the first 4 weeks of treatment.
- Gradual discontinuing of levetiracetam should be exercised to reduce the risk of withdrawal symptoms such as increased seizure frequency and status epilepticus.
- Some adults and children using levetiracetam (Keppra) have reported nonpsychotic symptoms such as aggression, agitation, anger, nervousness, etc.
- Patients should be monitored for any behavioral abnormalities that may be brought about by levetiracetam usage such as irritability, aggressive behavior, suicidal thoughts, etc.
- Reports of debilitating dermatologic conditions may occur such as Steven-Johnson’s syndrome and toxic epidermal necrolysis, with a median of 14-17 days onset while using levetiracetam.
- Reports of drug rash with eosinophilia and systemic syndrome (DRESS) have been recorded.
- Hematologic abnormalities have been reported like decreased white blood cell count, reduced hemoglobin and hematocrit counts, increases in eosinophil count, etc.
- Use cautiously for patients with renal problems. Dose adjustments and the use of immediate-release formulation should be used for patients with chronic kidney disease that requires dialysis.
- Episodes of anaphylaxis or edema have been recorded after the first dose or anytime during the treatment course.
Pregnancy and Levetiracetam (Keppra)
The following are the pharmacology behind the use of levetiracetam during pregnancy and lactating mothers:
- There are no sufficient studies on the use of levetiracetam in pregnant mothers. Drug-associated risk of major birth defects or miscarriage has not been established on the use of levetiracetam.
- In animal studies, teratogenic effects and developmental toxicity have been noted on doses at par or greater than the normal human doses.
- Caution should still be exercised when used during pregnancy. Only if the potential benefit outweighs the risk to both the mother and fetus.
- Therapeutic levels may decrease during pregnancy. This is due to the physiological changes that occur that alters plasma concentrations of the drug. This is more common towards the third trimester which would necessitate dose adjustments.
- Levetiracetam (Keppra) is excreted in human milk. However, no sufficient studies of the drug effects on the breastfed infant have been established.
- Consider the benefits, both developmental and health-related, when administering to the mother’s clinical need of the drug versus potential side effects to the breast-fed infant.
Levetiracetam (Keppra) Overdose
Levetiracetam overdose clinical manifestations include the following:
- decreased consciousness or loss of consciousness (coma)
- difficulty breathing
Nursing Care Plan for Patients on Levetiracetam (Keppra)
Possible Nursing Diagnoses
- Impaired Sleep Pattern related to the side effect of levetiracetam (Keppra)
- Acute Pain (headache) related to the side effect of levetiracetam (Keppra)
- Risk for Diarrhea related to the side effect of levetiracetam (Keppra)
- Risk for Suicidal Ideation related to the side effect of levetiracetam (Keppra)
- Deficient Knowledge related to levetiracetam (Keppra)
|Keppra Nursing Interventions||Rationale|
|Assess the patient for signs and symptoms of seizures and epilepsy.||To confirm the indication for administering levetiracetam (Keppra).|
|Assess if the patient has anemia, thrombocytopenia or low platelet count, suicidal thoughts, psychotic disorder, depression, or hallucinations.||Levetiracetam (Keppra) are generally contraindicated in patients with anemia, thrombocytopenia or low platelet count, suicidal thoughts, psychotic disorder, depression, or hallucinations.|
|Check the patient’s allergy status.||Previous allergic reaction to levetiracetam (Keppra) may render the patient unable to take them. Alternatives to levetiracetam (Keppra) should therefore be considered in case of allergy.|
|Assess if the patient is pregnant or lactating.||Levetiracetam (Keppra) should be prescribed in caution to a pregnant woman as this drug is under pregnancy category C and must only be taken under the direction of the physician.|
|Perform a focused neurological assessment of the patient.||To confirm the indication for administering levetiracetam (Keppra).|
|Assess the patient’s mucous membranes and his/her ability to swallow.||To check for any potential problems with administration, hydration, and absorption.|
To ensure that the right form of levetiracetam (Keppra) is given.
|Collect bloods for full blood count check.||Levetiracetam (Keppra) may cause low red blood cell count (anemia), low white cell count (leukopenia), and low platelet count (thrombocytopenia).|
Nursing Planning and Intervention
|Keppra Nursing Interventions||Rationale|
|Administer levetiracetam (Keppra) with or without food at the same time everyday.||To ensure optimal absorption and therapeutic action by levetiracetam (Keppra), as well as reduce possible side effects.|
|Ask the patient to swallow levetiracetam (Keppra) tablet whole, as prescribed. Do not crush the extended-release tablet.||This will ensure adequate absorption of the drug being administered.|
|Educate the patient about the action, indication, common side effects, and adverse reactions to note when taking levetiracetam (Keppra). Instruct the patient on how to self-administer levetiracetam (Keppra).||To inform the patient on the basics of levetiracetam (Keppra), as well as to empower him/her to safely self-administer the medication.|
|Monitor the patient’s input and output and commence stool chart.||levetiracetam (Keppra) may cause diarrhea or dysuria Early detection of either side effect can help institute a bowel program and relieve them effectively.|
|Discourage alcohol intake or cannabis consumption when on levetiracetam (Keppra).||Alcohol and cannabis can increase the nervous system side effects of Keppra, such as irritability, dizziness, and drowsiness.|
|Help the patient with activities of daily living as needed.||Levetiracetam (Keppra) may cause fatigue, dizziness, and drowsiness which may put the patient at risk for injury. Therefore, patients on Keppra require close supervision when doing ADLs.|
|Inform the patient that levetiracetam (Keppra) may cause mood swings and this should be reported to any healthcare professional once noticed.||To inform the patient of the possible side effect of levetiracetam on his or her behavior and emotional state.|
|Keppra Nursing Interventions||Rationale|
|Ask the patient to repeat the information about levetiracetam (Keppra).||To evaluate the effectiveness of health teaching on levetiracetam (Keppra).|
|Monitor the patient’s full blood count.||To ensure that the levetiracetam (Keppra) did not cause any anemia, leukopenia, or thrombocytopenia.|
|Commence a seizure chart.||To check for the effectiveness of levetiracetam (Keppra) on the patient’s seizure activity.|
|Monitor the patient’s emotional and behavioral status using a Behavioral Chart or Intentional Rounding Chart.||Levetiracetam (Keppra) may cause changes in mood, suicidal thoughts, depression, irritability, and other psychological effects. These should be monitored closely to ensure the patient’s safety and to check if the dose needs to be reduced or the drug must be discontinued.|
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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