Thread by @RGottliebSmith

1/🧵
What's your favorite anti-seizure medication (ASM)?

If you said levetiracetam (LEV), you're not alone.

Why do so many #neurologists ♥️ LEV? A #tweetorial.

#MedStudentTwitter #NeuroTwitter #MedTwitter @MedTweetorials

2/
What's so good about LEV? First, some #pharmacology:

✅ Fast PO absorption
✅ 1:1 PO:IV 💉
✅ Few med interactions
✅ Can load for status epilepticus

pubmed.ncbi.nlm.nih.gov/31029217/

3/
And lots of clinical uses:

1⃣ Focal and generalized seizures
2⃣ From 👶 to 🧓
3⃣ Often used in 🤰 (category C): pubmed.ncbi.nlm.nih.gov/28472982/
4⃣ Good for status epilepticus (60 mg/kg, up to 4500 mg) - similar efficacy to phenytoin & valproic acid:
pubmed.ncbi.nlm.nih.gov/32203691/

4/
When doesn't LEV work as well?

1⃣ Absence epilepsy - only 1/4 seizure free pubmed.ncbi.nlm.nih.gov/30458657/
2⃣ Neonatal seizures - 40-60 mg/kg not as effective as phenobarbital 20 mg/kg
pubmed.ncbi.nlm.nih.gov/32385134/
3⃣ Infantile spasms - 🚫 use LEV, for Tx options:
pubmed.ncbi.nlm.nih.gov/34266919/

5/
& maybe I should have been writing this about lamotrigine (LTG) instead...

4⃣ Newly diagnosed focal epilepsy
pubmed.ncbi.nlm.nih.gov/33838757/
LEV not as good as LTG:
◾️ Time to achieve 12-month seizure freedom longer for LEV
◾️ LEV more likely to fail due to adverse reactions

6/
But LEV is typically well tolerated. Some possible side effects:

◾️ Sedation (usually less v. other ASMs)
◾️ Headaches
◾️ Mood & behavior change - sometimes vitamin B6 can help: pubmed.ncbi.nlm.nih.gov/33823377/
◾️ Rare psychosis

🔑 Metabolized by kidneys: dose adjust for 🔻 renal fcn

7/
Short tangent for the new(er) kid on the block: brivaracetam

*⃣ LEV's cousin
*⃣ Similar mechanism: binds to synaptic vesicle protein 2A
*⃣ May be better for adverse behavioral effects:
pubmed.ncbi.nlm.nih.gov/33839453/
*⃣ 🔺 cost (goodrx.com)

8/
So is LEV your favorite ASM? 💊

If not, comment on which is your favorite (and why!) 👇

9/
Key points:
🔑 LEV is a broad spectrum Tx for focal and generalized epilepsy (w/ a few caveats)
🔑 Can be used across all ages & in 🤰
🔑 Usually well tolerated
🔑 Vitamin B6 may help w/ mood & behavior side effects