metricas
covid
Buscar en
Neurología (English Edition)
Toda la web
Inicio Neurología (English Edition) Experience of using subcutaneous levetiracetam in palliative patients
Journal Information
Vol. 36. Issue 6.
Pages 474-475 (July - August 2021)
Vol. 36. Issue 6.
Pages 474-475 (July - August 2021)
Letter to the Editor
Open Access
Experience of using subcutaneous levetiracetam in palliative patients
Experiencia de uso de levetiracetam subcutáneo en pacientes paliativos
Visits
1435
G. Más-Seséa,
Corresponding author
gemmasese@gmail.com

Corresponding author.
, D. Martín-Bautistaa, A. Navarro-Cataláb
a Unidad de Neurología, Hospital la Pedrera, Denia, Alicante, Spain
b Farmacia Hospitalaria, Hospital la Pedrera, Denia, Alicante, Spain
This item has received

Under a Creative Commons license
Article information
Full Text
Bibliography
Download PDF
Statistics
Tables (2)
Table 1. Clinical characteristics of our patient sample.
Table 2. Clinical response after subcutaneous levetiracetam administration.
Show moreShow less
Full Text
Dear Editor:

End-of-life care frequently involves the treatment of difficult-to-manage symptoms. Patients with central nervous system involvement (tumour, stroke) may present difficult-to-control epileptic seizures, which have significant physical and psychological consequences and a negative impact on the patient’s and his/her family’s quality of life. In palliative care, oral administration of drugs to treat seizures is usually preferable in the interest of patient well-being, but some circumstances may prevent the use of these drugs, making it necessary to use alternative routes, such as subcutaneous administration.

We present our experience in the use of subcutaneous levetiracetam (LEV) in the palliative care of patients with epileptic seizures attended at a chronic care and long-stay hospital.

Six patients were treated between July 2016 and December 2019. Table 1 describes the patients’ characteristics. Subcutaneous treatment was started because oral administration was impossible and due to difficulties placing a venous catheter.

Table 1.

Clinical characteristics of our patient sample.

Patient  Age  Sex  Diagnosis  Type of epilepsy  Duration of LEV treatment before subcutaneous administration 
60  Woman  Advanced Alzheimer disease and Down syndrome  Partial  2 years and 6 months 
70  Woman  Grade IV glioblastoma  Generalised  3 months 
64  Man  Grade IV glioblastoma  Partial  13 months 
50  Man  Anaplastic meningioma  Generalised  6 years and 2 months 
50  Woman  Grade IV glioblastoma  Generalised  2 years and 23 months 
67  Man  Metastatic non-Hodgkin lymphoma  Generalised  8 months 

Administration was intermittent, every 12 hours, with the drug diluted in 100 cc of saline solution, using a system with a 22 G butterfly needle. The system was placed in the lower hemiabdomen, with the injection site being rotated. The dose administered was the same as that previously taken by the patient, between 500 and 1500 mg every 12 hours. One patient presented cutaneous irritation at the administration site with doses of 1500 mg every 12 hours, so we reduced the dose to 2000 mg a day, with continuous subcutaneous administration; no further events were reported. Mean duration of subcutaneous LEV administration was 9.5 days (range: 3-16), and the total number of doses administered amounted to 103. No patient presented seizures after onset of subcutaneous treatment. Table 2 provides detailed information regarding treatment response.

Table 2.

Clinical response after subcutaneous levetiracetam administration.

Patient  Seizure frequency before onset of subcutaneous LEV  Seizure frequency after onset of subcutaneous LEV  Subcutaneous LEV treatment duration (days)  Dose (mg/12 h)  Dose adjustment during subcutaneous treatment  Injection site reactions 
7 in the last 15 days  None  16  1500  No  No 
2 in 3 months  None  11  500  No  No 
10 in the past month  None  1000  No  No 
1 every 15 days  None  1500  No  No 
1 in 3 months  None  12  1500  Yes (2000 mg/day, continuous infusion)  Erythema 
1 in 6 months  None  11  500  No  No 

LEV: levetiracetam.

Epileptic seizures may occur at some point in disease progression in up to 70% of patients with brain tumours, as well as in patients with some advanced neurodegenerative diseases.1,2 In recent years, LEV has been used more frequently than such other antiepileptic drugs as phenytoin and valproate, due to its favourable safety and tolerability profile. LEV causes less sedation than other drugs used in the treatment of seizures, such as benzodiazepines or phenobarbital; this is important in palliative care patients who do not want to limit their cognition or ability to interact with their surroundings during the final stages of their disease. Several authors have published their experience in the use of subcutaneous LEV (continuous infusion or every 12 hours) as an off-label indication for compassionate use.3–7 Therefore, our patients and their families were duly informed and consented to the treatment. Regarding tolerability and clinical response, published case series4,6 report good tolerability, safety, and effectiveness. In our series, after onset of subcutaneous LEV, all patients were seizure-free and we observed only one case of erythema at the infusion site, which immediately resolved after reducing the dose and switching to continuous administration. Publications determining the levels of LEV during the treatment period have shown that they always remain within therapeutic ranges.8,9 This technique is not available at our centre; however, as no seizures were observed in our patients, we believe that the doses administered were adequate.

Subcutaneous treatment lasted several days (between 3 and 16 days), until the death of the patient. We did not find treatment periods longer than one month in the literature3–7; therefore, it is unclear whether effectiveness or safety would be maintained for more prolonged periods.

To conclude, we consider that subcutaneous LEV is a safe and effective alternative in palliative care patients with epileptic seizures.

References
[1]
D.J. Englot, E.F. Chang, C.J. Vecht.
Epilepsy and brain tumors.
Handb Clin Neurol., 134 (2016), pp. 267-285
[2]
D. Friedman, L.S. Honig, N. Scarmeas.
Seizures and epilepsy in Alzheimer’s disease.
CNS Neurosci Ther., 18 (2012), pp. 285-294
[3]
O. Maison, B. de la Gastine, L. Peter-Derex, C. Berger, S. Goutelle.
Subcutaneous administration of levetiracetam in geriatrics.
Rev Neurol (Paris)., 171 (2015), pp. 398-399
[4]
C. Rémi, S. Lorenzl, B. Vyhnalek, K. Rastorfer, B. Feddersen.
Continuous subcutaneous use of levetiracetam: a retrospective review of tolerability and clinical effects.
J Pain Palliat Care Pharmacother., 28 (2014), pp. 371-377
[5]
G.H. Wells, L.D. Mason, E. Foreman, J. Chambers.
Continuous subcutaneous levetiracetam in the management of seizures at the end of life: a case report.
Age Ageing., 45 (2016), pp. 321-322
[6]
A.E. Sutherland, Curtin, V. Bradley, O. Bush, M. Presswood, V. Hedges, K. Naessens.
Subcutaneous levetiracetam for the management of seizures at the end of life.
BMJ Support Palliat Care., 8 (2018), pp. 129-135
[7]
J.M. López-Saca, J. Vaquero, A. Larumbe, J. Urdíroz, C. Centeno.
Repeated use of subcutaneous levetiracetam in a palliative care patient.
J Pain Symptom Manage., (2013),
[8]
M.A. Sancho-Zamora, N. EspadasHervás, I. Cañada-Millas.
Mantenimiento de niveles plasmáticos de levetiracetam en infusión paliativa subcutánea, continua y prolongada mediante infusores elastoméricos.
Rev Neurol., 69 (2019), pp. 392-393
[9]
Steigleder T, Ostagathe C. Tolerability and efficacy of subcutaneous levetiracetam in palliative care patients with symptomatic epilepsy. A case series. 8th World Research Congress of the European Association for Palliative Care (EAPC). Lleida, España, junio de 2014.

Please cite this article as: Más-Sesé G, Martín-Bautista D, Navarro-Catalá A. Experiencia de uso de levetiracetam subcutáneo en pacientes paliativos. Neurología. 2021;36:474–475.

Copyright © 2020. Sociedad Española de Neurología
Download PDF
Article options
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos