Levetiracetam as second-line treatment of status epilepticus – which dose should be applied?

SUMMARY Introduction Since 2004 many treatment episodes in different stages of status epilepticus (SE) have been reported. Nowadays the use of levetiracetam (LEV) is recommended as a second-line treatment of SE, when the use of a benzodiazepine was not successful. Aim The evidence based on randomized controlled trials for the application of a particular weight-based dose of LEV as a second-line treatment in benzodiazepine refractory SE is investigated. Methods Pubmedsearches were undertaken using the terms “Levetiracetam-status-epilepticus-trials” and “Levetiracetam-status-randomized” on May 8th 2021. We identified 17 studies reporting treatment with LEV as second line treatment and reporting dosages in mg/kg body weight. We grouped the studies according to the reported dosages (i.e. 20–25 mg/kg; 30 mg/kg; 40 mg/kg, 60 mg/kg). For each group we calculated the mean efficacy rate and the standard deviation of the efficacy rate weighted for the number of cases in the different studies. Twelve studies compared LEV with 20 mg/kg phenytoin (PHT). In these studies, we analysed the relative efficacy rate in comparison to PHT with the same procedure. Results Seven studies used LEV 20–25 mg/kg, two studies 30 mg/kg, six studies 40 mg/kg and one study 60 mg/kg. Efficacy rate was highest in the group given 30 mg/kg (95% CI 87.5–90.1%). The relative efficacy rate with this weight-based dose was 1.12. This is just above the upper range of the 95% CI of the relative efficacy rate in studies using 40 mg/kg LEV (i.e. 1.11). The relative efficacy rates in the two other groups were considerably lower. Conclusion According to the randomized controlled trials published so far a weight-based dose of 30–40 mg/kg LEV may be appropriate for the treatment of benzodiazepine-refractory SE.