Remember Keppra: seizure control with subcutaneous levetiracetam infusion

A 60-year-old woman with end-stage carcinoma of unknown primary and brain metastases was admitted to the hospice with global deterioration. Following a seizure some months earlier, she had been maintained on the oral antiepileptic levetiracetam. Shortly after admission seizure activity developed in her right leg; levetiracetam was increased from 500 to 750 mg two times a day with good effect. Gradually, she deteriorated spending more time asleep although had periods of alertness where she ‘held court’ with her family, including her devoted young grandson. Eight days following admission she was unable to take oral medication, a subcutaneous syringe driver (SCSD) was necessary to control pain, nausea and seizures. Midazolam was considered too sedating given the family visits she enjoyed. Levetiracetam is one of the least sedating antiepileptics. A SCSD was prescribed containing levetiracetam 1.5 g (100 mg/mL), (the levetiracetam oral to injectable conversion is 1:1), metoclopramide 30 mg and oxycodone 15 mg over 24 h, diluted with water to 48 mL in a 50 mL syringe. The Palliative …