@HopkinsNCCU
@PulmCrit
@drdangayach
@neurochristiana
@nirmalregency
@interneurona
@MicieliA_MD
@mettermd
@oneDRwoman_
@AvrahamCooperMD
@daniel_gewolb

@a_charidimou
@EricLawson90
@CajalButterfly
@Capt_Ammonia
@DrAtulRamesh1
@RamaniBalu1
@DSandsmarkMDPhD
@PennNeurology
@TJUHNeuroCrit
@namorrismd
@ShadiYaghi2
@MDNeurocritcare

End/ What are your thoughts on this #neurocritcare?

@neurocritcarej
@swarnarmd
@aartisarwal
@alyssafloseldes
@caseyalbin
@JimmySuhMD
@JimSiegler
@medinariojaMD

13/ So now, you have a new 😎 tool in your armamentarium! If a patient is seizing, you can now calculate mCrCl to see if they have #ARC – and if they do, understand that their dosing may be subtherapeutic!

12/ Based on simulation models, for patients with ARC. The authors also performed #MonteCarlo simulations based on mCrCl to assess what dose would be needed - a dose of 1500mg BID would be required to reach therapeutic levels – unless CrCl >200!! 🚨

12/ 70% of patients had #ARC, and #ARC patients were mostly men, with lower Cr and tended to be younger

Of these 50 pts, 8 had seizures and 7 had ARC

Furthermore, pts w/ ARC had:
👉 shorter elimination ½ life
👉 faster drug elimination
👉 lower Cmax
👉 lower Cmin

11/ Data on 50 patients was reported, providing 191 plasma samples. Most were men and most were patients with #TBI

10/ [LEV] was measured after steady state, at trough, then 1, 4 and 6 h after dose.

CrCl was calculated by: UCr x Uvol x 1.73 / SCr x Tmin X BSA

9/ In this article, the authors identified adults with:
👉 acute brain injury
👉 had an indwelling urinary catheter
👉 were taking #levetiracetam
🚫 pregnant or prisoners

8/ How common is this 🤔?
1️⃣ pubmed.ncbi.nlm.nih.... - ~36% of ICU
2️⃣ pubmed.ncbi.nlm.nih.... - 100% of pts with SAH!!!

How do we find it?
🚫 Cockcroft-Gault as underestimates GFR
👍 measure ClCr using urine collection method

7/ But what about people who have super kidney function? People with Augmented Renal Clearance or #ARC may face the opposite problem, where we are treating them with subtherapeutic doses and are considering them treatment failures

6/ This is also why it is SOOO important to adjust the dose when patients we are treating with #LEV develop kidney injury: once you are excreting less, the levels will build up in your body

5/ Part of what makes #levetiracetam have few interactions is:
✅ has high 1st pass oral bio-availability
✅ has low protein binding
✅ 2/3 are excreted in the urine unchanged, and the additional 1/3 is hydrolyzed through non-CYP450 pathways and then excreted in the liver

4/ ICYMI 🙏 remember that #levetiracetam loading for status epilepticus is 30-45mg/kg with a max at 4500mg. This is as per #ESETT trial www.nejm.org/doi/pdf...

3/ #levetiracetam has become many people’s go-to #ASM due to:
👉 don’t need to worry about interactions
👉 controls many different types of seizures
👉 it is even considered safe for use in pregnancy! (pubmed.ncbi.nlm.nih....)

2/ #levetiracetam is an anti-seizure 💊 (#ASM) that works by binding SV2A, which is believed to modulate transmission by ⬇️ excitatory neurotransmitter release and inhibiting Ca channels (image from: www.sciencedirect.co...)