Brivaracetam | Epilepsy clinician handbook
Brivaracetam can be used as add on treatment for focal and bilateral convulsive seizures.
Brivaracetam is similar to levetiracetam in its mechanism of action and the two medications cannot be used together.
PBS Indication: focal seizures with or without secondary generalisation from 4 years of age.
Important: Dosing information
Initiation and escalation dosing on this webpage are a guide only.
All medications must be individualised based on:
- patient age, weight, co-morbidities
- disease, seizure type, frequency, duration
- medication metabolism, interactions, side-effect profile characteristics.
Further consultation with appropriate formularies or a paediatric neurologist may be required.
Dosing information
> 4 years and < 50kgs:
- Common initial dose: 0.5mgs/kg twice daily
- A common maintenance dose is 1mg/kg twice daily.
- Dose adjustment may be titrated according to response, with adjustment each 2 weeks.
- Based on physician assessment, if a quicker therapeutic effect is required, may start 1mg/kg twice daily, titrate as above to 2mg/kg twice daily.
Adolescents > 50kgs:
- Common initial dose: 25 mgs twice daily
- A common maintenance dose is 50mgs twice daily
- On physician assessment, may start at 50mgs twice daily and titrate as above to 100mgs twice daily.
Preparations
- Tablets: 25mg, 50mg, 75mg, 100mg
- Oral liquid: 10mg/mL
Formulary
Possible side effects
- Drowsiness and fatigue
- Dizziness
- Irritability/Agitation
- Gastrointestinal symptoms – nausea, vomiting, constipation
- Anxiety, depression or insomnia
Rare side-effects
- Hypersensitivity (bronchospasm and angioedema)
- Neutropenia
- Aggression
- All anti-seizure medications are potentially teratogenic and this is often dose related
For a complete list of adverse effects appropriate formularies should be consulted.
Interactions
Carbamazepine, phenobarbitone and phenytoin decrease brivaracetam levels.
Brivaracetam may increase carbamazepine epoxide and phenytoin levels.
Brivaracetam does not decrease the efficacy of the contraceptive pill.
Resources
Precautions
- Brivaracetam has 15-30 times greater affinity for SV2A and faster brain permeability than levetiracetam.
- Generally advised not to use levetiracetam and brivaracetam together as it could lead to competitive binding of SV2A ligand.
- If there is a behavioural adverse effect with levetiracetam, there is some literature to support a switch to brivaracetam (Neuropsychiatric Disease and Treatment: 2019:15 2587-2600)
- Switching from levetiracetam to brivaracetam at a ratio of 10:1 - 15:1 is feasible as an immediate overnight switch (Neuropsychiatric Disease and Treatment: 2019:15 2587-2600).
- Dosing adjustment is needed for patients with hepatic impairment.
Weaning: Wean over weeks, not abruptly.
Pregnancy: There is limited data regarding brivaracetam during pregnancy and usage in pregnancy needs to be discussed with a neurologist.
This information is reviewed annually by the Sydney Children’s Hospitals Network Paediatric Epilepsy NSW working group which includes medical, nursing, and pharmacy representation