by: Professional Advisory Board Member, Joanne Rogin, MD
In spite of the availability of multiple antiepileptic drugs and nonpharmacological treatments for epilepsy, many individuals with epilepsy continue to have seizures. Each one of our new antiepileptic drugs has resulted in improvement in seizures for some individuals with epilepsy who have failed multiple other antiepileptic drugs. That has been the case with our newest antiepileptic drug, brivaracetam (Briviact) from UCB Pharmaceuticals.
Brivaracetam is approved by the FDA for use as add-on (or adjunctive therapy) for partial-onset seizures in patients who are 16 years and older with epilepsy. It belongs to the same class of drugs as levetiracetam (Keppra), but shows tighter binding to the brain target SV2A. Brivaracetam is taken twice daily and has very few drug interactions.
The effectiveness of brivaracetam was demonstrated in three controlled clinical trials, all of which had one group taking a placebo (sugar pill) being compared to groups receiving brivaracetam. Prior to approval in very refractory patients. In the groups taking the active treatment, it was started at an effective dose on the first day. In the first two studies, individuals who were already on levetiracetam were included in the study.. In the third study, individuals who had used levetiracetam in the past were included, but not if they were presently taking it. Brivaracetam was effective in patients who had had seizures or side effects on levetiracetam in the past. In the first two studies, no extra effectiveness was found in those who were on levetiracetam at the same time as brivaracetam compared to people who were not on leviteracretam at the same time.
As with any antiepileptic drug, side effects may occur in some people. Sedation, fatigue, dizziness, unsteadiness may occur and were generally mild to moderate and more common early in the treatment. Side effects may occur at any time, however. There was a low incidence of psychiatric side effects, with irritability occurring in 3% of individuals on brivaracetam compared to 1% of those on placebo.
Brivaracetam may be started at a dose level that is already effective in treating seizures. It is available as 25, 50, 75 and 100 mg tablets, and an oral solution. There is an intravenous form for use when the oral tablets or solution cannot be used temporarily. Brivaracetam is typically started at 50 mg twice daily with doses ranging from 25 mg twice daily up to 100 mg twice daily use. There are no labs or levels required.
Brivaracetam interacts with very few other medications, either for epilepsy or nonseizure medications. If combined with carbamazepine, there may be an increase in a metabolite of carbamazepine. It does not interact with oral contraceptives or phenytoin (Dilantin) at the doses used in everyday practice. There is no added benefit when brivaracetam is added to levetiracetam therapy. In my practice, brivaracetam has been added to individuals having side effects on levetiracetam, which is then tapered. At this time the FDA approval is for add-on therapy to at least one other antiseizure medication.
Brivaracetam is a new antiepileptic drug, related to levetiracetam, but effective in individuals who have previously had seizures or side effects on levetiracetam. It did not provide additional benefit in patients who were on levetiracetam when used in two studies. Side effects may occur but the incidence of psychiatric side effects was low. It may provide an option for individuals who had success with seizure control but who have had psychiatric side effects while on levetiracetam. The ability to start with the first dose being an effective dose as well as it being well-tolerated and not requiring laboratory blood draws makes brivaracetam another good option in treating epilepsy.