Levetiracetam

LEVETIRACETAM- levetiracetam tablet, film coated, extended release
Quinn Pharmaceuticals, LLC

1 INDICATIONS AND USAGE

Levetiracetam extended-release tablets USP are indicated as adjunctive therapy in the treatment of partial onset seizures in patients 12 years of age and older with epilepsy.

2 DOSAGE AND ADMINISTRATION

2.1 Recommended Dosing

Levetiracetam extended-release tablets are administered once daily.‎

Initiate treatment with a dose of 1000 mg once daily. The once daily dosage may be adjusted in increments of 1000 mg every 2 weeks to a maximum recommended daily dose of 3000 mg/day.

2 . 2 Dosage Adjustment in Adult Patients with Renal Impairment

Levetiracetam extended-release tablets dosing must be individualized according to the patient’s renal function status. Recommended dosage adjustments for adults are shown in Table 1. In order to calculate the dose recommended for patients with renal impairment, creatine clearance adjusted for body surface area must be calculated. To do this, an estimate of the patient’s creatinine clearance (CLcr) in mL/min must first be calculated using the following formula:

[140-age (years)] x weight (kg)

CLcr = ———————————————-(x 0.85 for female patients)

72 x serum creatinine (mg/dL)

Then CLcr is adjusted for body surface area (BSA) as follows:

CLcr (mL/min)

CLcr (mL/min/1.73m2) = —————————– x 1.73

BSA subject (m2)

Table 1: Dosage Adjustment Regimen for Adult Patients with Renal Impairment
Group Creatinine Clearance (mL/min/1.73m 2 ) Dosage (mg) Frequency
Normal >80 1000 to 3000 Every 24 hours
Mild 50 – 80 1000 to 2000 Every 24 hours
Moderate 30 – 50 500 to 1500 Every 24 hours
Severe < 30 500 to 1000 Every 24 hours

3 DOSAGE FORMS AND STRENGTHS

Levetiracetam extended-release tablets USP, 500 mg are white, oblong-shaped, film-coated extended-release tablets debossed with “500” on one side and contain 500 mg levetiracetam.

Levetiracetam extended-release tablets USP, 750 mg are white, oblong-shaped, film-coated extended-release tablets debossed with “750” on one side and contain 750 mg levetiracetam.

4 CONTRAINDICATIONS

None.

5 WARNINGS AND PRECAUTIONS

5. 1 Behavioral Abnormalities and Psychotic Symptoms

Levetiracetam extended release tablets may cause behavioral abnormalities and psychotic symptoms. Patients treated with ‎ levetiracetam extended-release should be monitored for psychiatric signs and symptoms.

Behavioral abnormalities

Levetiracetam Extended- release Tablets

A total of 7% of levetiracetam extended-release-treated patients experienced non-psychotic behavioral disorders (reported as irritability and aggression) compared to 0% of placebo-treated patients. Irritability was reported in 7% of levetiracetam extended-release-treated patients. Aggression was reported in 1% of levetiracetam extended-release-treated patients.

No patient discontinued treatment or had a dose reduction as a result of these adverse reactions.

The number of patients exposed to levetiracetam extended-release was considerably smaller than the number of patients exposed to immediate-release levetiracetam tablets in controlled trials. Therefore, certain adverse reactions observed in the immediate-release levetiracetam controlled trials will likely occur in patients receiving levetiracetam extended-release tablets.

Immediate-Release Levetiracetam Tablets

A total of 13% of adult patients and 38% of pediatric patients (4 to 16 years of age) treated with immediate-release levetiracetam experienced non-psychotic behavioral symptoms (reported as aggression, agitation, anger, anxiety, apathy, depersonalization, depression, emotional lability, hostility, hyperkinesias, irritability, nervousness, neurosis, and personality disorder), compared to 6% and 19% of adult and pediatric patients on placebo. A randomized, double-blind, placebo-controlled study was performed to assess the neurocognitive and behavioral effects of immediate-release levetiracetam tablets as adjunctive therapy in pediatric patients (4 to 16 years of age). An exploratory analysis suggested a worsening in aggressive behavior in patients treated with immediate-release levetiracetam tablets in that study [see Use in Specific Populations ( 8.4) ].

A total of 1.7% of adult patients treated with immediate-release levetiracetam discontinued treatment due to behavioral adverse reactions, compared to 0.2% of placebo-treated patients. The treatment dose was reduced in 0.8% of adult patients treated with immediate-release levetiracetam, compared to 0.5% of placebo-treated patients. Overall, 11% of pediatric patients treated with immediate-release levetiracetam experienced behavioral symptoms associated with ‎discontinuation or dose reduction, compared to 6.2% of placebo-treated pediatric patients.‎

One percent of adult patients and 2% of pediatric patients (4 to 16 years of age) treated with immediate-release levetiracetam experienced psychotic symptoms, compared to 0.2% and 2%, respectively, in adult and placebo-treated pediatric patients. In the controlled study that assessed the neurocognitive and behavioral effects of immediate-release levetiracetam in pediatric patients 4 to 16 years of age, 1.6% levetiracetam-treated patient experienced paranoia, compared to no placebo-treated patients. There were 3.1% patients treated with immediate-release levetiracetam who experienced confusional state, compared to no placebo-treated patients [see Use in Specific Populations ( 8.4) ].

Psychotic symptoms

Immediate-Release Levetiracetam tablets

One percent of levetiracetam-treated adult patients experienced psychotic symptoms compared to 0.2% of placebo-treated patients.

Two (0.3%) levetiracetam-treated adult patients were hospitalized and their treatment was discontinued due to psychosis. Both events, reported as psychosis, developed within the first week of treatment and resolved within 1 to 2 weeks following treatment discontinuation. There was no difference between drug and placebo-treated patients in the incidence of pediatric patients who discontinued treatment due to psychotic and non-psychotic adverse reactions.

5.2 Suicidal Behavior and Ideation

Antiepileptic drugs (AEDs), including levetiracetam extended-release tablets, increase the risk of suicidal thoughts or behavior in patients taking these drugs for any indication. Patients treated with any AED for any indication should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior.

Pooled analyses of 199 placebo-controlled clinical trials (mono- and adjunctive therapy) of 11 different AEDs showed that patients randomized to one of the AEDs had approximately twice the risk (adjusted Relative Risk 1.8, 95% CI:1.2, 2.7) of suicidal thinking or behavior compared to patients randomized to placebo. In these trials, which had a median treatment duration of 12 weeks, the estimated incidence rate of suicidal behavior or ideation among 27,863 AED-treated patients was 0.43%, compared to 0.24% among 16,029 placebo-treated patients, representing an increase of approximately one case of suicidal thinking or behavior for every 530 patients treated. There were four suicides in drug-treated patients in the trials and none in placebo-treated patients, but the number is too small to allow any conclusion about drug effect on suicide.

The increased risk of suicidal thoughts or behavior with AEDs was observed as early as one week after starting drug treatment with AEDs and persisted for the duration of treatment assessed. Because most trials included in the analysis did not extend beyond 24 weeks, the risk of suicidal thoughts or behavior beyond 24 weeks could not be assessed.

The risk of suicidal thoughts or behavior was generally consistent among drugs in the data analyzed. The finding of increased risk with AEDs of varying mechanisms of action and across a range of indications suggests that the risk applies to all AEDs used for any indication. The risk did not vary substantially by age (5-100 years) in the clinical trials analyzed. Table 2 shows absolute and relative risk by indication for all evaluated AEDs.

Table 2: Risk by Indication for Antiepileptic Drugs in the Pooled Analysis
Indication Placebo Patients with Events Per 1000 Patients Drug Patients with Events Per 1000 Patients Relative Risk: Incidence of Events in Drug Patients/Incidence in Placebo Patients Risk Difference: Additional Drug Patients with Events Per 1000 Patients
Epilepsy 1.0 3.4 3.5 2.4
Psychiatric 5.7 8.5 1.5 2.9
Other 1.0 1.8 1.9 0.9
Total 2.4 4.3 1.8 1.9

The relative risk for suicidal thoughts or behavior was higher in clinical trials for epilepsy than in clinical trials for psychiatric or other conditions, but the absolute risk differences were similar for the epilepsy and psychiatric indications.

Anyone considering prescribing levetiracetam extended-release tablets or any other AED must balance the risk of suicidal thoughts or behavior with the risk of untreated illness. Epilepsy and many other illnesses for which AEDs are prescribed are themselves associated with morbidity and mortality and an increased risk of suicidal thoughts and behavior. Should suicidal thoughts and behavior emerge during treatment, the prescriber needs to consider whether the emergence of these symptoms in any given patient may be related to the illness being treated.

Patients, their caregivers, and families should be informed that AEDs increase the risk of suicidal thoughts and behavior and should be advised of the need to be alert for the emergence or worsening of the signs and symptoms of depression, any unusual changes in mood or behavior, or the emergence of suicidal thoughts, behavior, or thoughts about self-harm. Behaviors of concern should be reported immediately to healthcare providers.

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