Seizure and behavioral outcomes after switching from levetiracetam to brivaracetam in pediatric epilepsy: A real-world cohort study and literature review

BACKGROUND: Purpose: Brivaracetam (BRV), an analog of levetiracetam (LEV), is designed with a higher affinity and selectivity for synaptic vesicle protein 2A (SV2A) than LEV. This study aimed to assess the efficacy and tolerability of shifting anti-seizure medication (ASM) from LEV to BRV in pediatric patients with epilepsy. Factors following the switch were analyzed. METHODS: A retrospective study included epilepsy patients under the age of 20 who transitioned from LEV to BRV between April 2022 and April 2023. Data at baseline (T0) and 6 months post-BRV (T1) were evaluated. Responders (seizure reduction ≥50 %) and non-responders were compared for factors linked to outcomes. RESULTS: Among 121 patients with epilepsy (mean age 10.8 ± 4.9 years), 59.5 % were responders at T1. EEG features with focal epileptiform discharge (p = 0.037) and lower average ASM amounts (p = 0.014) significantly related to better outcomes. There was no significant difference between responders and non-responders in age, gender and etiology of seizure. Importantly, in non-seizure adverse effects, 60 % reported improved tolerability, particularly in mood, attention, and irritability. Nevertheless, 19 % experienced worsened adverse effects during T1 and switch back to LEV. CONCLUSION: BRV is a promising alternative ASM for pediatric patients intolerant to LEV, especially with focal and non-drug-resistant seizures. Beyond seizure control, the improved tolerability profile, especially regarding behavioral side effects, may enhance developmental functioning and quality of life. These findings guide effective switching from LEV to BRV to improve outcomes.