Indian expert perspective on use of BRV in management of epilepsy

Brivaracetam (BRV), a highly selective synaptic vesicle protein 2A (SV2A) ligand with greater affinity than levetiracetam, offers a targeted mechanism with favorable pharmacokinetics and improved neuropsychiatric tolerability. Regulatory approvals vary: in the US, BRV is indicated for partial-onset seizures in patients ≥1 month; in the EU, as adjunctive therapy for partial-onset seizures with or without secondary generalization in adults, adolescents, and children ≥2 years; and in India, as adjunctive therapy in patients ≥16 years. This Indian expert perspective is based on 30 advisory board meetings involving 350 neurologists across India (April 2025-January 2026), supported by literature review. Experts highlighted challenges including poor adherence, psychiatric adverse effects, drug-resistant epilepsy, and cost concerns. BRV is preferred in focal epilepsy, especially in patients intolerant to levetiracetam, those with psychiatric comorbidities, post-stroke seizures, tumor-related epilepsy, and elderly patients. Clinical trials and real-world studies show significant seizure reduction, favorable responder rates, and good tolerability in focal-onset seizures, with emerging evidence in generalized tonic-clonic seizures and status epilepticus. Intravenous BRV is useful when oral therapy is not feasible. Overall, BRV is a valuable option in individualized epilepsy management due to efficacy, rapid onset, predictable pharmacokinetics, and lower behavioral adverse effects. Limited long-term pregnancy data warrant cautious use and further research.