16.16 Syringe pumps

Levetiracetam concentrate for intravenous infusion may be prescribed on the recommendation of a specialist when it is to be administered as a continuous subcutaneous infusion in the circumstances described below.

Supporting guidance for levetiracetam continuous subcutaneous infusion in the community setting has been developed by consultants in palliative medicine working across Devon. The guidance is hosted on the Rowcroft Hospice website.

Levetiracetam (24 hour continuous subcutaneous infusion)

• For patients with an ongoing seizure risk who were receiving oral levetiracetam and for whom oral administration is no longer possible:
  • on the recommendation of a palliative care specialist and
  • when midazolam is inappropriate or not desired due to sedative effects
• Off label use - levetiracetam concentrate for intravenous infusion is not licensed for use in patients without epilepsy or for subcutaneous administration. For information on its use as a continuous subcutaneous infusion in palliative care, see the Palliative Care Formulary version 7 (PCF7) and the Scottish Palliative Care Guidelines.
• Levetiracetam concentrate for intravenous infusion 500mg/5mls is to be diluted and administered as a 24 hour continuous subcutaneous infusion (see below).
• For a patient currently receiving oral levetiracetam the ratio for conversion from oral to subcutaneous use is 1:1.
• Renal impairment: dose adjustment is required, seek guidance from specialist palliative care team (for further information see the Palliative Care Formulary version 7 (PCF7) and the Scottish Palliative Care Guidelines.
• There is no need to reduce the dose in hepatic impairment unless associated with renal impairment.

Notes for prescriber

• Prescribe by brand to aid identification when different presentations are available (Desitrend ampoules or Keppra vials – see section 4.8.1 Control of the epilepsies).
• Each levetiracetam ampoule or vial contains 500mg levetiracetam (pack of 10). Order two packs for the first prescription if total daily oral dose is at the higher end of the dose range.
• Diluent: Use water for injection or sodium chloride 0.9% as a diluent. Should be diluted as much as is practical to avoid site irritation.
• Compatibility: refer to the Supporting guidance for levetiracetam continuous subcutaneous infusion hosted on the Rowcroft Hospice website.
• As with all palliative care medicines administered by syringe pump, responsibility for identifying when further supplies of medicines are needed lies with the nursing teams administering the medicines. Advice on planning for a supply of levetiracetam from community pharmacies is included in the Supporting guidance for levetiracetam continuous subcutaneous infusion. Levetiracetam concentrated solution for intravenous infusion is:
  • not routinely held in stock by community pharmacies, and
  • not included on the Specialist Medicines List, and therefore is not routinely stocked by specialist pharmacies
• Advanced care planning:
  • Most patients will have either primary or secondary brain tumours, and advanced disease with a prognosis of a short number of weeks, or less.
  • The community palliative care teams can assist by identifying patients known to the teams who are receiving oral levetiracetam to consider whether levetiracetam in a syringe pump is likely to be required.
  • Early warning that the patient may be approaching the point where oral administration is not possible would be helpful to ensure timely availability of levetiracetam for infusion from the community pharmacy. Anticipatory prescribing of injectable levetiracetam is not recommended.
  • The specialist palliative care teams are available to discuss patients not known to their teams who may be suitable for levetiracetam administered in a syringe pump. See section 16.1.
• Support from the palliative care teams: The palliative care consultants are available to provide specialist telephone advice, support on prescribing and help with decision making about levetiracetam prescribing 24/7 (see here section 16.1.).

Note for community pharmacies:

• Desitrend ampoules (Desitin Ltd) are available to order through Alliance Healthcare and AAH
• Keppra vials (UCB Pharma Ltd) are available to order through Alliance Healthcare.

Supporting guidance

Supporting guidance for levetiracetam continuous subcutaneous infusion in the community setting has been developed by consultants in palliative medicine working across Devon. The guidance is hosted on the Rowcroft hospice website.

In addition to the information provided above, the guidance covers:

• Dosing in renal impairment
• Compatibility with other medicines administered using a syringe pump
• Volumes and diluent
• Planning for a supply of levetiracetam concentrate for infusion from community pharmacy
• Side effects
• Action to take if levetiracetam is not available or in the event of seizures
• Palliative care team contact details