P3948 - Leve-TOX-cetam

Benjamin Heriford, DO¹, Grace Hopp, DO, MBA¹, Lisa Pedicone, PhD², Carmen Landaverde, MD³, Eric Lawitz, MD³, Jan Petrasek, MD, PhD⁴, Fred Poordad, MD³, Fabian Rodas, MD³, Francis Sharkey, MD¹, Eugenia Tsai, MD^3
1UT Health San Antonio, San Antonio, TX; ²Texas Liver Institute, San Antonio, TX; ³UT Health San Antonio, Texas Liver Institute, San Antonio, TX; ⁴UT Health San Antonio, Texas Liver Institute, Jackson, MS

Introduction: Levetiracetam (LEV) is one of the most widely prescribed anti-epileptic medications. We present a case of drug induced liver injury (DILI) from levetiracetam.

Case Description/Methods: A 46-year-old female with history of seizure and hypertension presented to the hospital with abdominal pain. LEV 1,000 mg daily was started ten days prior for a new diagnosis of seizure. Patient reported no fever, myalgias, respiratory or urinary symptoms, hypotension, or recurrent seizure activity. She reported no recent travel, sick contacts, over-the-counter medications, alcohol, acetaminophen, non-steroidal anti-inflammatory, dietary or herbal supplement use. Laboratory tests revealed AST 728 U/L, ALT 1,089 U/L, ALP 271 U/L, TB 0.5 mg/dL and INR 1.0, increased compared to liver tests two days prior (AST 23 U/L, ALT 48 U/L, ALP 119 U/L, TB 0.2 mg/dL.) Viral and autoimmune workup were negative. Abdominal ultrasound showed mildly echogenic liver with patent vasculature, and normal gallbladder and common bile duct. LEV was discontinued on admission for suspicion of DILI based on Roussel Uclaf Causality Assessment Method (RUCAM) score 12.0. Liver biopsy demonstrated mild lobular hepatitis, minimal steatosis, lobular disarray and intralobular collapse (Figure 1). By day four of admission, liver tests were AST 28 U/L, ALT 73 U/L and ALP 143 U/L.

Discussion: Levetiracetam is a pyrrolidine derivative indicated for the treatment of focal and primary generalized tonic-clonic seizures. The mechanism of levetiracetam is not well understood, but it has been widely used due to its tolerability and rapid efficacy. DILI with levetiracetam is rare because there is minimal hepatic metabolism and does not utilize cytochrome P450. LEV has a toxicity likelihood score of C per LiverTox NIH bookshelf, representing probable rare cause of clinically apparent liver injury. Mechanism of action is a hypersensitivity reaction involving a T-cell mediated response and manifests as hepatocellular injury with onset ranging from 5 days to 5 months after drug initiation. Acute liver failure from LEV is exceedingly rare but has been reported. Histological evaluation typically reveals lobular hepatitis, nonspecific findings as often seen in DILI.



Levetiracetam has been established as a mainstream antiepileptic. Healthcare providers must maintain a high clinical suspicion and be vigilant on its potential for liver toxicity despite its rarity.



Disclosures:


Benjamin Heriford, DO¹, Grace Hopp, DO, MBA¹, Lisa Pedicone, PhD², Carmen Landaverde, MD³, Eric Lawitz, MD³, Jan Petrasek, MD, PhD⁴, Fred Poordad, MD³, Fabian Rodas, MD³, Francis Sharkey, MD¹, Eugenia Tsai, MD³. P3948 - Leve-TOX-cetam, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.