Briviact® (brivaracetam) for epilepsy

Medication safety Medicine Elementary Preteens Seniors

The bottom line

Briviact® (brivaracetam) is an antiepileptic drug (AED) that is used in combination with another AED to improve control of both focal and generalized seizures. Brivaracetam commonly causes drowsiness and dizziness, so it should be used with caution when taking other sedating medications or alcohol. It can interact with drugs that are metabolized by the liver enzyme CYP2C19.

Prevention Tips

Keep all medications in child-resistant containers, stored away from children and pets.
Ask your pharmacist and physician about potential drug interactions between brivaracetam and your other medications. Mention all prescription, over-the-counter, and dietary supplement medications you take.
Don’t stop taking brivaracetam without consulting your healthcare provider. Discontinuing an AED abruptly creates a risk of increased seizure frequency and severity.
Avoid taking brivaracetam with other sedating medications, alcohol, or cannabis. Be aware that additive drowsiness and dizziness can occur.

This Really Happened

Case 1: The manufacturer of brivaracetam reports that one patient took 1400 mg of brivaracetam at once, which was 14 times the maximum recommended single dose. The person became somnolent and dizzy. Other people who took overdoses had symptoms like vertigo, difficulty with balance, fatigue, nausea, double vision, anxiety, and low heart rate (from Briviact prescribing information).

Case 2: When cannabidiol (CBD) was added to help control seizures in five patients already taking brivaracetam, blood levels of brivaracetam increased by 95% to 280%. When CBD inhibited CYP2C19, brivaracetam was not broken down effectively, so it built up in the blood. Two of the patients had mild adverse effects of drowsiness and self-limited diarrhea. The dosage of brivaracetam in one patient was reduced to avoid recurrence of the problem (from Klotz et al. 2019).

Epilepsy and seizures

About 1 in 100 Americans has been diagnosed with epilepsy, and more than 65 million people are affected worldwide. It is characterized by recurring seizures, and is often diagnosed when someone has had two or more seizures. Epilepsy can result from genetic disorders or neurologic damage such as head trauma, stroke, and brain infections, but for two-thirds of epilepsy patients the cause of seizures is not known.

Seizures can happen when sudden bursts of electrical activity in the brain disrupt the normal communication between brain cells (neurons). Generalized seizures affect both sides of the brain, while focal (or partial) seizures affect a single area of the brain. Knowing the type of seizure can help determine which treatments are most likely to help.

What is Briviact^® prescribed for?

Briviact^® (brivaracetam) was approved by the FDA in 2016 to treat focal seizures that have not responded adequately to other antiepileptic drugs (AEDs) in people who are 16 years of age and older. It is now commonly used as add-on therapy with other AEDs to treat generalized seizures. Its mechanism of action is unknown. The recommended starting dosage of brivaracetam is 50 mg twice daily.

Brivaracetam binds to the same brain receptors as the related drug Keppra (levetiracetam), which is a commonly used AED. Brivaracetam and levetiracetam appear to have similar effectiveness and side effect profiles, but there are no studies directly comparing them. Brivaracetam is not available as a generic drug, so the cost of Briviact^® is much higher than generic levetiracetam. Some people whose seizures were not controlled by levetiracetam have responded to brivaracetam.

What are the side effects of Briviact^®?

Brivaracetam’s adverse effects are similar to other AEDs. Here are the most common ones reported by patients in clinical trials:

Somnolence, sedation: 16%
Dizziness: 12%
Fatigue: 9%
Nausea, vomiting: 5%
Anxiety, depression: 5%

Is Briviact^® a controlled substance?

Brivaracetam is classified as a Schedule V Controlled Substance because the usual maximum adult dose (200 mg) has caused euphoria in some individuals. Its tendency to cause drowsiness as a side effect can result in extra sedation when brivaracetam is added to other drugs that cause sedation including alcohol, opioid pain relievers, cannabis, and many drugs used for neurologic and psychiatric conditions. Avoid taking brivaracetam with other substances that have sedation as a side effect until you know how the combination affects you. There is no specific antidote for a brivaracetam overdose.

What should I avoid while taking Briviact^®?

Brivaracetam can interact with medications that are metabolized by the same enzyme in the liver (CYP2C19). An interaction can occur when two or more of these drugs are taken, and it can change the effectiveness and/or safety of one or both of the interacting medications. Fortunately, drug interactions involving brivaracetam and these other medications can usually be managed by adjusting the dosage of one or both drugs.

Here are some examples of potential drug interactions between brivaracetam and other medications for epilepsy that are metabolized by CYP2C19:

If a person with epilepsy takes Tegretol (carbamazepine) plus brivaracetam to control seizures, the CYP2C19 interaction could increase carbamazepine levels and reduce brivaracetam levels in the blood. Carbamazepine toxicity could result, and brivaracetam might drop too low to keep seizures in check. The dose of one or both drugs might need to be adjusted.
If brivaracetam is taken with the AED Dilantin^® (phenytoin), the blood concentration of phenytoin might increase to toxic levels.
When patients have added cannabidiol (CBD) to brivaracetam for seizure control, a CYP2C19 interaction has caused brivaracetam blood levels to double and even quadruple in some people. (See: This Really Happened, Case 2)

What should I do if someone accidentally takes Briviact^® or takes too much Briviact^®?

If you suspect someone has unintentionally taken brivaracetam or is experiencing its side effects, use the webPOISONCONTROL^® online tool to get help, or call your poison center at 1-800-222-1222. Whether online or by phone, expert guidance is always free, confidential, and available 24 hours a day.