A Rare Case of Levetiracetam-induced Transaminitis

Thursday, November 16, 2023

Primary Author(s)

Matthew Hutcherson, MD (he/him/his)

Resident Physician
University of Toledo PM&R Program
Toledo, Ohio

Co-Author(s)

BD

Brock DeAngelo, DO

Resident Physician
University of Toledo PM&R Program
Toledo, Ohio
JG

Jacob D. Goatley, MD

Resident Physician
University of Toledo PM&R Program
Toledo, Ohio
JP

Jordan Perlman, MD

Resident Physician
University of Toledo PM&R Program
Toledo, Ohio
AS

Ashley Schneider, MD

Associate Program Director
University of Toledo PM&R Program
Toledo, Ohio

Case Diagnosis: A rare instance of levetiracetam-induced transaminitis which resolved following transition to alternative medication.

Case Description or Program Description: The patient is a 45 year old female who presented to acute inpatient rehab following hospitalization for large subarachnoid hemorrhage complicated by hydrocephalus requiring EVD placement, inability to wean from ventilator, and multiple operations including hematoma evacuation, anterior communicating artery aneurysm repair, and hemicraniectomy. The patient was noted to exhibited right arm jerking concerning for clinical seizure and was started on levetiracetam. While admitted to the rehab hospital, periodic laboratory monitoring revealed elevated transaminases. Ammonia was within normal limits and hepatitis panel was negative. Medication review did not find anything typically concerning for hepatotoxicity, though literature review indicated levetiracetam has been linked to rare instances of serum aminotransferase elevation. Levetiracetam was discontinued and patient was started on phenytoin 100 mg 3 times daily. Subsequent laboratory monitoring showed improvement and eventual resolution of transaminitis.

Setting: Acute inpatient rehabilitation hospital.

Assessment/Results: The patient exhibited an instance of levetiracetam-induced transaminitis, which resolved by transitioning to alternative anticonvulsant.

Discussion (relevance): While not typically considered hepatotoxic, levetiracetam has been linked to rare cases of elevated transaminases. In addition, the time to onset of injury can range from one week to several months, so levetiracetam may not be initially considered as the culprit for elevated LFTs. In this reported patient, transaminitis resolved following discontinuation of levetiracetam.

Conclusions: Despite not depending on any cytochrome P450 enzymes for metabolism, levetiracetam should be considered among the underlying cause of transaminitis, especially if other causes have been ruled out.