PPF80 Subcutaneous levetiracetam in palliative care: evaluating mixed drug use in syringe drivers – a case series

<h3>Background</h3> Seizures are a common and distressing symptom at the end of life (EOL), often resulting from cerebral neoplasms or uncontrolled epilepsy. They can cause further neurological damage and emotional distress for patients and caregivers. When oral or intravenous routes are not viable, subcutaneous (SC) levetiracetam is increasingly used off-label in palliative care. It offers a non-sedating alternative to benzodiazepines like midazolam and has shown efficacy in controlling seizures in structural focal epilepsy and other disorders. However, compatibility concerns may necessitate multiple syringe drivers, as evidence on mixing levetiracetam with other drugs is limited. <h3>Aim</h3> To evaluate the tolerability and clinical effects of mixing levetiracetam with other palliative medications used at EOL for seizure management. <h3>Methods</h3> A retrospective case note review was conducted, collecting data on patient age, diagnosis, drug doses, duration, diluent used, and site reactions. <h3>Results</h3> Nineteen patients (mean age 70.7 years; 13 male, 6 female) were included. Epilepsy was the most frequent indication (47%), followed by metastatic melanoma and cerebral infarcts. Levetiracetam was administered at a median dose of 1000 mg (range 500–1500 mg) over a median of 2 days (range 0–14). Midazolam was the most common co-administered drug, followed by morphine, oxycodone, and hyoscine butyl bromide. Four patients (21%) received three-drug combinations. Two patients received 1500 mg for 14 days. Higher doses and multi-drug combinations used 30 ml syringes. No site reactions or compatibility issues were reported. Water for injection was used as the diluent in most of the cases. <h3>Conclusions</h3> Levetiracetam appears safe and compatible when mixed with commonly used palliative drugs such as morphine, midazolam, oxycodone and hyoscine butyl bromide supporting its use in seizure management at EOL. Its inclusion in combination syringe drivers may reduce the need for multiple infusion devices, improving patient comfort and simplifying care delivery.