Optimizing anti-seizure medication management in therapeutic plasma exchange: A practical case report

Therapeutic plasma exchange (TPE) is a widely employed procedure for treating several diseases. However, its impact on drug removal is understudied. In critical care settings, the therapeutic window is often narrow but crucial to optimize drug efficacy. This case report details a new onset of refractory status epilepticus, which required the administration of four concomitant anti-seizure medications and the implementation of TPE. We conducted drug monitoring before and after TPE sessions, describing for the first time the removal rate of midazolam and propofol during TPE (low removal rate), and confirming existing data concerning levetiracetam and phenytoin. In critically ill patients, the concomitant use of narrow therapeutic index drugs and plasma exchange requires close drug monitoring.