Levetiracetam (Keppra) Dosing Recommendations
For adults with epilepsy, initiate levetiracetam at 500 mg twice daily (1000 mg/day total) and increase by 1000 mg/day every 2 weeks to a maximum of 3000 mg/day as needed for seizure control. 1
Adult Dosing (16 years and older)
Partial Onset Seizures
- Starting dose: 500 mg twice daily (1000 mg/day)
- Titration: Increase by 1000 mg/day every 2 weeks
- Maximum recommended dose: 1500 mg twice daily (3000 mg/day)
- No evidence that doses above 3000 mg/day provide additional benefit 1
Myoclonic Seizures (Juvenile Myoclonic Epilepsy)
- Starting dose: 500 mg twice daily (1000 mg/day)
- Titration: Increase by 1000 mg/day every 2 weeks
- Target dose: 3000 mg/day
- Note: Doses lower than 3000 mg/day have not been adequately studied 1
Primary Generalized Tonic-Clonic Seizures
- Starting dose: 500 mg twice daily (1000 mg/day)
- Titration: Increase by 1000 mg/day every 2 weeks
- Target dose: 3000 mg/day 1
Pediatric Dosing
Ages 4 to <16 years
- Starting dose: 10 mg/kg twice daily (20 mg/kg/day)
- Titration: Increase by 20 mg/kg/day every 2 weeks
- Target dose: 30 mg/kg twice daily (60 mg/kg/day)
- Maximum daily dose: 3000 mg/day 1
Ages 6 months to <4 years
- Starting dose: 10 mg/kg twice daily (20 mg/kg/day)
- Titration: Increase by 20 mg/kg after 2 weeks
- Target dose: 25 mg/kg twice daily (50 mg/kg/day) 1
Ages 1 month to <6 months
- Starting dose: 7 mg/kg twice daily (14 mg/kg/day)
- Titration: Increase by 14 mg/kg/day every 2 weeks
- Target dose: 21 mg/kg twice daily (42 mg/kg/day) 1
Loading Dose Considerations
For rapid initiation in emergency situations:
- Oral loading: 1500 mg as a single dose has been shown to be well-tolerated 2
- IV loading: For status epilepticus, 40 mg/kg (maximum 2500 mg) as a bolus 3
- Maintenance can begin 12 hours after loading with 500-1000 mg twice daily 2
Dosage Adjustments for Renal Impairment
| Renal Function | Creatinine Clearance (mL/min/1.73m²) | Dosage (mg) | Frequency |
|---|---|---|---|
| Normal | >80 | 500-1500 | Every 12h |
| Mild | 50-80 | 500-1000 | Every 12h |
| Moderate | 30-50 | 250-750 | Every 12h |
| Severe | <30 | 250-500 | Every 12h |
| ESRD on dialysis | - | 500-1000* | Every 24h |
*Following dialysis, a 250-500 mg supplemental dose is recommended 1
Special Considerations
Administration: Can be given with or without food 1
Seizure Prophylaxis: For CAR T-cell therapy patients, levetiracetam 500-750 mg twice daily for 30 days is recommended for seizure prophylaxis 3
Oral Loading: Oral loading with 1500 mg has been shown to achieve therapeutic levels within 1-2 hours (mean concentration ~30 μg/mL) with minimal side effects 2
Weight-Based Dosing:
- For patients 20-40 kg: Start with 250 mg twice daily, increase by 500 mg/day every 2 weeks to maximum 750 mg twice daily
- For patients >40 kg: Adult dosing applies 1
Tolerability: Levetiracetam is generally well-tolerated with common side effects including somnolence, dizziness, and fatigue 4
Common Pitfalls to Avoid
- Underdosing: Starting at too low a dose may delay seizure control
- Rapid titration: While levetiracetam can be titrated faster than many other antiepileptics, watch for increased side effects with rapid titration
- Missing renal adjustment: Always check renal function and adjust accordingly
- Behavioral effects: Monitor for irritability, mood changes, or behavioral issues, especially in pediatric patients 1
Levetiracetam's favorable pharmacokinetic profile allows for twice-daily dosing, minimal drug interactions, and relatively rapid titration compared to many other antiepileptic medications 4.