What is the recommended Keppra (levetiracetam) loading dose IV and maintenance dose?

Levetiracetam (Keppra) IV Loading and Maintenance Dosing

For adults with seizures requiring IV levetiracetam, the recommended loading dose is 30-50 mg/kg (up to a maximum of 4500 mg) administered at 100 mg/min, followed by a maintenance dose of 500-1500 mg twice daily. 1

Loading Dose Protocol

The loading dose should be administered based on the clinical scenario:

• Standard loading dose: 30 mg/kg IV at 100 mg/min
• Status epilepticus: 40-50 mg/kg IV at 100 mg/min
• Maximum loading dose: 4500 mg

Administration Guidelines

• Administer through a dedicated IV line
• Do not dilute prior to use (comes in ready-to-use bags) 2
• Infuse over 15 minutes to minimize adverse effects

Maintenance Dosing

After the loading dose, maintenance therapy should be initiated:

• Initial maintenance: 500 mg IV twice daily
• Titration: Increase by 500 mg twice daily every 2 weeks as needed 2
• Target maintenance dose: 1000-1500 mg twice daily
• Maximum daily dose: 3000 mg (1500 mg twice daily)

Special Populations

Renal Impairment

Dose adjustment is necessary based on creatinine clearance 2:

• CrCl >80 mL/min: No adjustment needed
• CrCl 50-80 mL/min: 500-1000 mg every 12 hours
• CrCl 30-50 mL/min: 250-750 mg every 12 hours
• CrCl <30 mL/min: 250-500 mg every 12 hours

Elderly Patients

Consider starting at the lower end of the dosing range (1500 mg loading dose followed by 500 mg twice daily) due to potential for decreased renal clearance 3.

Clinical Efficacy and Safety

Levetiracetam is highly effective for seizure termination:

• 84-93% seizure termination rate within 60 minutes regardless of loading dose 4
• Minimal cardiovascular adverse effects compared to other IV antiepileptics 5
• No need for serum level monitoring due to wide therapeutic window

Common Pitfalls and Caveats

1. Higher loading doses may increase intubation risk: Loading doses ≥40 mg/kg were associated with higher rates of intubation (45.8%) compared to lower doses (26.8-28.2%) 4

2. Adverse effects: Monitor for somnolence, asthenia, and dizziness, which are the most common side effects 2

3. Psychiatric reactions: Behavioral abnormalities including psychotic symptoms, irritability, and aggressive behavior may occur; monitor patients closely 2

4. Switching from IV to oral: When transitioning from IV to oral therapy, maintain the same total daily dose and frequency 2

5. Withdrawal seizures: Levetiracetam must be gradually withdrawn to prevent seizure recurrence 2

Practical Approach

1. Calculate weight-based loading dose (30-50 mg/kg)
2. Administer loading dose over 15 minutes
3. Begin maintenance dose (500-1500 mg twice daily) 12 hours after loading dose
4. Monitor for clinical response and adverse effects
5. Adjust dose based on renal function and clinical response

By following this protocol, levetiracetam can be safely and effectively administered intravenously for seizure management with minimal risk of serious adverse effects.