Initial Dosing of Levetiracetam (Keppra) for Seizure Control
The initial dose of levetiracetam for seizure control in adults is 500 mg twice daily (1000 mg/day), with gradual titration by 1000 mg/day every 2 weeks to a maximum recommended dose of 3000 mg/day. 1
Adult Dosing (16 years and older)
- Starting dose: 1000 mg/day given as 500 mg twice daily
- Titration: Increase by 1000 mg/day every 2 weeks
- Maximum recommended dose: 3000 mg/day
- Administration: Can be given with or without food
Pediatric Dosing
Children 4 to <16 years:
- Starting dose: 20 mg/kg/day divided into two doses (10 mg/kg twice daily)
- Titration: Increase by 20 mg/kg every 2 weeks
- Target dose: 60 mg/kg/day (30 mg/kg twice daily)
- Mean effective dose in clinical trials: 52 mg/kg/day 1
Weight-based dosing guide for children:
- 20.1-40 kg: Start with 500 mg/day (250 mg twice daily)
40 kg: Start with 1000 mg/day (500 mg twice daily) 1
Special Clinical Scenarios
Status Epilepticus
For status epilepticus, higher loading doses are typically used:
Electrical Status Epilepticus in Sleep (ESES)
- Recommended dose: 40-50 mg/kg/day divided into two doses (maximum 2.5g) 3
Formulation Considerations
- Patients weighing ≤20 kg should receive oral solution
- Patients weighing >20 kg can receive either tablets or oral solution
- Oral solution calculation: Total daily dose (mL/day) = Daily dose (mg/kg/day) × patient weight (kg) ÷ 100 mg/mL 1
Common Side Effects
- Most common: Somnolence and asthenia
- Side effect frequency and severity may increase with higher doses 4
- Generally well-tolerated compared to other antiepileptic medications, with adverse events reported in approximately 8% of patients (versus 21% with other antiseizure medications) 5
Clinical Pearls
- Levetiracetam does not require therapeutic drug monitoring
- No significant drug interactions with other antiepileptic drugs
- Doses greater than 3000 mg/day have been used in open-label studies but without evidence of additional benefit 1
- In patients with renal impairment, dose adjustment is necessary based on creatinine clearance
When initiating levetiracetam therapy, it's important to start at the recommended initial dose and titrate gradually to minimize side effects while achieving seizure control. The medication's favorable safety profile and minimal drug interactions make it a practical choice for many patients requiring seizure control.