Levetiracetam Dosing in Pediatric Patients with Impaired Renal Function
For pediatric patients with impaired renal function, levetiracetam dosage should be adjusted based on creatinine clearance, with recommended doses ranging from 250-750 mg every 12 hours for moderate impairment (creatinine clearance 30-50 mL/min) to 250-500 mg every 12 hours for severe impairment (creatinine clearance <30 mL/min). 1
Standard Pediatric Dosing
Before discussing renal adjustments, it's important to understand standard pediatric dosing:
- Initial dosing: 20 mg/kg/day divided into two doses (10 mg/kg twice daily) 1
- Titration: Increase by 20 mg/kg increments every 2 weeks 1
- Target maintenance dose: 60 mg/kg/day (30 mg/kg twice daily) 1
- Administration: Can be given orally with or without food 1
Renal Impairment Dosing Adjustments
Levetiracetam is primarily eliminated unchanged through the kidneys, making dose adjustment necessary in renal impairment. For pediatric patients with impaired renal function, adjust dosing according to creatinine clearance:
| Renal Function | Creatinine Clearance | Dosage | Frequency |
|---|---|---|---|
| Normal | >80 mL/min | 500-1,500 mg | Every 12 hours |
| Mild impairment | 50-80 mL/min | 500-1,000 mg | Every 12 hours |
| Moderate impairment | 30-50 mL/min | 250-750 mg | Every 12 hours |
| Severe impairment | <30 mL/min | 250-500 mg | Every 12 hours |
| ESRD using dialysis | - | 500-1,000 mg | Every 24 hours* |
*Following dialysis, a 250-500 mg supplemental dose is recommended 1
Calculating Pediatric Renal Dosing
Estimate creatinine clearance using the modified Schwartz formula:
- CLcr (mL/min/1.73m²) = (k × height in cm) / serum creatinine (mg/dL)
- Where k = 0.45 for infants 1-52 weeks, 0.55 for children 1-13 years, 0.55 for adolescent females, and 0.7 for adolescent males
Calculate dose based on weight and renal function:
- For moderate impairment: Start with 50% of the normal dose
- For severe impairment: Start with 30-50% of the normal dose
Special Considerations
- Monitoring: More frequent monitoring of drug levels may be beneficial in pediatric patients with renal impairment
- Side effects: Common adverse effects include somnolence (10.5-15.2%), asthenia, dizziness, and irritability 2
- Behavioral effects: Children with intellectual disability or psychiatric history may be at higher risk for behavioral side effects (12-15% of patients) 2
- Titration: Consider slower titration in patients with significant renal impairment to avoid adverse effects
Clinical Pearls
- Levetiracetam has a favorable safety profile with minimal drug interactions, making it preferable in patients receiving other medications 2
- For patients requiring seizure prophylaxis (such as those with CNS disease), the recommended dose is 10 mg/kg (up to 500 mg) every 12 hours for 30 days 3
- In status epilepticus, a loading dose of 30-50 mg/kg IV administered over 10-15 minutes may be used, but should be adjusted for renal function 2
- For children with renal impairment who are at higher risk for behavioral side effects, consider starting at the lower end of the dosing range and titrating more slowly 2
By following these guidelines, levetiracetam can be safely and effectively administered to pediatric patients with impaired renal function while minimizing the risk of adverse effects and maintaining therapeutic efficacy.