What is the recommended loading and maintenance dose of Keppra (levetiracetam) for a patient with a recent frontal ischemic stroke and a generalized tonic-clonic seizure?

Levetiracetam Dosing for Post-Stroke Seizure Management

For a 73-year-old patient with recent frontal ischemic stroke who experienced a 5-minute generalized tonic-clonic seizure, the recommended loading dose is 1,500 mg of levetiracetam IV, followed by a maintenance dose of 1,000 mg twice daily (2,000 mg/day). 1

Loading Dose Rationale

The loading dose of levetiracetam should be administered immediately after confirming the seizure has stopped and ruling out intracranial hemorrhage on neuroimaging:

• 1,500 mg IV loading dose is recommended for rapid achievement of therapeutic levels 1
• This dose is well-tolerated in post-stroke patients and provides rapid seizure control
• For a 70 kg patient, this equates to approximately 20-22 mg/kg, which falls within the safe loading range

Maintenance Dosing

After the loading dose, initiate maintenance therapy:

• Start with 1,000 mg twice daily (2,000 mg/day) 1, 2
• This dosing regimen has shown efficacy in post-stroke seizure management with 77.1% of patients achieving seizure freedom 3
• The maintenance dose can be administered orally if the patient can swallow, or continued IV if swallowing is impaired

Dosing Considerations for This Patient

Several factors support this dosing recommendation for this specific patient:

1. Age consideration: At 73 years old, starting with a moderate dose (2,000 mg/day) balances efficacy with minimizing adverse effects
2. Post-stroke context: Levetiracetam is particularly suitable for post-stroke seizures due to minimal drug interactions and favorable side effect profile 3
3. Weight-based dosing: For a 70 kg patient, this maintenance dose (approximately 30 mg/kg/day) falls within the effective range

Monitoring and Dose Adjustment

• Assess clinical response and tolerability after 24-48 hours
• If seizures recur, consider increasing to 1,500 mg twice daily (3,000 mg/day) 2
• Monitor for adverse effects, particularly:
  • Somnolence and fatigue (most common)
  • Neuropsychiatric symptoms (irritability, mood changes, aggression) which occur in approximately 8% of patients 4
  • Dizziness

Important Considerations

• Levetiracetam has demonstrated efficacy specifically in post-stroke seizures with 77.1% of patients achieving seizure freedom at doses between 1,000-2,000 mg/day 3
• The drug can be administered with or without food 2
• No dose adjustment is needed for hepatic impairment, but dose reduction may be necessary with significant renal impairment
• Avoid abrupt discontinuation as this may increase seizure risk

This dosing recommendation balances the need for rapid seizure control with minimizing adverse effects in an elderly post-stroke patient, focusing on the outcomes of reducing morbidity and mortality while maintaining quality of life.