Recommended Usage and Dosage of Keppra (Levetiracetam) for Treating Seizures
For treating seizures, Keppra (levetiracetam) should be initiated at 1000 mg/day (500 mg twice daily) for adults, with titration up to 3000 mg/day maximum based on clinical response, while children require weight-based dosing starting at 20 mg/kg/day divided into two doses. 1
Adult Dosing Guidelines
Partial Onset Seizures (Adults ≥16 years)
- Initial 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
- No evidence that doses >3000 mg/day provide additional benefit 1
Myoclonic Seizures (≥12 years with juvenile myoclonic epilepsy)
- Initial dose: 1000 mg/day given as 500 mg twice daily
- Titration: Increase by 1000 mg/day every 2 weeks
- Recommended dose: 3000 mg/day
- Lower doses have not been adequately studied 1
Primary Generalized Tonic-Clonic Seizures (Adults ≥16 years)
- Initial dose: 1000 mg/day given as 500 mg twice daily
- Titration: Increase by 1000 mg/day every 2 weeks
- Recommended dose: 3000 mg/day 1
Pediatric Dosing Guidelines
Partial Onset Seizures (Ages 4 to <16 years)
- Initial dose: 20 mg/kg/day divided into two doses (10 mg/kg twice daily)
- Titration: Increase by 20 mg/kg/day every 2 weeks
- Recommended dose: 60 mg/kg/day (30 mg/kg twice daily)
- Mean daily dose in clinical trials: 52 mg/kg 1
Primary Generalized Tonic-Clonic Seizures (Ages 6 to <16 years)
- Initial dose: 20 mg/kg/day divided into two doses
- Titration: Increase by 20 mg/kg/day every 2 weeks
- Recommended dose: 60 mg/kg/day 1
Special Considerations
Renal Impairment
- Dose adjustments required based on creatinine clearance
- For creatinine clearance 50-80 ml/min: 500-1000 mg every 12 hours 2
Administration
- Can be given with or without food 1
- For children ≤20 kg: Use oral solution
- For children >20 kg: Can use either tablets or oral solution 1
Safety Profile and Adverse Effects
- Common adverse effects: somnolence (10.5-15.2%), asthenia, dizziness, and irritability 2
- Behavioral adverse effects occur in approximately 12-15% of patients, particularly those with intellectual disability or psychiatric history 2
- Approximately 89% of patients do not report significant adverse effects after loading dose 2
Special Clinical Scenarios
Status Epilepticus
- Loading dose: 30 mg/kg IV (maximum 2500 mg)
- Administration rate: 5 mg/kg per minute 2
- Efficacy: 67-73% in controlling refractory status epilepticus 2
Seizure Prophylaxis in Neurocritical Care
- Higher doses (>1000 mg/day, typically 2000 mg/day) may be more effective for seizure prophylaxis in patients with subarachnoid hemorrhage or traumatic brain injury 3
CAR T-Cell Therapy Patients
- For patients with CNS disease or history of seizures receiving CAR T-cell therapy:
- Dose: 10 mg/kg (maximum 500 mg per dose) every 12 hours
- Duration: 30 days following infusion 4
Clinical Efficacy
- Median reduction in total seizure frequency: 57.7%
- 50% responder rate: 56.6%
- Seizure-free rate: 12.5% throughout clinical trials 5
- Dose-response relationship has been observed, with higher doses providing greater seizure control 6
Key Advantages
- Minimal drug interactions, especially important for patients on multiple medications 2
- Well-tolerated with favorable safety profile 7
- No clinically relevant interactions with digoxin, warfarin, probenecid, or oral contraceptives 7
Remember that while the FDA-approved maximum dose is 3000 mg/day, recent evidence suggests that higher doses may be beneficial in certain clinical scenarios such as neurocritical care, though this should be balanced against the potential for increased adverse effects.