Levetiracetam (Keppra) Dosing in Children
The recommended dosing of levetiracetam in children is 10-20 mg/kg/day initially, increased every 2 weeks by 20 mg/kg/day increments to a target dose of 60 mg/kg/day divided into two doses. 1
Age-Specific Dosing Guidelines
Children 4 to <16 years (Partial Onset Seizures):
- 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
- Target dose: 60 mg/kg/day (30 mg/kg twice daily)
- Mean effective dose in clinical trials: 52 mg/kg/day 1
Children 6 to <16 years (Primary Generalized Tonic-Clonic Seizures):
- Same dosing as for partial onset seizures
- Effectiveness of doses lower than 60 mg/kg/day has not been adequately studied 1
Children 12 years and older (Myoclonic Seizures):
- Initial dose: 1000 mg/day (500 mg twice daily)
- Titration: Increase by 1000 mg/day every 2 weeks
- Target dose: 3000 mg/day 1
Administration Guidelines
- For children weighing ≤20 kg: Use oral solution
- For children weighing >20 kg: Can use either tablets or oral solution
- Administer with or without food 1
Weight-Based Dosing Table
| Patient Weight | 20 mg/kg/day (BID dosing) | 40 mg/kg/day (BID dosing) | 60 mg/kg/day (BID dosing) |
|---|---|---|---|
| 20.1 to 40 kg | 500 mg/day (250 mg BID) | 1000 mg/day (500 mg BID) | 1500 mg/day (750 mg BID) |
| >40 kg | 1000 mg/day (500 mg BID) | 2000 mg/day (1000 mg BID) | 3000 mg/day (1500 mg BID) |
Special Considerations
Titration Speed
- Consider slower titration in patients with history of behavioral problems or psychiatric disorders, as behavioral side effects occur in approximately 12-15% of patients 2
- In children, doses above 20 mg/kg/day should be introduced with caution to avoid paradoxical effects 3
Prophylactic Use
- For children receiving CAR T-cell therapy with CNS disease or history of seizures: 10 mg/kg (maximum 500 mg per dose) every 12 hours for 30 days 4
Pharmacokinetics in Children
- Children have approximately 30-40% higher clearance of levetiracetam compared to adults
- A daily maintenance dose equivalent to 130-140% of the usual adult dose on a weight-normalized basis is recommended 5
Side Effects to Monitor
- Most common: Somnolence (7-15%), dysphoria, nervousness 6
- Behavioral side effects are more common in children with intellectual disability or psychiatric history 2, 3
- Paradoxical effect (seizure worsening) may occur in 43% of children, particularly in those with mental retardation and on higher doses 3
Important Precautions
- Warning: A paradoxical increase in seizures can occur, particularly in mentally retarded patients during the first 2 months of treatment 3
- To minimize risk of paradoxical effects, consider:
- Lower initial dose (10 mg/kg/day)
- Slower dose escalation than manufacturer recommendations
- Extra caution when exceeding 20 mg/kg/day 3
Levetiracetam is generally well-tolerated and effective for a wide range of epileptic seizures in children, with studies showing 64.8% of patients becoming seizure-free and 83% achieving at least 50% seizure reduction 6.