Maximum Single Dose of Levetiracetam (Keppra) in Children
The maximum single dose of levetiracetam in children for status epilepticus is 50 mg/kg IV (maximum 2500 mg) administered over 10-15 minutes. 1
Dosing Guidelines by Indication
Status Epilepticus
- Loading dose: 30-50 mg/kg IV administered over 10-15 minutes 1
- Maximum single dose: 50 mg/kg (not to exceed 2500 mg) 2
Maintenance Therapy
- Initial daily dose: 20 mg/kg/day divided into two doses (10 mg/kg twice daily) 3
- Titration: Increase by 20 mg/kg/day every 2 weeks 3
- Recommended maintenance dose: 60 mg/kg/day divided into two doses (30 mg/kg twice daily) 3
- Maximum FDA-approved daily dose: 60 mg/kg/day 3
Weight-Based Dosing Guide
For children weighing:
- ≤20 kg: Use oral solution
- 20.1-40 kg:
- Starting: 500 mg/day (250 mg twice daily)
- Maximum: 1500 mg/day (750 mg twice daily)
40 kg:
- Starting: 1000 mg/day (500 mg twice daily)
- Maximum: 3000 mg/day (1500 mg twice daily) 3
Special Considerations
Higher Doses in Refractory Cases
Some children with refractory epilepsy may benefit from and tolerate doses higher than the standard 60 mg/kg/day. A study found that doses up to 275 mg/kg/day (median 146 mg/kg/day) were used in selected cases with 44% of patients showing >50% seizure reduction and only 12% experiencing adverse effects 4.
Age-Related Pharmacokinetics
- Children have approximately 30-40% higher clearance of levetiracetam compared to adults 5
- Half-life in children: 6.0 ± 1.1 hours (vs. longer in adults) 5
- This may necessitate relatively higher weight-based dosing in children compared to adults
Adverse Effects
- Most common: somnolence (10.5-15.2%), fatigue, dizziness, and irritability 1
- Behavioral side effects (irritability, agitation) occur in approximately 12-15% of patients 1, 6
- Higher risk in patients with intellectual disability or psychiatric history 1
Practical Recommendations
For routine epilepsy management:
- Start with 10 mg/kg twice daily
- Titrate up by 10-20 mg/kg/day increments every 2 weeks
- Standard target: 60 mg/kg/day in two divided doses
For status epilepticus:
- Use loading dose of 50 mg/kg IV (maximum 2500 mg) over 10-15 minutes
- Monitor for respiratory depression when combined with other sedative agents
For special situations (e.g., busulfan-induced seizure prophylaxis):
- 10 mg/kg twice daily (20 mg/kg/day in 2 divided doses) 7
While some studies have explored much higher doses (up to 275 mg/kg/day) in refractory cases, these should be considered exceptional rather than routine practice, and require careful monitoring for adverse effects.