Starting Dose of Levetiracetam (Keppra) for Epilepsy
The recommended starting dose of levetiracetam (Keppra) for epilepsy in adults is 1000 mg/day, given as 500 mg twice daily. 1
Adult Dosing (16 years and older)
- Initial dose: 1000 mg/day (500 mg twice daily)
- Titration: Increase by 1000 mg/day every 2 weeks
- Maximum recommended dose: 3000 mg/day
- Administration: Can be taken with or without food
Pediatric Dosing
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
- Target dose: 60 mg/kg/day (30 mg/kg twice daily)
- Weight-based dosing guide:
- 20.1-40 kg: Start with 500 mg/day (250 mg twice daily)
40 kg: Start with 1000 mg/day (500 mg twice daily)
Dosing for Specific Seizure Types
Partial Onset Seizures
- Follow standard adult or pediatric dosing as outlined above
Myoclonic Seizures (12 years and older with juvenile myoclonic epilepsy)
- Initial dose: 1000 mg/day (500 mg twice daily)
- Titration: Increase by 1000 mg/day every 2 weeks
- Target dose: 3000 mg/day
Primary Generalized Tonic-Clonic Seizures
- Adults: Same as standard adult dosing
- Children 6 to <16 years: Same as standard pediatric dosing (20 mg/kg/day initially)
Special Considerations
Renal Impairment
- Dosage adjustments are necessary for patients with moderate to severe renal impairment as levetiracetam is primarily excreted unchanged in urine 2
Pharmacokinetic Advantages
- Rapid absorption (peak concentration at 1.3 hours)
- High bioavailability (>95%)
- No significant protein binding
- Linear pharmacokinetics (proportional increase with dose)
- No autoinduction
- Minimal drug interactions with other antiepileptic drugs 2
Monitoring and Follow-up
- Steady-state blood concentrations are achieved within 24-48 hours 2
- Monitor for common adverse effects:
Clinical Efficacy
- Both 1000 mg/day and 2000 mg/day doses significantly decrease seizure frequency compared to placebo
- Higher doses (2000 mg/day) show greater response rates than lower doses (1000 mg/day) 5
- Some patients may benefit from doses higher than the standard maximum, but adverse effects increase with higher doses 3, 4
Levetiracetam's favorable pharmacokinetic profile makes it a straightforward medication to initiate, with minimal drug interactions and predictable dose-response relationships. The starting dose of 1000 mg/day for adults provides a good balance of efficacy and tolerability, with the option to titrate upward based on clinical response.