Levetiracetam Loading Dose in Status Epilepticus
The recommended loading dose of Keppra (levetiracetam) for status epilepticus in adults is 30-60 mg/kg IV (maximum 4500 mg) administered at a rate of 100 mg/min. 1
Adult Dosing
- For adult patients, a loading dose of 30-50 mg/kg IV at a rate of 100 mg/min is recommended 2, 1
- Typical fixed dosing in adults ranges from 1500-3000 mg IV 1
- Maximum single dose should not exceed 4500 mg 1
- Administration rate should not exceed 100 mg/min to minimize adverse effects 1
Pediatric Dosing
- For children with status epilepticus, the recommended loading dose is 20 mg/kg IV (maximum 1000 mg) infused over 10 minutes 2, 1
- For neonates with status epilepticus, a loading dose of 10 mg/kg IV is recommended 1
- The recommended infusion time for pediatric patients is 10-20 minutes 1
Administration Considerations
- Levetiracetam can be administered as an IV push (IVP) or IV piggyback (IVPB) infusion 3
- IV push administration has been shown to reduce time to administration compared to IVPB (12 vs. 38 minutes) without increasing adverse events 3
- Unlike phenytoin/fosphenytoin, levetiracetam does not require cardiac monitoring during administration 1
- Levetiracetam has minimal drug interactions, making it suitable for patients on multiple medications 1
Efficacy and Safety
- Levetiracetam is considered a second-line agent after benzodiazepines for status epilepticus 1
- Recent evidence suggests that higher loading doses (≥40 mg/kg) do not result in significantly better seizure termination rates compared to moderate doses (21-39 mg/kg) or lower doses (≤20 mg/kg) 4
- Higher doses (≥40 mg/kg) may be associated with increased rates of intubation (45.8% vs. 28.2% for moderate doses and 26.8% for lower doses) 4
- In pediatric patients, levetiracetam has shown seizure termination in 43% of cases with refractory status epilepticus, with higher efficacy (57%) in children younger than 2 years 5
Clinical Pearls
- Doses above 30 mg/kg may not provide additional benefit in seizure termination, similar to findings with valproate in status epilepticus 6
- In status epilepticus patients, IV push administration of levetiracetam may reduce ICU admissions compared to IV piggyback infusion 3
- Levetiracetam can be repeated once after 15 minutes if necessary (maximum total dose: 40 mg/kg) 2
- Monitor for adverse effects including nausea and rash, though these are uncommon 2