What is the loading dose for Levetiracetam (Keppra)?

From the Guidelines

The loading dose for Levetiracetam (Keppra) is 1,500 mg oral load or up to 60 mg/kg rapid IV loading. This recommendation is based on the most recent and highest quality study available, which suggests that a loading dose of 1,500 mg oral load or up to 60 mg/kg rapid IV loading is safe and well tolerated 1. The study found that no seizures occurred within 24 hours of loading in a study of oral loading, and fatigue, dizziness, and rarely pain at the infusion site were the only reported adverse effects.

Key Considerations

• The loading dose can be administered orally or intravenously, with the IV route being faster to load but potentially more serious adverse effects 1.
• The medication achieves therapeutic levels quickly after IV administration, with peak concentrations occurring at the end of infusion.
• Patients should be monitored for side effects including fatigue, dizziness, and behavioral changes.
• Dose adjustments may be necessary for patients with renal impairment, as levetiracetam is primarily eliminated through the kidneys.

Administration Options

• Oral loading: 1,500 mg single oral load
• IV loading: up to 60 mg/kg rapid IV loading
• Maintenance therapy: usually begins with 500-1,500 mg twice daily, with adjustments based on clinical response and tolerability 1.

From the FDA Drug Label

Treatment should be initiated with a daily dose of 1000 mg/day, given as twice-daily dosing (500 mg BID) Treatment should be initiated with a daily dose of 20 mg/kg in 2 divided doses (10 mg/kg BID) The loading dose for Levetiracetam (Keppra) is 1000 mg/day for adults, given as twice-daily dosing (500 mg BID), and 20 mg/kg in 2 divided doses (10 mg/kg BID) for pediatric patients 2.

From the Research

Levetiracetam Loading Dose

• The loading dose for Levetiracetam (Keppra) can vary depending on the clinical situation and patient population.
• A study published in 2008 3 investigated the tolerability and efficacy of oral loading of levetiracetam, where adult patients received a single dose of 1,500 mg.
• Another study published in 2023 4 used an IV loading dose of 20 mg/kg for children with status epilepticus.
• A 2024 study 5 evaluated the safety and efficacy of three loading doses of levetiracetam (≤20 mg/kg, 21-39 mg/kg, and ≥40 mg/kg) in adult patients with benzodiazepine-refractory status epilepticus.
• The same study 5 found that the loading dose of levetiracetam did not result in a statistically significant difference in rate of seizure termination at 60 min, but higher rates of intubation were observed in patients who received levetiracetam >40 mg/kg.
• Other studies have used different loading doses, such as 20-60 mg/kg up to a maximum dose of 4500 mg 5, and 1000-4000 mg per day as add-on therapy in patients with refractory epilepsy 6.
• A 2024 study 7 compared the efficiency and safety of high-dose undiluted intravenous push levetiracetam loading doses compared to intravenous infusion in seizing patients, with doses >2000 mg or ≥20 mg/kg.

Key Findings

• Levetiracetam loading doses can be administered orally or intravenously, depending on the clinical situation.
• The choice of loading dose may depend on factors such as patient population, seizure type, and clinical setting.
• Higher loading doses may be associated with increased rates of intubation, but may not necessarily result in improved seizure termination rates 5.
• Levetiracetam has been shown to be effective and well-tolerated in various studies, with common adverse events including somnolence and asthenia 3, 6.