What is the recommended dosage of Levetiracetam (Keppra) for a child?

Levetiracetam Dosage for Children

The recommended dosage of levetiracetam for children is 20-60 mg/kg/day divided into two doses, with treatment typically initiated at 20 mg/kg/day (10 mg/kg twice daily) and increased by 20 mg/kg increments every 2 weeks to the recommended maintenance dose of 60 mg/kg/day (30 mg/kg twice daily). 1, 2

Initial Dosing and Titration

• For children aged 4 to <16 years with partial onset seizures, treatment should be initiated at 20 mg/kg/day divided into two doses (10 mg/kg twice daily) 1
• Dose should be increased every 2 weeks by increments of 20 mg/kg/day to reach the recommended maintenance dose of 60 mg/kg/day (30 mg/kg twice daily) 1
• For children aged 6 to <16 years with primary generalized tonic-clonic seizures, the same dosing regimen applies (20 mg/kg/day initially, titrated to 60 mg/kg/day) 1
• If a child cannot tolerate the target dose of 60 mg/kg/day, the dose may be reduced to a tolerated level 1

Weight-Based Dosing Guidelines

• Children weighing ≤20 kg should receive the oral solution formulation 1
• Children weighing >20 kg can receive either tablets or oral solution 1
• For tablet dosing during titration to 60 mg/kg/day, follow this weight-based guide 1:
  • 20.1-40 kg: 500 mg/day (1×250 mg BID) → 1000 mg/day (1×500 mg BID) → 1500 mg/day (1×750 mg BID)

  • 40 kg: 1000 mg/day (1×500 mg BID) → 2000 mg/day (2×500 mg BID) → 3000 mg/day (2×750 mg BID)

Dosing Considerations by Age

• For children aged 4 years and older with partial onset seizures: 20-60 mg/kg/day in two divided doses 1
• For children aged 6 years and older with primary generalized tonic-clonic seizures: 20-60 mg/kg/day in two divided doses 1
• For adolescents aged 12 years and older with juvenile myoclonic epilepsy: adult dosing applies (starting at 1000 mg/day and increasing to 3000 mg/day) 1

Pharmacokinetic Considerations

• Children have approximately 30-40% higher apparent body clearance of levetiracetam compared to adults 3
• The half-life of levetiracetam in children is approximately 6 hours (compared to 7-8 hours in adults) 3
• Due to these pharmacokinetic differences, children may require higher weight-normalized doses than adults to achieve similar serum concentrations 3

Efficacy and Safety

• In clinical trials, the mean daily dose used was 52 mg/kg/day 1
• Studies have shown that 64.8-74% of children achieve >50% reduction in seizure frequency with levetiracetam, with 16-23% becoming seizure-free 4, 5
• Common adverse effects in children include somnolence, behavioral difficulties, irritability, and headaches 4, 5
• The incidence of adverse effects is approximately 26-47.5%, but most are mild to moderate 4, 5
• Only about 3.3% of children discontinue levetiracetam due to intolerable side effects 4

Special Situations

• Some children may benefit from doses higher than the standard 60 mg/kg/day if they partially respond to lower doses 6
• In refractory cases, doses up to 146 mg/kg/day (range 70-275 mg/kg/day) have been used with 44% of patients achieving >50% seizure reduction and 16% becoming seizure-free 6
• Higher doses may be associated with increased behavioral side effects (12% in one study) 6
• There is no clear correlation between plasma concentration and efficacy in children 5

Administration

• Levetiracetam can be given with or without food 1
• For oral solution, use a calibrated measuring device rather than household spoons 1
• The following formula can be used to calculate the appropriate daily dose of oral solution: Total daily dose (mL/day) = Daily dose (mg/kg/day) × patient weight (kg) ÷ 100 mg/mL 1

Status Epilepticus Considerations

• For status epilepticus in children, higher loading doses of 20-60 mg/kg IV have been used 2
• In non-convulsive status epilepticus, levetiracetam 40 mg/kg (maximum 2,500 mg) IV bolus has been used 2
• In convulsive status epilepticus, levetiracetam 40 mg/kg (maximum 2,500 mg) IV bolus has been used 2