Levetiracetam (Keppra) Loading Dose Recommendations
The recommended loading dose for Keppra (levetiracetam) in status epilepticus is 30-60 mg/kg IV (maximum 4500 mg), administered at a rate of 100 mg/min for adults. 1
Adult Loading Dose Recommendations
- For status epilepticus in adults, a loading dose of 30-50 mg/kg IV at a rate of 100 mg/min is recommended by the American College of Emergency Physicians 1
- Typical fixed dosing in adults commonly ranges from 1500-3000 mg IV 1
- The administration rate should not exceed 100 mg/min to minimize adverse effects 1
- Higher doses (≥40 mg/kg) have been associated with increased rates of intubation compared to lower doses, without significant differences in seizure termination rates 2
Pediatric Loading Dose Recommendations
- For status epilepticus in children, a loading dose of 20-30 mg/kg IV (maximum 1000 mg per dose) is recommended 1
- For non-convulsive status epilepticus in children, a higher loading dose of 40 mg/kg (maximum 2,500 mg) IV bolus has been shown to be effective 1
- For neonates with status epilepticus, a lower loading dose of 10 mg/kg IV is recommended 1
- The recommended infusion time for pediatric patients is 10-20 minutes 1
Clinical Considerations
- Levetiracetam is considered a second-line agent after benzodiazepines for status epilepticus 1
- 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
- Single-dose bioavailability studies show that IV levetiracetam and oral tablets are bioequivalent, with steady state reached within 48 hours of multiple dosing 3
- The most common adverse events associated with IV levetiracetam administration are somnolence and postural dizziness 3
Maintenance Dosing After Loading
- After resolution of status epilepticus in children, maintenance doses of levetiracetam 15 mg/kg (maximum 1,500 mg) IV every 12 hours for non-convulsive status are recommended 1
- For seizure prophylaxis in critically ill patients, higher maintenance doses (750-1000 mg twice daily) are more likely to achieve target serum levels and reduce seizure risk compared to lower doses (500 mg twice daily) 4
- Studies show that only 54% of patients achieve target serum levels with standard dosing, highlighting the importance of appropriate dosing strategies 4
Important Considerations
- Recent research suggests that higher loading doses (≥40 mg/kg) may not provide additional benefit in seizure termination rates compared to moderate doses (21-39 mg/kg) but may increase intubation risk 2
- Critically ill patients eliminate levetiracetam more rapidly than healthy individuals, which may necessitate higher maintenance dosing 4
- Levetiracetam doses from 1000 to 4000 mg per day have shown efficacy in refractory epilepsy, with somnolence and asthenia increasing at higher doses 5