Recommended Dosage of Levetiracetam (Keppra) per Kilogram
The recommended dosage of levetiracetam for adults is 20-60 mg/kg/day divided into two doses, with a typical starting dose of 20 mg/kg/day (10 mg/kg twice daily) and titration up to 60 mg/kg/day as needed for seizure control. 1, 2
Adult Dosing
- Starting dose: 1000 mg/day (500 mg twice daily) 2
- Titration: Increase by 1000 mg/day every 2 weeks 2
- Maximum recommended dose: 3000 mg/day 2
- For status epilepticus: 20-30 mg/kg IV has been used effectively 1
Pediatric Dosing
- Ages 4 to <16 years: Start with 20 mg/kg/day in 2 divided doses (10 mg/kg twice daily) 2
- Titration: Increase by 20 mg/kg every 2 weeks 2
- Target dose: 60 mg/kg/day (30 mg/kg twice daily) 2
- Mean effective dose in clinical trials: 52 mg/kg/day 2
Weight-Based Dosing Guidelines
For Children:
- 20-40 kg:
- Starting: 500 mg/day (250 mg twice daily)
- Target: 1500 mg/day (750 mg twice daily) 2
40 kg:
- Starting: 1000 mg/day (500 mg twice daily)
- Target: 3000 mg/day (1500 mg twice daily) 2
For Special Situations:
- Seizure prophylaxis in CAR T-cell therapy: 10 mg/kg (maximum 500 mg) every 12 hours for 30 days 1
- Busulfan-induced seizure prevention: 10 mg/kg twice daily in children; 500-1000 mg twice daily in adults 3
- Status epilepticus: 20-30 mg/kg IV (up to 4500 mg) 4
Dosage Adjustments
Renal Impairment in Adults:
- Normal (CrCl >80 mL/min): 500-1500 mg every 12 hours 2
- Mild (CrCl 50-80 mL/min): 500-1000 mg every 12 hours 2
- Moderate (CrCl 30-50 mL/min): 250-750 mg every 12 hours 2
- Severe (CrCl <30 mL/min): 250-500 mg every 12 hours 2
- ESRD on dialysis: 500-1000 mg every 24 hours with 250-500 mg supplemental dose after dialysis 2
Clinical Considerations
- Levetiracetam has a favorable safety profile with minimal drug interactions 5, 6
- Most common adverse effects are CNS-related: somnolence, asthenia, headache, and dizziness 5
- Higher doses (≥40 mg/kg) for status epilepticus may be associated with increased intubation rates compared to lower doses 4
- No clear dose-response relationship for efficacy has been established between 20-60 mg/kg in status epilepticus 4
- Volume of distribution is approximately 0.65 L/kg 7
- Elimination half-life ranges from 8.7-10.1 hours in patients with normal renal function 7
Important Caveats
- Dosing should be calculated based on actual body weight 2
- For oral solution, use the formula: Total daily dose (mL/day) = Daily dose (mg/kg/day) × patient weight (kg) ÷ 100 mg/mL 2
- Always use a calibrated measuring device for oral solution, not household spoons 2
- When switching between oral and IV formulations, the same total daily dose can be maintained 2
- Abrupt discontinuation may increase seizure frequency; taper gradually when discontinuing 2