Levetiracetam (Levipil) Dosing in Pediatrics
For routine epilepsy management in children, start with 20 mg/kg/day divided twice daily, with a target maintenance dose of 40-60 mg/kg/day in two divided doses. 1, 2
Standard Maintenance Dosing for Epilepsy
- Initial dose: 20 mg/kg/day divided into two doses (10 mg/kg twice daily) 1
- Target maintenance dose: 40-60 mg/kg/day in two divided doses 2, 3
- Titration: Increase over 6 weeks to reach target dose 2
The pharmacokinetic data demonstrates that children require approximately 30-40% higher weight-normalized doses than adults due to faster clearance rates (1.43 ± 0.36 ml/min/kg in children versus lower rates in adults). 3
Status Epilepticus Dosing
For status epilepticus, use a loading dose of 40-60 mg/kg IV (maximum 2,500 mg) as recommended by the American Academy of Neurology and American College of Emergency Physicians. 4
- Loading dose range: 20-60 mg/kg IV, with 40 mg/kg being the most commonly recommended 4
- Maximum single dose: 2,500 mg 4
- Route: Intravenous bolus 4
- Efficacy: In refractory status epilepticus, response was observed in 45% of cases when doses ≥30 mg/kg/day were used, with median time to seizure cessation of 1.5 days 5
High-Dose Considerations for Refractory Seizures
For children who partially respond to standard doses but continue having breakthrough seizures, higher doses may be beneficial:
- High-dose range: 70-275 mg/kg/day has been used safely in refractory cases 6
- Median effective high dose: 146 mg/kg/day 6
- Response rate: 44% achieved >50% seizure reduction with high doses, including 16% who became seizure-free 6
- Tolerability: Only 12% experienced adverse effects (primarily behavioral) at these high doses 6
Age-Specific Considerations
- Ages 6-12 years: Standard dosing of 20-40 mg/kg/day is well-established 2
- Ages 4-16 years: Population pharmacokinetic modeling supports weight-based dosing across this range 1
- Infants and toddlers: Levetiracetam has been used in children as young as 2 days old for status epilepticus, though data is more limited 5
Important Clinical Pearls
Body weight is the primary determinant of dosing—both clearance and volume of distribution scale with weight, making weight-based dosing essential. 1
No dose adjustment needed for drug interactions: Levetiracetam does not significantly affect plasma concentrations of other antiepileptic drugs, and concomitant AEDs do not alter levetiracetam pharmacokinetics. 1, 2
Adverse effects are generally mild: The most common side effects include headache, infection, anorexia, and somnolence, with behavioral effects being the primary concern at higher doses. 6, 2
Common Pitfalls to Avoid
- Underdosing in status epilepticus: Don't use maintenance doses for acute status epilepticus—loading doses of 40-60 mg/kg are required for rapid seizure control 4
- Stopping at 60 mg/kg/day in refractory cases: If seizures persist with good tolerability, doses can be safely increased well beyond 60 mg/kg/day 6
- Not accounting for faster pediatric clearance: Children clear levetiracetam 30-40% faster than adults, necessitating higher weight-normalized doses 3