What is the appropriate dose of Keppra (Levetiracetam) for a child weighing 28 kg?

Levetiracetam Dosing for a 28 kg Child

For a child weighing 28 kg, initiate levetiracetam at 20 mg/kg/day divided into two doses (10 mg/kg twice daily), which equals 280 mg twice daily (560 mg/day total), and titrate up every 2 weeks by 20 mg/kg/day increments to the target dose of 60 mg/kg/day (30 mg/kg twice daily), which equals 840 mg twice daily (1,680 mg/day total). 1

Standard Maintenance Dosing by Indication

For Partial Onset Seizures

• Initial dose: 280 mg twice daily (10 mg/kg twice daily) 1
• Titration: Increase by 560 mg/day (20 mg/kg/day) every 2 weeks 1
• Target maintenance dose: 840 mg twice daily (30 mg/kg twice daily = 1,680 mg/day total) 1
• Maximum dose: 1,500 mg twice daily (3,000 mg/day total) for children in this weight range 1

For Primary Generalized Tonic-Clonic Seizures

• Use the identical dosing regimen as partial onset seizures 1
• The 60 mg/kg/day target dose has been shown necessary for adequate efficacy in this indication 1

Formulation Selection

• For this 28 kg child: Either tablets or oral solution may be used 1
• Oral solution is prescribed for children ≤20 kg, while either formulation works for children >20 kg 1
• If using oral solution (6 mg/mL concentration), the 280 mg dose requires 46.7 mL, which should be measured with a calibrated device 1

Status Epilepticus Dosing (Emergency Setting)

• Loading dose: 40 mg/kg IV bolus (1,120 mg for this 28 kg child), maximum 2,500 mg 2
• This higher loading dose (20-60 mg/kg) is used specifically for status epilepticus, not routine seizure management 2
• The strength of evidence for this approach is moderate according to neurological guidelines 2

Dosing Considerations and Optimization

Higher Doses for Refractory Epilepsy

• Some children may require doses exceeding the standard 60 mg/kg/day if seizures remain uncontrolled 3
• Research demonstrates that doses up to 146 mg/kg/day (median in one study) can be tolerated, with 44% of children achieving >50% seizure reduction at these higher doses 3
• However, start with standard dosing and only escalate if inadequate response occurs 3

Practical Dosing Insights

• Children typically require 130-140% of adult weight-adjusted doses due to faster clearance 4
• The mean effective dose in clinical trials was 44-47 mg/kg/day for children 4-16 years 1
• Population pharmacokinetic studies support 20 mg/kg twice daily to achieve therapeutic plasma concentrations of 6-20 mg/L 5

Important Caveats

Titration Speed

• Slow titration is critical to minimize behavioral adverse effects and paradoxical seizure worsening 4
• The standard 2-week interval between dose increases should be maintained 1
• Rapid titration increases risk of behavioral problems, particularly in children with pre-existing behavioral issues 4

Tolerability Monitoring

• Behavioral adverse effects occur in approximately 26% of children, most commonly drowsiness, behavioral difficulties, and headaches 6
• These effects are more frequent in patients with prior behavioral problems 4
• Approximately 12% of children may experience paradoxical seizure worsening, which can be mitigated by slower titration 4, 3

Plasma Level Monitoring

• Routine therapeutic drug monitoring is not necessary as no clear correlation exists between plasma concentration and efficacy in children 6
• Responders had plasma concentrations ranging from 5-40 mcg/mL, but this wide range did not predict response 6
• Monitoring may be useful only for assessing compliance or investigating toxicity 6

Renal Function

• No dose adjustment is needed for this child unless renal impairment is present 1
• If creatinine clearance is reduced, consult renal dosing adjustments per FDA labeling 1