What is the proper dosing and administration of Brevipil (Levetiracetam)?

Brevipil (Levetiracetam) Dosing and Administration

For status epilepticus or acute seizure management, administer levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) at a rate not exceeding 100 mg/min, followed by maintenance dosing of 15-30 mg/kg IV every 12 hours (maximum 1,500 mg per dose). 1, 2

Loading Dose for Acute Seizures/Status Epilepticus

Adults:

• 40 mg/kg IV bolus (maximum 2,500 mg) for status epilepticus 1, 2
• Alternative dosing range: 30-60 mg/kg IV (maximum 4,500 mg) 2
• Fixed dosing option: 1,500-3,000 mg IV 2
• Infusion rate: Do not exceed 100 mg/min to minimize adverse effects 2

Pediatric Patients:

• 40 mg/kg IV bolus (maximum 2,500 mg) for both convulsive and non-convulsive status epilepticus 2, 3
• Alternative range: 20-30 mg/kg IV (maximum 1,000 mg per dose) 2
• Neonates: 10 mg/kg IV 2
• Infusion time: 10-20 minutes 2

Maintenance Dosing After Loading

Adults:

• Non-convulsive status epilepticus: 15 mg/kg IV every 12 hours (maximum 1,500 mg per dose) 1
• Convulsive status epilepticus: 30 mg/kg IV every 12 hours (maximum 1,500 mg per dose) 1
• Continue for at least 3 doses after seizure termination 1

Pediatric Patients:

• Non-convulsive status: 15 mg/kg IV every 12 hours (maximum 1,500 mg) 2
• Convulsive status: 30 mg/kg IV every 12 hours OR increase prophylaxis dose by 10 mg/kg (to 20 mg/kg) every 12 hours (maximum 1,500 mg) 2

Adjunctive Therapy for Refractory Focal Epilepsy

Titration Schedule:

• Start at 20 mg/kg/day or 1,000 mg/day 4
• Titrate every two weeks 4
• Target dose: 60 mg/kg/day or 3,000 mg/day 4
• This approach achieved 38.7% responder rate (≥50% seizure reduction) versus 14.3% with placebo 4

Special Situations

CAR T-Cell Therapy Seizure Prophylaxis:

• 10 mg/kg IV every 12 hours (maximum 500 mg per dose) for 30 days following infusion 5, 1
• Alternative: 500-750 mg orally every 12 hours for 30 days 5
• Note: This is for prevention, not treatment of active seizures 1

Renal Dysfunction:

• Dose adjustment required 1
• Levetiracetam is extensively renally cleared, necessitating modifications in renal impairment 1

Clinical Advantages Over Phenytoin/Fosphenytoin

• No cardiac monitoring required during administration 2
• Can be administered more rapidly than phenytoin 5
• Fewer adverse effects, particularly less hypotension 5
• Minimal drug interactions 2
• No need for dose adjustment when combined with other antiepileptic drugs 6

Common Pitfalls to Avoid

Underdosing in Status Epilepticus:

• Use the full 40 mg/kg loading dose rather than lower prophylactic doses 1
• Studies show 83% seizure termination within 24 hours with adequate loading 1

Infusion Rate:

• Never exceed 100 mg/min to minimize adverse effects 2

Timing of Use:

• Levetiracetam is a second-line agent after benzodiazepines 2
• Should be administered in addition to, not instead of, benzodiazepines for status epilepticus 1

Adverse Effects Profile

Most Common:

• Somnolence, asthenia, dizziness 7, 8
• These typically appear early and resolve without medication withdrawal 7

Most Serious:

• Behavioral disturbances (agitation, hostility, psychosis) 9, 7
• More common in children and patients with prior behavioral problems 7
• Occurs in 13.3% of adults, with severe symptoms in 0.7% 9
• Psychosis prevalence: approximately 1.4% 9
• Caution in patients with schizoaffective disorder or psychiatric history 9

Efficacy Data

• Efficacy rates for status epilepticus: 38-89% 2
• As adjunctive therapy: 67-73% seizure cessation in refractory status epilepticus 5
• Responder rates (≥50% seizure reduction) in focal epilepsy: 38.7% versus 14.3% placebo 4