Recommended Dose of Keppra (Levetiracetam)
For adults with partial onset seizures, initiate levetiracetam at 1000 mg/day (500 mg twice daily), with the option to increase by 1000 mg/day every 2 weeks up to a maximum recommended dose of 3000 mg/day. 1
Adult Dosing for Partial Onset Seizures
- Starting dose: 1000 mg/day given as 500 mg twice daily 1
- Titration: Increase by 1000 mg/day increments every 2 weeks as needed 1
- Target dose: 3000 mg/day (1500 mg twice daily) 1
- Maximum dose: 3000 mg/day is the maximum recommended dose, as doses greater than 3000 mg/day have not been shown to confer additional benefit 1
The FDA label clearly states that while daily doses of 1000 mg, 2000 mg, and 3000 mg have all been shown effective, there is no consistent evidence that higher doses provide greater response 1. Research confirms this, showing efficacy across the 1000-3000 mg/day range, though individual patients may tolerate up to 4000 mg/day 2, 3.
Pediatric Dosing (Ages 4-16 Years)
- Starting dose: 20 mg/kg/day in 2 divided doses (10 mg/kg twice daily) 1
- Titration: Increase by 20 mg/kg/day every 2 weeks 1
- Target dose: 60 mg/kg/day (30 mg/kg twice daily) 1
- Dose adjustment: If 60 mg/kg/day is not tolerated, the dose may be reduced 1
For children weighing ≤20 kg, use oral solution; for those >20 kg, either tablets or oral solution may be used 1.
Myoclonic Seizures (Ages 12+ with Juvenile Myoclonic Epilepsy)
- Starting dose: 1000 mg/day (500 mg twice daily) 1
- Titration: Increase by 1000 mg/day every 2 weeks 1
- Target dose: 3000 mg/day 1
- Important caveat: The effectiveness of doses lower than 3000 mg/day has not been adequately studied for this indication 1
Primary Generalized Tonic-Clonic Seizures
Adults (16+ years): Same dosing as myoclonic seizures—start at 1000 mg/day and titrate to 3000 mg/day 1
Children (6-16 years): Start at 20 mg/kg/day and titrate to 60 mg/kg/day, as doses lower than 60 mg/kg/day have not been adequately studied 1
Status Epilepticus Loading Doses
When rapid seizure control is needed, higher loading doses are appropriate:
- Adults: 30-60 mg/kg IV (maximum 4500 mg) at a rate of 100 mg/min 4
- Children: 20-30 mg/kg IV (maximum 1000 mg per dose) over 10-20 minutes 4
- Alternative pediatric dosing: 40 mg/kg IV (maximum 2500 mg) has shown effectiveness for both convulsive and non-convulsive status epilepticus 4
Special Population: CAR T-Cell Therapy
For seizure prophylaxis in patients receiving CAR T-cell therapy with CNS disease or seizure history, use 10 mg/kg (maximum 500 mg per dose) every 12 hours for 30 days following infusion 5
Administration Considerations
- Levetiracetam may be taken with or without food 1
- No therapeutic drug monitoring is required in most patients 6
- The drug has minimal drug interactions, making it suitable for polypharmacy 4
- Unlike phenytoin, cardiac monitoring is not required during IV administration 4
Common Pitfalls to Avoid
Do not exceed 3000 mg/day in routine epilepsy management, as research shows no additional benefit and increased adverse effects (particularly somnolence and asthenia) at 4000 mg/day 2. While some patients in open-label studies have used higher doses for extended periods, this is not supported by controlled evidence 1.
Do not use subtherapeutic doses for myoclonic or primary generalized tonic-clonic seizures—the 3000 mg/day target (or 60 mg/kg/day in children) is based on the only adequately studied dose for these indications 1.