What is the recommended dosage of intravenous Levetiracetam (Keppra) for a patient?

Intravenous Levetiracetam Dosing

For status epilepticus, administer levetiracetam 30 mg/kg IV (maximum 3000 mg) over 5-15 minutes as a second-line agent after benzodiazepines, followed by maintenance dosing of 500-1500 mg every 12 hours. 1, 2

Status Epilepticus (Second-Line Treatment After Benzodiazepines)

Loading Dose:

• 30 mg/kg IV over 5 minutes (approximately 2000-3000 mg for average adults) 1, 2
• This dose achieves 68-73% efficacy in benzodiazepine-refractory status epilepticus 1
• Lower doses of 20 mg/kg show significantly reduced efficacy (38-67%) and should be avoided 2, 3

Administration:

• Can be given as rapid IV push over 5 minutes or as 15-minute infusion 2, 4
• No cardiac monitoring required (unlike phenytoin/fosphenytoin) 1
• Minimal cardiovascular effects with no hypotension risk 1

Maintenance Dosing After Status Epilepticus

For convulsive status epilepticus:

• 30 mg/kg IV every 12 hours OR 20 mg/kg IV every 12 hours (maximum 1500 mg per dose) 1

For non-convulsive status epilepticus:

• 15 mg/kg IV every 12 hours (maximum 1500 mg per dose) 1

Standard Adjunctive Therapy (Non-Emergency)

Initial dosing when oral administration is not feasible:

• 500 mg IV every 12 hours as starting dose 4
• Administer each dose over 15 minutes 4
• Increase by 500 mg twice daily every 2 weeks to maximum of 1500 mg twice daily 4

When switching from oral to IV:

• Use equivalent total daily dose and frequency as oral regimen 4

Renal Impairment Adjustments

Dosing must be adjusted based on creatinine clearance: 4

• Normal (CrCl >80 mL/min): 500-1500 mg every 12 hours
• Mild (CrCl 50-80 mL/min): 500-1000 mg every 12 hours
• Moderate (CrCl 30-50 mL/min): 250-750 mg every 12 hours
• Severe (CrCl <30 mL/min): 250-500 mg every 12 hours
• ESRD on dialysis: 500-1000 mg every 24 hours, with 250-500 mg supplemental dose after dialysis 4

Critical Safety Considerations

Advantages over alternative second-line agents:

• No hypotension risk (0% vs 12% with fosphenytoin) 1
• No need for continuous ECG monitoring 1
• Minimal drug interactions 5
• Can be administered rapidly without cardiovascular toxicity 1, 2

Common adverse effects:

• Somnolence and fatigue (monitor but generally mild) 4
• CNS depression at higher doses 6
• Higher intubation rates observed with doses >40 mg/kg (45.8% vs 26-28% with lower doses) 3

Monitoring requirements:

• Monitor complete blood count periodically 6
• No therapeutic drug monitoring required for routine use 6
• For neurocritical care patients, target trough concentrations of 6-20 μg/mL may require doses of 1000 mg every 8 hours or 1500-2000 mg every 12 hours 7

Important Clinical Pitfalls

Do not use inadequate loading doses: The 30 mg/kg dose is evidence-based; lower doses of 20 mg/kg show only 38% efficacy compared to 68-73% with 30 mg/kg 2, 3

Avoid abrupt discontinuation: Taper gradually to reduce risk of increased seizure frequency and status epilepticus 4

Do not delay administration: Levetiracetam can be given rapidly (over 5 minutes) without the cardiovascular monitoring requirements of phenytoin, making it ideal for emergency situations 1, 2

Faster clearance in neurocritical care: These patients may require higher or more frequent dosing than standard recommendations to maintain therapeutic levels 7