What is the maximum recommended dose of Keppra (Levetiracetam) for intravenous (IV) push administration?

Maximum IV Push Keppra (Levetiracetam) Dose

The maximum recommended dose for IV push levetiracetam is 4500 mg in adults, administered undiluted over 5 minutes, and up to 1500 mg in pediatric patients over 12 months of age, based on recent safety data. 1, 2

Adult Dosing Parameters

Maximum Single Dose

• Up to 4500 mg can be safely administered as undiluted IV push in adult patients, as demonstrated in a large retrospective study of 8561 doses 2
• Standard loading doses for status epilepticus range from 30-60 mg/kg IV (maximum 4500 mg) 3
• Typical fixed dosing in adults is 1500-3000 mg IV 3

Administration Rate

• Administer at 100 mg/min maximum rate to minimize adverse effects 3
• Most commonly administered over 5 minutes in clinical practice 4, 2
• Can be given undiluted (100 mg/mL concentration) 1, 2

Access Considerations

• Peripheral IV access is acceptable - 79.1% of doses in one large study were given peripherally 2
• Central access is not required, unlike phenytoin which carries extravasation risk 5

Pediatric Dosing Parameters

Maximum Single Dose by Age

• Children ≥12 months: up to 1500 mg (or 40 mg/kg, whichever is less) administered as IV push over 5 minutes 1, 3
• Neonates: 10 mg/kg IV (maximum 1000 mg per dose) 3
• Children with status epilepticus: 20-30 mg/kg IV (maximum 1000 mg per dose for standard dosing, up to 2500 mg for refractory cases) 3

Administration Time

• Recommended infusion time is 10-20 minutes in pediatric patients per traditional guidelines 6
• However, 5-minute IV push has been demonstrated safe in children receiving up to 1500 mg 1

Safety Profile

Documented Adverse Events

• Extremely low adverse event rate: only 12 adverse events documented among 8561 adult doses (0.14%) 2
• Four events potentially related to IV push: local injection site reactions (redness, burning, loss of peripheral IV) 2
• Pediatric adverse event rate similar between IV push (5.5%) and IV piggyback (7.5%) 1

Key Safety Advantages

• No cardiac monitoring required, unlike phenytoin/fosphenytoin 3
• No risk of hypotension or cardiac dysrhythmias seen with phenytoin or valproate 5
• Minimal drug interactions 3
• No respiratory depression risk compared to benzodiazepines or phenobarbital 5

Clinical Implementation Algorithm

For Status Epilepticus (Adults)

1. First-line: Benzodiazepines 3
2. Second-line: Levetiracetam 30-60 mg/kg IV push (maximum 4500 mg) at 100 mg/min 3
3. May repeat or add additional agents if seizures persist after 15 minutes 3

For Status Epilepticus (Pediatrics)

1. Standard loading: 20-30 mg/kg IV (maximum 1000 mg) 3
2. Refractory cases: 40 mg/kg IV (maximum 2500 mg) 3
3. Administer over 5 minutes for rapid effect 1

Time Efficiency Benefit

• IV push reduces time to administration by 27 minutes compared to IV piggyback (23 minutes vs 50 minutes) 1
• This time savings is critical in status epilepticus where each minute increases morbidity and mortality risk 1

Important Caveats

Renal Adjustment

• Dose adjustment required for creatinine clearance <80 mL/min (though specific adjustments not detailed in emergency dosing) 6

Concentration Considerations

• Undiluted formulation (100 mg/mL) is safe for IV push administration 1, 2
• No need for dilution, which further reduces preparation time 2

Not Recommended Scenarios

• Infants <12 months: limited safety data for rapid IV push 1
• Use traditional 10-20 minute infusion in neonates 6, 3