Levetiracetam (Levipil) Dosing
For status epilepticus or acute seizure management, administer levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) over 5-15 minutes as a second-line agent after benzodiazepines, followed by maintenance dosing of 30 mg/kg IV every 12 hours (maximum 1,500 mg per dose) for convulsive seizures or 15 mg/kg IV every 12 hours for non-convulsive seizures. 1
Acute Seizure Management (Status Epilepticus)
Loading Dose
- Administer 40 mg/kg IV bolus (maximum 2,500 mg) over 5-15 minutes as second-line therapy after benzodiazepines 1
- Alternative dosing: 30 mg/kg IV (maximum 2,500-3,000 mg) over 5 minutes is also effective, with 68-73% seizure termination rates 2
- The American Academy of Neurology supports 20-60 mg/kg IV loading doses for status epilepticus, with adult loading doses of 2,500 mg IV showing 83% seizure termination within 24 hours 1
Maintenance Dosing After Acute Seizures
- For convulsive status epilepticus: 30 mg/kg IV every 12 hours (maximum 1,500 mg per dose) 1, 2
- For non-convulsive status epilepticus: 15 mg/kg IV every 12 hours (maximum 1,500 mg per dose) 1, 2
- Continue maintenance dosing for at least 3 doses after seizure termination 1
Chronic Epilepsy Management (Oral Dosing)
Adults (≥16 years)
- Initial dose: 500 mg twice daily (1,000 mg/day total) 3
- Titration: Increase by 1,000 mg/day every 2 weeks as needed 3
- Target dose: 1,500 mg twice daily (3,000 mg/day total) 3
- Maximum dose: 3,000 mg/day; doses above this provide no additional benefit 3
Pediatric Patients (4-16 years)
- Initial dose: 10 mg/kg twice daily (20 mg/kg/day total) 3
- Titration: Increase by 20 mg/kg/day every 2 weeks 3
- Target dose: 30 mg/kg twice daily (60 mg/kg/day total) 3
- Mean effective dose in clinical trials was 52 mg/kg/day 3
Renal Dose Adjustments
Levetiracetam requires dose modification in renal dysfunction 1, 4:
| Creatinine Clearance | Dosage | Frequency |
|---|---|---|
| >80 mL/min (Normal) | 500-1,500 mg | Every 12 hours |
| 50-80 mL/min (Mild) | 500-1,000 mg | Every 12 hours |
| 30-50 mL/min (Moderate) | 250-750 mg | Every 12 hours |
| <30 mL/min (Severe) | 250-500 mg | Every 12 hours |
| ESRD on dialysis | 500-1,000 mg* | Every 24 hours |
*Following dialysis, a 250-500 mg supplemental dose is recommended 3
Special Clinical Situations
Seizure Prophylaxis (CAR T-cell therapy)
- Dose: 10 mg/kg (maximum 500 mg per dose) every 12 hours for 30 days following infusion 1, 4
- For adults: 500-750 mg every 12 hours 4
Elderly Patients
- Start with lower doses due to higher likelihood of renal impairment 1
- 1,500 mg has been used successfully in elderly patients for status epilepticus 4
Critical Pitfalls to Avoid
- Do not underdose in status epilepticus: Use the full 40 mg/kg loading dose rather than lower prophylactic doses 1
- Do not skip second-line agents: Levetiracetam should be given after benzodiazepines but before proceeding to third-line anesthetic agents 2
- Do not use neuromuscular blockers alone: They only mask motor manifestations while allowing continued electrical seizure activity and brain injury 2
- Higher loading doses (>40 mg/kg) may increase intubation risk without improving seizure termination rates 5
Comparative Efficacy Context
When levetiracetam is used as a second-line agent for benzodiazepine-refractory status epilepticus, it demonstrates 68-73% efficacy with minimal cardiovascular effects and no hypotension risk 2. This compares favorably to alternatives: valproate (88% efficacy, 0% hypotension), fosphenytoin (84% efficacy, 12% hypotension), and phenobarbital (58.2% efficacy, higher respiratory depression risk) 2.