What is the recommended dosage of Levetiracetam (Levera) for a pediatric patient?

Levetiracetam Pediatric Dosing

For pediatric patients with epilepsy, start levetiracetam at 20 mg/kg/day divided twice daily (10 mg/kg BID), titrate by 20 mg/kg every 2 weeks to a target maintenance dose of 60 mg/kg/day (30 mg/kg BID), with a maximum of 3000 mg/day. 1

Standard Maintenance Dosing by Age and Indication

Partial Onset Seizures (Ages 4-16 years)

• Initial dose: 20 mg/kg/day in 2 divided doses (10 mg/kg BID) 1
• Titration: Increase by 20 mg/kg/day every 2 weeks 1
• Target maintenance: 60 mg/kg/day (30 mg/kg BID) 1
• Maximum daily dose: 3000 mg/day 1
• If the patient cannot tolerate 60 mg/kg/day, the dose may be reduced; the mean effective dose in clinical trials was 52 mg/kg/day 1

Primary Generalized Tonic-Clonic Seizures (Ages 6-16 years)

• Same dosing regimen as partial seizures: 20 mg/kg/day initial, titrate to 60 mg/kg/day 1
• Doses lower than 60 mg/kg/day have not been adequately studied for this indication 1

Myoclonic Seizures (Ages 12 years and older)

• Initial dose: 1000 mg/day (500 mg BID) 1
• Titration: Increase by 1000 mg/day every 2 weeks 1
• Target maintenance: 3000 mg/day 1
• Doses lower than 3000 mg/day have not been studied for this indication 1

Status Epilepticus Dosing

For acute seizure control or status epilepticus, use a loading dose of 40-60 mg/kg IV (maximum 2500 mg) as a bolus, followed by standard maintenance dosing. 2

• Convulsive status epilepticus: 40 mg/kg IV bolus (maximum 2500 mg) with moderate strength of evidence per the American Academy of Neurology 2
• Non-convulsive status epilepticus: 40 mg/kg IV bolus (maximum 2500 mg) per the American College of Emergency Physicians 2
• Infants with acute seizures: Loading dose of 20-60 mg/kg IV is safe and effective when immediate seizure control is needed 3

Weight-Based Tablet Dosing Guide

For children >20 kg who can swallow tablets (only whole tablets should be administered): 1

20.1-40 kg patients:

• 20 mg/kg/day: 250 mg BID
• 40 mg/kg/day: 500 mg BID
• 60 mg/kg/day: 750 mg BID

>40 kg patients:

• 20 mg/kg/day: 500 mg BID
• 40 mg/kg/day: 1000 mg BID (2 × 500 mg tablets)
• 60 mg/kg/day: 1500 mg BID (2 × 750 mg tablets)

Children ≤20 kg should be dosed with oral solution using a calibrated measuring device 1

Important Clinical Considerations

Formulation Selection

• Patients ≤20 kg: Must use oral solution 1
• Patients >20 kg: Can use either tablets or oral solution 1
• Oral solution calculation: Total daily dose (mL/day) = [Daily dose (mg/kg/day) × patient weight (kg)] ÷ 100 mg/mL 1

Administration

• May be given with or without food; administration with food may improve GI tolerability 3
• Use a calibrated measuring device for oral solution, not household spoons 1

Titration Strategy

• Slow titration is critical to avoid behavioral side effects and paradoxical seizure increase 4
• Standard titration is 20 mg/kg increments every 2 weeks 1
• Some patients may require slower titration if behavioral problems emerge 4

Dosing Adjustments

• Children require 30-50% higher weight-based doses than adults due to increased clearance 5
• Population pharmacokinetic studies support 10 mg/kg BID as the starting dose to achieve plasma concentrations similar to the adult 500 mg BID dose 6
• No renal dose adjustment needed in healthy infants, but consider adjustment if renal dysfunction is present 3

Common Pitfalls to Avoid

• Behavioral adverse effects are most common in patients with pre-existing behavioral problems; consider slower titration in these patients 4
• Paradoxical seizure increase can occur but may be avoided with slow titration 4
• Most frequent side effects are CNS-related: somnolence, asthenia, headache, and dizziness 7
• Somnolence and irritability occur in approximately 9.5% of pediatric patients 8
• Do not use household measuring spoons for oral solution; always use calibrated devices 1