What is the recommended dose of Levetiracetam (Keppra) for adults and children with epilepsy?

Levetiracetam Dosing for Epilepsy

For adults with epilepsy, start levetiracetam at 500 mg twice daily (1000 mg/day) and titrate by 1000 mg/day every 2 weeks to a target of 3000 mg/day; for children ≥4 years, start at 10 mg/kg twice daily (20 mg/kg/day) and increase by 20 mg/kg/day every 2 weeks to a target of 60 mg/kg/day (30 mg/kg twice daily). 1

Adult Dosing (≥16 Years)

Partial Onset Seizures

• Initiate at 500 mg twice daily (1000 mg/day total) 1
• Increase by 1000 mg/day increments every 2 weeks as needed 1
• Target maintenance dose: 3000 mg/day (1500 mg twice daily) 1
• Maximum studied dose is 3000 mg/day; higher doses have been used in open-label studies but show no additional benefit 1

Primary Generalized Tonic-Clonic Seizures and Myoclonic Seizures (≥12 years for myoclonic)

• Same dosing as partial seizures: start 500 mg twice daily, titrate to 3000 mg/day 1
• Doses below 3000 mg/day have not been adequately studied for efficacy in these seizure types 1

Pediatric Dosing

Ages 4 to <16 Years (Partial Onset Seizures)

• Start at 10 mg/kg twice daily (20 mg/kg/day total) 1
• Increase by 20 mg/kg/day every 2 weeks 1
• Target dose: 30 mg/kg twice daily (60 mg/kg/day total) 1
• If 60 mg/kg/day is not tolerated, reduce to lower dose (mean effective dose in trials was 52 mg/kg/day) 1
• Children ≤20 kg must use oral solution; those >20 kg can use tablets or solution 1

Ages 6 to <16 Years (Primary Generalized Tonic-Clonic Seizures)

• Identical dosing to partial seizures: 20-60 mg/kg/day 1
• Doses below 60 mg/kg/day have not been adequately studied 1

Weight-Based Tablet Dosing Guide

For children >20 kg at target 60 mg/kg/day: 1

• 20.1-40 kg: 750 mg twice daily (1500 mg/day)
• >40 kg: 1500 mg twice daily (3000 mg/day)

Acute Seizure Management and Status Epilepticus

Loading Doses for Active Seizures

• For status epilepticus: 40 mg/kg IV bolus (maximum 2500 mg) in addition to benzodiazepines 2
• This applies to both convulsive and non-convulsive status epilepticus 2
• Alternative loading doses of 20-60 mg/kg IV have been studied and are safe 2, 3

Maintenance After Status Epilepticus

• Non-convulsive SE: 15 mg/kg IV every 12 hours (maximum 1500 mg per dose) 2
• Convulsive SE: 30 mg/kg IV every 12 hours (maximum 1500 mg per dose) 2
• Continue for at least 3 doses of lorazepam plus ongoing levetiracetam 2

Common pitfall: Avoid underdosing in status epilepticus—use the full 40 mg/kg loading dose rather than lower prophylactic doses 2

Renal Dose Adjustments

Levetiracetam requires dose reduction in renal impairment 2, 1:

• Normal (CrCl >80): 500-1500 mg every 12 hours
• Mild (CrCl 50-80): 500-1000 mg every 12 hours
• Moderate (CrCl 30-50): 250-750 mg every 12 hours
• Severe (CrCl <30): 250-500 mg every 12 hours
• ESRD on dialysis: 500-1000 mg every 24 hours, with 250-500 mg supplemental dose after dialysis 1

Special Considerations

Higher Doses in Children

• Some children may benefit from doses exceeding 60 mg/kg/day if they partially respond to standard dosing 4
• Doses up to 275 mg/kg/day have been tolerated in pediatric studies, with 44% achieving >50% seizure reduction 4
• However, start with FDA-approved dosing and only escalate if inadequate response and good tolerability 4

Administration

• Can be given with or without food 1
• IV formulations can be given over 5-15 minutes 3
• Pediatric IV loading of 50 mg/kg (maximum 2500 mg) over 15 minutes is safe and well-tolerated 5

Seizure Prophylaxis (CAR T-cell therapy)

• 10 mg/kg (maximum 500 mg) every 12 hours for 30 days following infusion 2
• This is for prevention, not treatment of active seizures 2