Improving Liquid Levetiracetam (Keppra) Taste to Prevent Vomiting
Mix the crushed tablet or liquid formulation with applesauce or enteral nutrition formulas, as this method maintains full drug absorption without significantly affecting pharmacokinetics while masking the unpleasant taste. 1
Evidence-Based Mixing Strategies
Preferred Mixing Options
Applesauce (4 oz): Crushing levetiracetam tablets and mixing with applesauce does not significantly impair absorption, with similar AUC values compared to intact tablets (165.7 vs 191.9 μg/mL·h), though peak concentrations may occur slightly later (1.32 vs 1.08 hours) 1
Enteral nutrition formulas (120 mL): Mixing crushed tablets with standard enteral formulas maintains therapeutic absorption (AUC 168.3 μg/mL·h) with comparable 12-hour serum concentrations (4.0 μg/mL) to control administration 1
Both methods achieve therapeutic serum levels: Mean concentrations at 12 hours post-dosing remain consistent across all administration methods (3.9-4.1 μg/mL), ensuring adequate seizure control 1
Managing Nausea and Vomiting
If Taste-Related Nausea Persists
Consider adding antiemetic therapy to prevent vomiting while maintaining levetiracetam treatment:
Ondansetron: 4-8 mg twice or three times daily, available in sublingual formulation for easier administration 2
Granisetron: 1 mg twice daily orally, or 34.3 mg transdermal patch applied weekly for sustained effect 2
Prochlorperazine: 5-10 mg four times daily if serotonin antagonists are insufficient 2
Levetiracetam's Inherent Nausea Profile
Nausea is a recognized adverse effect of levetiracetam itself, occurring in approximately 23% of patients in clinical trials 2
Most adverse effects are mild to moderate: Common side effects include somnolence, irritability, dizziness, and nausea, but serious adverse effects are rare 3, 4
Transient nausea with oral loading: In studies of 1,500 mg oral loading doses, only mild, transient nausea was reported in a small subset of patients 2, 5
Clinical Considerations
Administration Timing
Administer with food or immediately after meals to minimize gastric irritation, as food does not significantly affect overall levetiracetam absorption 1
Maintain 12-hour dosing intervals when using twice-daily regimens to ensure consistent therapeutic levels 1, 5
Alternative Formulations
Consider IV formulation if oral intolerance persists despite mixing strategies, as IV levetiracetam is well-tolerated with rapid loading (up to 60 mg/kg) causing minimal adverse effects 2
Extended-release formulation (Keppra XR) allows once-daily dosing with relatively constant plasma concentrations, which may minimize concentration-related adverse effects including nausea 3
Important Caveats
Do not assess long-term stability: The stability of levetiracetam mixed with food or formulas beyond immediate administration has not been studied, so prepare mixtures immediately before dosing 1
Monitor for behavioral effects: While nausea is manageable, levetiracetam has been associated with behavioral adverse effects (irritability, mood changes) in some patients that may be mistaken for medication intolerance 4
Avoid enzyme-inducing anticonvulsants: If adding other medications, levetiracetam has minimal drug interactions and does not interact with cytochrome P450 systems, making it safer than alternatives like phenytoin or carbamazepine 6, 4, 7