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Antiepileptic — Status Epilepticus (Second-Line) Pregnancy: Use with caution; register with UK Epilepsy and Pregnancy Register; evidence suggests lower teratogenicity than older AEDs

Levetiracetam (IV)

Brand names: Keppra (IV), Desitrend

Adult dose

Dose: 60 mg/kg IV (max 4500 mg) over 10 minutes
Route: Intravenous infusion
Frequency: Single loading dose; maintenance 1000-3000 mg/day IV in divided doses if needed
Max: 4500 mg loading dose
NICE NG217: Second-line for established status epilepticus alongside phenytoin/fosphenytoin and sodium valproate IV — choice based on clinical context and comorbidities

Paediatric dose

Dose: 60 mg/kg IV (max 3000 mg) over 10 minutes mg/kg
Route: IV
Frequency: Single loading dose
Max: 3000 mg loading dose
Child 1 month to 17 years: 60 mg/kg (max 3000 mg) IV over 10 minutes. Neonates: seek specialist opinion

Dose adjustments

Renal

Reduce maintenance dose in renal impairment — eGFR 30-79: 750-1500 mg/day; eGFR under 30: 500-1000 mg/day

Hepatic

No dose adjustment required

Paediatric weight-based calculator

Child 1 month to 17 years: 60 mg/kg (max 3000 mg) IV over 10 minutes. Neonates: seek specialist opinion

Clinical pearls

  • EsCCAPE, ConSEPT, and ESETT trials: levetiracetam IV equivalent in efficacy to fosphenytoin for established status epilepticus — now a first-choice second-line agent with more predictable pharmacokinetics
  • Major practical advantages: no cardiac monitoring required (unlike phenytoin), no liver toxicity (unlike valproate), no teratogenicity concern, minimal drug interactions — ideal in polymedicated or pregnant patients
  • Behavioural side effects (irritability, aggression) are more pronounced in patients with pre-existing brain injury or intellectual disability — monitor closely
  • Renally cleared — dose reduction essential in eGFR under 80; otherwise broadly safe across organ function
  • Can be given as fast bolus (10 minutes) versus slow phenytoin infusion (30-60 minutes) — faster seizure termination potential

Contraindications

  • Hypersensitivity to levetiracetam

Side effects

  • Somnolence and fatigue
  • Behavioural disturbance (aggression, agitation — especially in brain injury patients)
  • Dizziness
  • Headache
  • Thrombocytopenia (rare)

Interactions

  • No significant pharmacokinetic interactions — advantage over phenytoin and valproate
  • Additive CNS depression with other antiepileptics or sedatives

Monitoring

  • Seizure activity
  • Level of consciousness
  • Renal function
  • FBC (thrombocytopenia)

Reference: BNFc; BNF 90; NICE NG217 (Epilepsy); EsCCAPE Trial; ConSEPT Trial; ESETT Trial; APLS Guidelines. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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