Levetiracetam: Clinical Indications and Dosing

00:00 Now let's take a look at the labeled indications for administering levetiracetam.

00:05 Now it can be used for focal partial onset seizures.

00:09 Generalized onset seizures which includes juvenile myoclonic epilepsy and primary generalized tonic clonic seizure.

00:18 Now we're going to look at the off label adult indications.

00:21 It can be used in craniotomies.

00:23 It's is used as a seizure prophylaxis can be used in status epilepticus.

00:28 Can also be used with subarachnoid hemorrhage for short term seizure prophylaxis. And finally, traumatic brain injury and severe acute a short term seizure prophylaxis.

00:41 So the primary indications where you most likely see this prescribed is for seizure prophylaxis in neurosurgical patients, subarachnoid hemorrhage, traumatic brain injury, focal onset seizures and general onset seizures and status epilepticus.

00:56 In this part of our discussion, we're going to look at specific dosage recommendations for healthcare providers.

01:01 Now we're going to look specifically at levetiracetam what the dosage recommendations are. Now we know that this medication can be used for focal partial onset seizures and generalized onset seizures.

01:13 I wanted to make a special note.

01:15 The FDA approved this medication for both mono and adjunctive therapy of focal partial onset seizures and adjunctive therapy of juvenile myoclonic epilepsy, and also primary generalized tonic clonic seizures. Now this is used off label for other seizure types.

01:35 Now the oral dosage it's immediate release.

01:37 There's tablets or oral solution or tablets for oral suspension.

01:41 Initially, it's 500mg twice daily.

01:44 You're going to increase that every two weeks by 500mg per dose, based on how the client responds and the tolerability to the maximum recommended dose of 1.5g twice daily.

01:57 Now for extended release.

01:59 The FDA approved only for focal or partial onset seizures initially one gram once daily increase every two weeks by one gram per day.

02:08 Based on the patient's response and again the tolerability to a maximum of three grams once daily for the extended release version.

02:17 Now again, another note in patients with epilepsy, oral loading doses of one and a half to two grams the immediate release had been well tolerated and may be useful for more rapidly achieving a steady state serum concentration. So however, the necessity of an oral loading dose has not been well established.

02:37 For IV administration, the initial dose will be 500mg twice daily.

02:42 Now you can increase that every two weeks by 500mg per dose based on response and tolerability to a maximum of 1.5g twice daily for the IV route.

02:54 Now, the additional benefit of oral or IV doses greater than three grams a day has not been established. However, there is a caveat oral doses of four grams a day have been studied in patients with refractory epilepsy, but just know that it may be associated with a greater incidence of somnolence or feeling tired. Now there's an off label use for craniotomies seizure prophylaxis.

03:19 So this is used initially IV 500mg to one gram.

03:24 It's given intraoperatively prior to the incision.

03:28 Now the maintenance dosage will be IV or oral one gram a day and two divided doses. The usual dosage ranged from 500mg to 3g a day. And you will adjust the dose based on the response and the tolerability.

03:43 There's another off label use and that's status epilepticus.

03:47 Now this is 1 to 3g as a single dose, administered at a rate of 2 to 5mg/kg per minute, or 40 to 60mg/kg as a single dose, infused over 5 to 15 minutes in combination with parenteral benzodiazepine.

04:03 Now the maximum single dose should be 4.5g.

04:07 Now, if you're giving levetiracetam for subarachnoid hemorrhage, this is another off label use short term seizure prophylaxis.

04:16 Consider use in patients with seizure at presentation.

04:19 So onset seizure or patients at high risk for seizures for example those with ruptured middle cerebral artery aneurysms, high grade aneurysmal, subarachnoid hemorrhage and cranial hemorrhage, hydrocephalus, and cortical infarction.

04:34 Now, the loading dose for IV would be 20mg/kg, rounded to the nearest 250mg as a one time dose.

04:42 The maintenance dose IV is one gram every 12 hours for up to seven days.

04:47 Now, this can be increased to a maximum dose of 1.5g every 12 hours if necessary. Now, in the case of traumatic brain injury, this is severe, acute or short term seizure prophylaxis.

04:59 Again, this is an off label use.

05:02 The loading dose is IV 20mg/kg, rounded to the nearest 250mg as a one time dose.

05:09 The maintenance dose is IV one gram every 12 hours for seven days, but it can be increased to a maximum dose of 1.5g every 12 hours if necessary. Now, the conversion between oral levetiracetam IR and ER dosage forms when switching between extended release and air formulations of levetiracetam is the same total daily dose should be used.