Drug reference

Levetiracetam

Antiepileptic

Also known as Keppra, Levipil, Levacetam, Levesam

START

500 mg PO BID (titrate over 2 weeks to 1,500 mg BID if needed)

TYPICAL MAX

3,000 mg/day (some refractory 4,500 mg/day)

STOP IF

Severe behavioral side effects · severe rash

WATCH

Mood/irritability · Cr (q3-6 mo) · CBC at start (rare thrombocytopenia)

CDSCO approvedSchedule HJan AushadhiATC N03AX14

Dose laddermg/d

Renal dose adjustmenteGFR mL/min/1.73m²

KDIGO 2024 + manufacturer label

Pharmacokineticsplasma · t hours

ONSET: 1h · absorption (rapid)
PEAK: 1.5h · Cmax
t½: 7h · plasma t½
DURATION: 12h · BID dosing window

EXCRETION

66% renal unchanged · no CYP metabolism

route + CYP

INTERACTIONS

3 major

SEVERE in our sources

PREGNANCY

Category C — among safer AEDs in pregnancy

FDA category + note

Top interactionssee all 8 →

BuprenorphineSevereDatabaseDDInter
DextropropoxypheneSevereDatabaseDDInter
Sodium OxybateSevereDatabaseDDInter

Available in India

548 branded formulations. Look up specific brands in the Drugs workspace.

Jan Aushadhi — generic available at GoI pharmacies

Mechanism

Levetiracetam's precise mechanism is not fully elucidated, but it is believed to exert its antiepileptic effects primarily through selective binding to the synaptic vesicle glycoprotein 2A (SV2A) in the brain. This binding modulates neurotransmitter release, particularly by inhibiting abnormal neuronal burst firing without affecting normal neuronal excitability. It also influences N-type calcium channels and partially inhibits GABA- and glycine-gated currents.

Indications

Partial-onset seizures with or without secondary generalization in adults and children 1 month and olderMyoclonic seizures in adults and adolescents 12 years and older with juvenile myoclonic epilepsyPrimary generalized tonic-clonic seizures in adults and adolescents 6 years and older with idiopathic generalized epilepsyStatus epilepticus (off-label)refractory partial seizures with or without generalization (adjuvant and monotherapy)CPSGTCS (mainly add-on drug)myoclonic epilepsy (mainly add-on drug)

Dosing

Adult: Initial: 500 mg orally twice daily (or 1000 mg once daily for extended-release). Increase by 500 mg twice daily (or 1000 mg once daily for XR) every 2 weeks, up to a maximum of 1500 mg twice daily (3000 mg/day). IV administration: Same doses, infused over 15 minutes.
Pediatric: 1 month to <6 months: Initial 7 mg/kg twice daily; max 21 mg/kg twice daily. 6 months to <4 years: Initial 10 mg/kg twice daily; max 30 mg/kg twice daily. 4 years to <16 years: Initial 10 mg/kg twice daily; max 30 mg/kg twice daily. (For children 20-40 kg, initial 250 mg twice daily, increasing by 250 mg twice daily every 2 weeks to a max of 750 mg twice daily).
Renal adjustment: CrCl 50-80 mL/min: 500-1500 mg every 12 hours. CrCl 30-50 mL/min: 250-750 mg every 12 hours. CrCl <30 mL/min: 250-500 mg every 12 hours. ESRD (on dialysis): 500-1000 mg every 24 hours, with an additional 250-500 mg post-dialysis.
Hepatic adjustment: No dose adjustment is typically required for mild to moderate hepatic impairment. For severe hepatic impairment, consider initiating with 500 mg twice daily and monitor clinical response and renal function.
Geriatric: Initiate with a lower dose (e.g., 250 mg orally twice daily) and titrate slowly due to potential age-related decline in renal function. Closely monitor renal function.
Max dose: 3000 mg/day (1500 mg twice daily)

Pharmacokinetics

Onset

Rapid (within minutes for IV, approximately 1 hour for oral immediate-release).

Peak effect

Oral: Approximately 1 hour (immediate-release). IV: At the end of infusion.

Duration

Not explicitly defined, but dosed twice daily indicating sustained action over 12 hours.

Half-life

6-8 hours in adults; 5-7 hours in children.

Bioavailability

100%

Protein binding

<10%

Metabolism

Minimal hepatic metabolism, primarily by enzymatic hydrolysis of the acetamide group; not via CYP450 enzymes.

Excretion

Primarily renal excretion (66% as unchanged drug, 24% as inactive metabolite).

Contraindications

Hypersensitivity to levetiracetam or any component of the formulation
children below 4 years

Side effects

Common

Somnolenceastheniadizzinessheadachefatigueirritabilitynasopharyngitisinfectionanorexiaataxiadyspepsiabehavioral changes (e.g., aggression, hostility, agitation)sleepinessweaknessgood tolerabilityfree of drug interactions

Serious

Suicidal ideation and behavior
anaphylaxis
angioedema
Stevens-Johnson Syndrome (SJS)
toxic epidermal necrolysis (TEN)
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)
severe cutaneous adverse reactions (SCARs)
blood dyscrasias (e.g., neutropenia, agranulocytosis, leukopenia)
psychiatric and behavioral symptoms (e.g., psychosis, paranoia, mood changes, severe aggression)
behavioural changes (rarely)
driving may be impaired

Pregnancy & lactation

Pregnancy

Category C — among safer AEDs in pregnancy

Lactation

Levetiracetam is excreted into breast milk. Monitor breastfed infants for potential adverse effects such as sedation, irritability, poor feeding, or developmental delays. Use with caution, and consider alternative feeding methods or close infant monitoring if continued use is deemed necessary.

Drug interactions

Buprenorphine

Severe

Database

Drug interaction classified as: synergy.

Source: DDInter

Dextropropoxyphene

Severe

Database

Clinical effect not specified

Source: DDInter

Sodium Oxybate

Severe

Database

Source: DDInter

Alcohol

Moderate

Database

Increased drowsiness, dizziness, impaired coordination, and psychomotor performance.

Advise patients to avoid or limit alcohol consumption while taking levetiracetam due to potential for additive CNS depression.

Carbamazepine

Moderate

Database

Potential for additive CNS depression (drowsiness, dizziness, ataxia) at higher doses or in sensitive individuals.

Monitor for increased CNS depressant effects. Adjust doses if necessary. Patients should be cautioned about operating machinery.

Source: DDInter

Methotrexate

Moderate

Database

Increased methotrexate plasma concentrations, leading to potential methotrexate toxicity (myelosuppression, mucositis, nephrotoxicity).

Monitor methotrexate levels and for signs of toxicity. Consider dose reduction of methotrexate, especially in patients with renal impairment. Monitor renal function.

Source: DDInter

Sedatives/hypnotics (e.g., Benzodiazepines)

Moderate

Database

Increased drowsiness, dizziness, and sedation.

Monitor for increased CNS depression. Consider lower doses of sedatives/hypnotics or levetiracetam if significant sedation occurs. Caution patients about operating machinery.

Tramadol

Moderate

Database

Increased somnolence, dizziness, respiratory depression, profound sedation, and potentially coma.

Monitor for increased CNS depression and respiratory depression. Use with caution, especially in opioid-naïve patients or those with respiratory compromise. Consider dose reduction of one or both drugs.

Source: DDInter

4 additional low-confidence interactions hidden — those rows lack a documented mechanism or management plan in our sources.