Keppra (levetiracetam) is an antiepileptic drug (AED) indicated for the adjunctive treatment of partial onset seizures, myoclonic seizures, and primary generalized tonic-clonic seizures in adults and children with epilepsy. As a second-generation AED, it offers a favorable pharmacokinetic profile and a distinct mechanism of action, targeting synaptic vesicle protein 2A (SV2A), which is involved in the modulation of neurotransmitter release. Its established efficacy, broad-spectrum potential, and generally well-tolerated nature make it a cornerstone in modern epilepsy management protocols for neurologists and epileptologists.

Features

• Active Ingredient: Levetiracetam
• Available Formulations: Film-coated tablets (250 mg, 500 mg, 750 mg, 1000 mg), oral solution (100 mg/mL), and injectable solution (100 mg/mL)
• Mechanism of Action: Binds to synaptic vesicle protein 2A (SV2A), modulating presynaptic neurotransmitter release
• Bioavailability: Oral bioavailability is greater than 95% and is not food-dependent
• Half-life: Approximately 6–8 hours in adults; 5–6 hours in children
• Metabolism: Minimally hepatic; primarily hydrolyzed enzymatically in the blood; not significantly cytochrome P450 dependent
• Excretion: Primarily renal (66% unchanged); clearance is correlated with creatinine clearance

Benefits

• Rapid Onset of Action: Achieves therapeutic serum concentrations quickly, allowing for efficient titration and early assessment of response.
• Broad-Spectrum Efficacy: Effective across multiple seizure types, including focal and generalized seizures, reducing the need for polytherapy.
• Favorable Safety Profile: Lower incidence of severe adverse reactions compared to many traditional antiepileptics; minimal drug-drug interactions.
• Linear Pharmacokinetics: Predictable dose-response relationship simplifies dosing adjustments and therapeutic monitoring.
• Neuropsychological Tolerability: Generally associated with fewer cognitive side effects, supporting better patient quality of life and adherence.
• Pediatric and Adult Formulations: Availability of oral solution and tablets allows for flexible dosing across age groups.

Common use

Keppra is primarily used as adjunctive therapy in the management of partial onset seizures with or without secondary generalization in adults and children aged 1 month and older. It is also approved for the treatment of myoclonic seizures in adults and adolescents aged 12 years and older with juvenile myoclonic epilepsy, and for primary generalized tonic-clonic seizures in adults and children aged 6 years and older with idiopathic generalized epilepsy. Its use may extend to off-label applications under specialist supervision, such as in status epilepticus protocols (intravenous formulation) and certain pediatric epilepsy syndromes.

Dosage and direction

Dosing must be individualized based on clinical response, tolerability, renal function, and age. For adjunctive therapy in adults and adolescents (≥16 years), the initial recommended dose is 500 mg twice daily. This may be increased by 500 mg twice daily every 2 weeks to a maximum recommended daily dose of 3000 mg. For partial onset seizures in children, dosing is weight-based. The oral solution is advised for easy titration in pediatric populations or those with swallowing difficulties. The intravenous formulation is bioequivalent to oral forms and is used when oral administration is temporarily not feasible. Administration with or without food is acceptable, though consistency is advised to maintain stable plasma levels.

Precautions

Patients should be monitored for the emergence or worsening of depression, suicidal ideation, or unusual changes in behavior. Caution is advised in patients with a history of psychiatric disorders. Dose-dependent somnolence and fatigue may occur; patients should be cautioned about operating machinery or driving until they understand how Keppra affects them. Renal impairment necessitates dosage adjustment based on creatinine clearance. Abrupt withdrawal may increase seizure frequency; gradual discontinuation is recommended. Pregnancy and lactation require careful risk-benefit evaluation; available human data do not suggest major malformative risks, but levetiracetam is excreted in breast milk.

Contraindications

Keppra is contraindicated in patients with a known hypersensitivity to levetiracetam, other pyrrolidine derivatives, or any excipients in the formulations. There are no other absolute contraindications, though severe renal impairment (CrCl < 30 mL/min) requires significant dose reduction and careful monitoring.

Possible side effect

Common adverse reactions (≥5%) include somnolence, asthenia, dizziness, and infection. Behavioral effects such as agitation, aggression, anxiety, irritability, and depression may occur, particularly in pediatric populations. Less frequently, patients may experience coordination difficulties, diplopia, or hematological abnormalities (e.g., leukopenia). Serious but rare side effects include severe dermatological reactions, psychosis, hallucinations, and pancytopenia. Most side effects are dose-related and may diminish with time or dose adjustment.

Drug interaction

Keppra has no clinically significant pharmacokinetic interactions with other antiepileptic drugs such as carbamazepine, valproic acid, phenytoin, phenobarbital, or lamotrigine. It does not inhibit or induce CYP450 enzymes. However, probenecid moderately inhibits the renal tubular secretion of the primary metabolite, potentially increasing its plasma concentration, though this is not considered clinically significant. No interactions with oral contraceptives, digoxin, or warfarin have been observed.

Missed dose

If a dose is missed, it should be taken as soon as possible. However, if it is near the time of the next scheduled dose, the missed dose should be skipped. Doubling the dose to compensate for a missed dose is not recommended, as it may increase the risk of adverse effects.

Overdose

Symptoms of overdose may include pronounced drowsiness, agitation, aggression, respiratory depression, and coma. There is no specific antidote. Management consists of supportive care, including monitoring of vital signs and general symptomatic treatment. Hemodialysis is effective, removing approximately 50% of the drug over 4 hours, and should be considered in severe cases.

Storage

Store at room temperature (15–30°C or 59–86°F). Protect from light and moisture. Keep the oral solution in its original container; do not freeze. Keep all medications out of reach of children and pets.

Disclaimer

This information is intended for educational and professional medical use only and does not constitute medical advice. Treatment decisions must be made by a qualified healthcare provider based on individual patient circumstances. Always refer to the full prescribing information and latest clinical guidelines.

Reviews

Clinical trials and post-marketing surveillance consistently demonstrate Keppra’s efficacy in reducing seizure frequency, with many patients achieving significant improvement or seizure freedom. It is often praised for its rapid titration schedule and tolerability. Some criticisms involve its potential behavioral side effects in vulnerable populations, though these are generally manageable with dose adjustment or discontinuation. Overall, it remains a widely trusted option in both adult and pediatric neurology.