• Treatment of partial onset seizures with or without secondary generalization in adults, children from 6 years of age with epilepsy.
• Treatment myoclonic seizures in adults and adolescent from 12 years of age with juvenile Myoclonic.
• Treatment of primary generalized tonic-clonic seizures in adults and children from 12 years of age with idiopathic Generalized Epilepsy.

The tablets must be taken orally, swallowed with liquid. It may be taken with or without food. The daily dose is administered in two equally divided doses.

Monotherapy

The recommended starting dose is 250 mg twice daily which should be increased to an initial therapeutic dose of 500 mg twice daily after two weeks. The dose can be further increased by 250 mg twice daily very two weeks depending upon the clinical response. The maximum dose is 1,500 mg twice daily.

Add-On Therapy

Adults (> 18 years of age) and Adolescents (aged 12 to 17 years of age) weighing 50 kg or more As adjunctive therapy, the therapeutic dose is 500 mg twice daily. This dose can be started on the first day of treatment. Depending upon the clinical response and tolerance, the daily dose can be increased up to 1,500 mg twice daily. Dose changes can be made in 500 mg twice daily increments or decrements every two to four weeks.

When satisfactory control of seizures has been attained, monotherapy with levetiracetam may be envisaged by progressively decreasing and withdrawing the concomitant antiepileptic medication.

Elderly (65 years and older)

Adjustment of the dose is recommended in the elderly with compromised renal function (see “Patients with Renal Impairment”, below).

Children (aged 4 to 11 years of age) and Adolescents (aged 12 to 17 years of age) weighing less than 50 kg

The initial therapeutic dose is 10 mg/kg twice daily (see Table 1).

Depending on the clinical response and tolerance, the daily dose can be increased up to 60 mg/kg daily (in two 30 mg/kg doses). Dose changes can be made in 10 mg/kg twice daily dose increme nts or decrements every two weeks. The lowest effective dose should be used.

The dosage in children 50 kg or greater is the same as in adults.

The doctor should prescribe the most appropriate pharmaceutical form and strength according to weight and dose.

Table 1: Recommended dosing in children aged 4 years and older

(1) Children 20 kg or less should preferably start the treatment with a Levetiracetam 100 mg/mL oral solution.

(2) Dosage in children and adolescents 50 kg or more is the same as in adults.

Infants & Children less than 4 Years of Age

There are insufficient data to recommend the use of levetiracetam in children under 4 years of age.

Patients with Renal Impairment

The levetiracetam daily dose must be individualised according to renal function. For adult patients, see Table 2 and adjust the dose as indicated.

To use this dosing table an estimate of the patient's creatinine clearance (ClCr) in mL/minute is needed. The ClCr in mL/minute may be estimated from serum creatinine (µmol/L) determination using the following formula.

CLcr (mL/min/1.73m2) =      CLcr (mL/min) x 1.73     

                                                     BSA subject (m2)

CLcr =      [140 – age (years)] x weight (kg)  (x 0.85 for women)

                        0.8136 x serum creatinine (µmol/L)

The CICr is adjusted for body surface area (BSA) as follows:

Table 2: Adult dosage schedule based on renal function

(1) A 750 mg loading dose is recommended on the first day of treatment with levetiracetam.

(2) Following dialysis, a 250 to 500 mg supplemental dose is recommended.

For children with renal impairment, levetiracetam dose needs to be adjusted based on the renal function as levetiracetam clearance is related to renal function. This recommendation is based on a study in adult renally impaired patients.

Patients with Hepatic Impairment

No dose adjustment is needed in patients with mild and moderate hepatic impairment. In patients with severe hepatic impairment, the creatinine clearance may underestimate the renal insufficiency. Therefore, a 50% reduction of the daily maintenance dose is recommended when the creatinine clearance is < 70 mL/minute.

In accordance with current clinical practice, if levetiracetam has to be discontinued it is recommended to withdraw it gradually.

Due to its complete and linear absorption, plasma levels can be predicted from the oral dose of levetiracetam expressed as mg/kg bodyweight. There is no need, therefore, for plasma level monitoring of levetiracetam.

To date, there are no data to support the use of levetiracetam in patients less than 4 years of age. No data on the interaction of levetiracetam with alcohol are available.

Suicidal Behaviour & Ideation

Antiepileptic drugs, including levetiracetam, increase the risk of suicidal thoughts or behaviour in patients taking these drugs for any indication. Patients treated with any AED for any indication should be monitored for the emergence or worsening of depression, suicidal thoughts or behaviour and/or any unusual changes in mood or behaviour.

Pooled analyses of 199 placebo-controlled clinical trials (mono- and adjunctive therapy) of 11 different AEDs showed that patients randomised to one of the AEDs had approximately twice the risk (adjusted Relative Risk 1.8, 95% CI: 1.2, 2.7) of suicidal thinking or behaviour compared to patients randomised to placebo. In these trials, which had a median treatment duration of 12 weeks, the estimated incidence rate of suicidal behaviour or ideation among 27,863 AED-treated patients was 0.43%, compared to 0.24% among 16,029 placebo-treated patients, representing an increase of approximately one case of suicidal thinking or behaviour for every 530 patients treated. There were four suicides in drug-treated patients in the trials and none in placebo-treated patients, but the number is too small to allow any conclusion about drug effect on suicide.

The increased risk of suicidal thoughts or behaviour with AEDs was observed as early as one week after starting drug treatment with AEDs and persisted for the duration of treatment assessed. Because most trials included in the analysis did not extend beyond 24 weeks, the risk of suicidal thoughts or behaviour beyond 24 weeks could not be assessed.

The risk of suicidal thoughts or behaviour was generally consistent among drugs in the data analysed. The finding of increased risk with AEDs of varying mechanisms of action and across a range of indications suggests that the risk applies to all AEDs used for any indication. The risk did not vary substantially by age (5-100 years) in the clinical trials analysed. Table 3 shows absolute and relative risk by indication for all evaluated AEDs.

Table 3: Risk by indication for antiepileptic drugs in the pooled analysis

The relative risk for suicidal thoughts or behaviour was higher in clinical trials for epilepsy than in clinical trials for psychiatric or other conditions, but the absolute risk differences were similar for the epilepsy and psychiatric indications.

Anyone considering prescribing levetiracetam or any other AED must balance this risk with the risk of untreated illness. Epilepsy and many other illnesses for which AEDs are prescribed are themselves associated with morbidity and mortality and an increased risk of suicidal thoughts and behaviour. Should suicidal thoughts and behaviour emerge during treatment, the prescriber needs to consider whether the emergence of these symptoms in any given patient may be related to illness being treated.

Patients, their caregivers, and families should be informed that AEDs increase the risk of suicidal thoughts and behaviour and should be advised of the need to be alert for the emergence of worsening of the signs and symptoms of depression, any unusual changes in mood or behaviour, or the emergence of suicidal thoughts, behaviour, or thoughts about self-harm. Behaviours of concern should be reported immediately to the treating doctor.

Impaired Renal Function

The administration of levetiracetam to patients with renal impairment may require dose adaptation. Monitoring of renal function in patients with severe hepatic impairment is recommended before dose selection (see DOSAGE AND ADMINISTRATION).

Impaired Hepatic Function

See “Impaired Renal Function”.

Carcinogenesis and Mutagenesis

Carcinogeniticy

There was no evidence of carcinogenicity following administration of levetiracetam in the diet to rats or orally to mice for 104 weeks, associated with respective systemic exposures (plasma AUC) up to fourfold and eightfold that in humans at the maximal recommended clinical dose of 3,000 mg/day.

Genotoxicity

Levetiracetam was negative in gene mutation assays (bacterial, Chinese hamster ovary/ HGPRT locus) and in assays for chromosomal damage in vitro and in vivo (Chinese hamster ovary cells, mouse micronucleus assay). The hydrolysis product and major human metabolite (ucb L057) was not mutagenic in bacterial reverse mutation assays or the in vitro mouse lymphoma assay.

In vitro, levetiracetam and its major metabolite (ucb L057) have been shown not to inhibit the major human liver cytochrome P450 isoforms, glucuronyl transferase, (valproic acid) and epoxide hydroxylase activities. In human hepatocytes in culture, levetiracetam did not cause enzyme induction.

Probenecid has been shown to inhibit the renal clearance of the major metabolite (ucb L057) but not levetiracetam. Nevertheless, the concentration of ucb L057 remains low. It is expected that other drugs excreted by active tubular secretion could also reduce the renal clearance of the metabolite. The effect of levetiracetam on probenecid was not studied and the effect of levetiracetam on other actively secreted drugs (e.g. NSAIDs, sulphonamides, and methotrexate) is unknown.

Pre-marketing data from clinical studies conducted in adults indicate that levetiracetam did not influence the serum concentrations of existing antiepileptic medicinal products (phenytoin, carbamazepine, valproic acid, phenobarbitone, lamotrigine, gabapentin and primidone) and that these antiepileptic medicinal products did not influence the pharmacokinetics of levetiracetam.

Consistent with formal pharmacokinetic studies in adults, there has been no clear evidence of clinically significant drug interactions in paediatric patients receiving up to 60 mg/kg/day.

A retrospective assessment of pharmacokinetic interactions in children and adolescents with epilepsy (4 to 17 years) confirmed that adjunctive therapy with levetiracetam did not influence the steady-state serum concentrations of concomitantly administered carbamazepine, valproate, topiramate and lamotrigine. However, data suggested that enzyme inducing antiepileptic medicinal products increase levetiracetam clearance by 22%. Dosage adjustment is not required.

Pharmacokinetic studies demonstrated a lack of interaction with digoxin, oral contraceptives (ethinyloestradiol and levonorgestrel) and warfarin. Endocrine parameters (luteinising hormone (LH) and progesterone) and prothrombin times were not modified.

No data on the influence of antacids on the absorption of levetiracetam are available.

Effects on Fertility

There are no human data on the effects of levetiracetam on male or female fertility. No adverse effects on male or female fertility or reproductive performance were observed in rats at oral doses of levetiracetam up to 1,800 mg/kg/day (corresponding to approximately six times the maximal recommended clinical dose on a mg/m2 basis) administered for at least two weeks prior to, and throughout, mating.

Use in Pregnancy (Category C)

In rats and rabbits, levetiracetam and/or its metabolites cross the placenta and the foetal levels approximate maternal plasma levels. In these species, levetiracetam produced evidence of developmental toxicity at doses similar to or greater than human therapeutic doses.

Oral administration to female rats from two weeks prior to mating and throughout pregnancy and lactation was associated with increased incidences of minor foetal skeletal abnormalities and retarded offspring growth prenatally and/or postnatally at doses greater than or equal to 350 mg/kg/day (approximately equivalent to the maximal recommended clinical dose of 3,000 mg/day on a mg/m2 basis) and with increased pup mortality and offspring behavioural alterations at a dose of 1,800 mg/kg/day (six times the maximal human dose on a mg/m2 basis). The developmental no effect dose was 70 mg/kg/day (equivalent to 0.2 times the maximal human dose on a mg/m2 basis). There was no overt maternal toxicity at the doses used in this study.

Oral administration to pregnant rabbits during the period of organogenesis resulted in increased embryofoetal mortality and increased incidences of minor foetal skeletal abnormalities at doses greater than or equal to 600 mg/kg/day (about four times the maximal human dose on a mg/m2 basis) and in decreased foetal weights and increased incidences of minor foetal skeletal anomalies at a dose of 1,800 mg/kg/day (12 times the maximal human dose on a mg/m2 basis). The developmental no effect dose was 200 mg/kg/day (1.3 times the maximal human dose on a mg/m2 basis). Maternal toxicity was also observed at 1,800 mg/kg/day.

Oral administration to pregnant rats during the period of organogenesis resulted in reduced foetal weight and increased incidence of embryofoetal mortality and increased incidence of foetal skeletal variations at a dose of 3,600 mg/kg/day (12 times the maximal human dose on a mg/m2 basis). The developmental no effect dose was 1,200 mg/kg/day (four times the maximal human dose on a mg/m2 basis). There was no overt maternal toxicity.

Oral administration to rats during the late gestation and throughout lactation produced no adverse developmental or maternal effects at doses of up to 1,800 mg/kg/day (six times the maximal human dose on a mg/m2 basis). Neonatal and juvenile animal studies in rats and dogs demonstrated that there were no adverse effects seen in any of the standard developmental or maturation endpoints at doses of up to 1,800 mg/kg/day (30 times the maximal human dose).

The risk of having an abnormal child as a result of antiepileptic medication is far outweighed by the dangers to the mother and foetus of uncontrolled epilepsy.

It is recommended that:

• Women on AEDs receive pre-pregnancy counselling with regard to the risk of foetal abnormalities;
• AEDs should be continued during pregnancy and monotherapy should be used if possible at the lowest effective dose as risk of abnormality is greater in women taking combined medication;
• Folic acid supplementation (5 mg) should be commenced four weeks prior to and continue for 12 weeks after conception;
• Specialist prenatal diagnosis including detailed mid-trimester ultrasound should be offered.

To date, insufficient clinical data on exposed pregnancies are available. Levetiracetam should be used during pregnancy only if the potential benefit justifies the potential risk to the foetus. As with other antiepileptic drugs, physiological changes during pregnancy may affect levetiracetam concentration. There have been reports of decreased levetiracetam concentrations during pregnancy.

Use in Lactation

Levetiracetam and/or its metabolites are excreted in milk in lactating rats; peak milk concentrations occurred three hours after oral administration (milk:plasma ratio 0.9). Levetiracetam is excreted in breast milk. Because of the potential for serious adverse reactions in breastfeeding infants from levetiracetam, a decision should be made whether to discontinue breastfeeding or discontinue the drug, taking into account the importance of the drug to the mother.

No studies on the effects on the ability to drive and use machines have been performed.

Due to possible different individual sensitivity, some patients might experience, at the beginning of treatment or following a dosage increase, somnolence or other central nervous system (CNS) related symptoms. Therefore, caution is recommended in those patients when performing skilled tasks, e.g. driving vehicles or operating machinery.

The prescriber should be aware that the following data were obtained from studies where levetiracetam was added to concomitant antiepileptic therapy. Therefore, it was not possible in all cases to determine which agent(s), if any, was associated with the adverse events. It is also difficult to predict the frequency of adverse events in the course of usual medical practice where patient characteristics and other factors may differ from those prevailing during clinical studies.

Adult Patients

Levetiracetam has been administered to more than 3,000 subjects and patients. Of these, 780 patients were treated for more than six months, 592 for more than one year, 366 for more than two years and 185 for more than three years.

1,023 adult patients with epilepsy participated in controlled clinical trials (672 patients were treated with levetiracetam and 351 patients with placebo).

From placebo controlled studies conducted in adults, 46.4 and 42.2% of patients experienced drug related, treatment emergent adverse events in the levetiracetam group and placebo group, respectively. 2.4 and 2.0% of patients experienced serious drug related, treatment emergent adverse events in the levetiracetam group and placebo group, respectively.

During monotherapy treatment with levetiracetam, 79.6% of subjects experienced at least one adverse event and 49.8% experienced at least one drug related undesirable effect. The most frequently reported adverse effects were fatigue and somnolence.

Very Common Adverse Events (greater than or equal to 10%)

The very common adverse events (greater than or equal to 10%) were somnolence, asthenia, infection, headache and accidental injury. Of these, somnolence, asthenia and infection appeared to occur more frequently in levetiracetam treated patients than in placebo treated patients, whereas accidental injury was more common in the placebo group and headache was similarly reported in the two groups (see Table 4).

Table 4: Incidence (%) of very common treatment emergent adverse events in adult placebo controlled studies, by body system

In the pooled safety analysis, there was no clear dose response relationship but incidence and severity of CNS related undesirable effects decreased over time.

More than 93% of events categorised under the COSTART preferred term 'infection' are symptoms of community acquired infections (common cold and upper respiratory tract infections). There was no increase in incidence of other infections (e.g. lower respiratory tract infections, urinary tract infections). Minor, but statistically significant, decreases compared to placebo in total mean RBC count (0.03 x 106/mm2), mean haemoglobin (0.9 g/L) and mean haematocrit (0.38%) were seen in levetiracetam treated patients in controlled trials. A total of 3.2% of treated and 1.8% of placebo patients had at least one possibly significant (less than or equal to 2.8 x 109/L) decreased WBC, and 2.4% for treated and 1.4% of placebo patients had at least one possible significant (less than or equal to 1.0 x 109/L) decreased neutrophil count. Of the treated patients with a low neutrophil count, all but one rose towards or to baseline with continued treatment. No patient was discontinued secondary to low neutrophil counts.

Common Adverse Events (greater than or equal to 1% and < 10%)

See Table 5.

Table 5: Incidence (%) of common treatment emergent adverse events in adult placebo controlled studies, by body system

The incidence of serious adverse events in placebo controlled studies was 9.9% in the levetiracetam group versus 8.9% in the placebo group. Many of the serious adverse events are typical for a population of patients with epilepsy.

The serious adverse events which occurred in more than 1% of patients were convulsion (1.8% in levetiracetam group versus 1.4% in placebo group) and accidental injury (1.6% in both levetiracetam and placebo group).

Paediatric Patients

A study conducted in paediatric patients (4 to 16 years of age) showed that 55.4 and 40.2% of the paediatric patients experienced undesirable effects in the levetiracetam and placebo groups, respectively, and that 0.0 and 1.0% of the paediatric patients experienced serious undesirable effects in the levetiracetam and placebo groups, respectively.

In the paediatric clinical study, 16.8% of patients receiving levetiracetam and 20.6% receiving placebo either discontinued or had a dose reduction as a result of an adverse event. The most commonly reported undesirable effects in the paediatric population were somnolence, hostility, nervousness, emotional lability, agitation, anorexia, asthenia and headache. Safety results in paediatric patients were consistent with the safety profile of levetiracetam in adults, except for behavioural and psychiatric undesirable effects which were more common in children than in adults (38.6 versus 18.6%). However, the relative risk was similar in children as compared to adults as there was also a higher incidence of behavioural psychiatric adverse events in the placebo group in children as compared to adults (27.8 versus 10.5%) (see Table 6).

Table 6: Incidence (%) of treatment emergent adverse events in a placebo controlled, add-on study in paediatric patients aged 4-16 years, by body system (adverse events occurred in at least 2% of Levetiracetam treated patients and occurred more frequently than placebo treated patients)

Other events occurring in 2% or more of paediatric patients treated with levetiracetam but as or more frequent in the placebo group were the following: abdominal pain, allergic reaction, ataxia, convulsion, epistaxis, fever, headache, hyperkinesia, infection, insomnia, nausea, otitis media, rash, sinusitis, status epilepticus (not otherwise specified), thinking abnormal, tremor and urinary incontinence.

Other Controlled Clinical Trials

The following adverse effects, listed by body system, have been observed in additional controlled clinical trials.

General Disorders

Very Common:            Fatigue.

Respiratory System

Common:        Nasopharyngitis.

Nervous System

Common:        Balance disorder, disturbance in attention, memory impairment.

Skin & Subcutaneous Tissue Disorders

Common:        Eczema, pruritus.

Eye Disorders

Common:        Vision blurred.

Blood & Lymphatic System Disorders

Common:        Thrombocytopenia.

Musculoskeletal & Connective Tissue Disorders

Common:        Myalgia.

Psychiatric Disorders

Common:        Irritability, mood swings, personality disorder.

Post-Marketing Experience

In post-marketing experience, nervous system and psychiatric disorders have been most frequently reported.

In addition to the adverse reactions reported during clinical studies and listed above, the following adverse reactions have been reported in post-marketing experience. Data are insufficient to support an estimate of their incidence in the population to be treated.

Blood & Lymphatic System Disorders

Pancytopenia with bone marrow suppression identified in some of these cases, leucopenia and neutropenia.

Psychiatric Disorders

Abnormal behaviour, aggression, anger, confusion, hallucination, psychotic disorder, suicide, suicide attempt and suicidal ideation.

Skin & Subcutaneous Tissue Disorders

Alopecia; in several cases, recovery was observed when levetiracetam was discontinued.

Liver & Biliary System Disorders

Hepatitis, hepatic failure and abnormal liver function test.

Metabolic & Nutritional Disorders

Weight loss, pancreatitis.

-  To report any side effect(s):

Symptoms

The highest known dose of levetiracetam received in the clinical development program was 6,000 mg/day. Other than drowsiness, there were no adverse events in the few known cases of overdose in clinical trials.

Cases of somnolence, agitation, aggression, depressed level of consciousness, respiratory depression and coma were observed with levetiracetam overdoses in post-marketing use.

Treatment

There is no specific antidote for levetiracetam. Treatment for an overdose will be symptomatic and may include haemodialysis. The dialyser extraction efficiency is 60% for levetiracetam and 74% for the major metabolite (ucb L057).

Pharmacodynamics in Animals

Levetiracetam is not active in the classical screening models for anticonvulsants, however it induces potent protection in a broad range of animal models of partial and primary generalised seizures, with an unusually high safety margin between therapeutic doses and doses inducing adverse effects.

Levetiracetam also displays potential antiepileptogenic properties by dose dependently inhibiting the development of kindling, even after discontinuation of the active substance.

Withdrawal from chronic treatment did not decrease the seizure threshold. Anxiolytic action and an absence of undesirable effects on cognitive function have also been observed.

The major metabolite, ucb L057, is inactive in seizure models.

Pharmacodynamics in Humans

Both partial and generalised epilepsy models (epileptiform discharge/photoparoxysmal response) confirmed the broad spectrum preclinical pharmacological profile.

Levetiracetam is a highly soluble and permeable compound. The pharmacokinetic profile is linear and time independent with low intrasubject and intersubject variability. There is no modification of the clearance after repeated administration. There is no evidence for any relevant gender, race or circadian variability. The pharmacokinetic profile is comparable in healthy volunteers and in patients with epilepsy.

Due to its complete and linear absorption, plasma levels can be predicted from the oral dose of levetiracetam expressed as mg/kg bodyweight. Therefore, there is no need for plasma level monitoring of levetiracetam.

A significant correlation between saliva and plasma concentrations has been shown in adults and children (ratio of saliva/ plasma concentrations ranged from 1 to 1.7 for oral tablet formulation and after four hours postdose for oral solution formulation).

A single dose of levetiracetam 1,500 mg diluted in 100 mL of a compatible diluent and infused intravenously over 15 minutes is bioequivalent to levetiracetam 1,500 mg oral intake, given as three 500 mg tablets.

The intravenous administration of doses up to 4,000 mg diluted in sodium chloride 0.9% 100 mL infused over 15 minutes and doses up to 2,500 mg diluted in sodium chloride 0.9% 100 mL infused over five minutes was evaluated.

The pharmacokinetic and safety profiles did not identify any safety concerns.

Adults and Adolescents

Absorption: 

Levetiracetam is rapidly absorbed after oral administration. Oral absolute bioavailability is close to 100%. Peak plasma concentrations (Cmax) are achieved at 1.3 hours after dosing. Steady state is achieved after two days of a twice daily administration schedule. Peak concentrations (Cmax) are typically 31 and

43 µg/mL following a single 1,000 mg dose and repeated 1,000 mg twice daily (bid) dose, respectively. The extent of absorption is dose independent and is not altered by food but the rate of absorption is slightly reduced.

Distribution:

No tissue distribution data are available in humans. Neither levetiracetam nor its major metabolite

(ucb L057) are significantly bound to plasma proteins (< 10%). The volume of distribution of levetiracetam is approximately 0.5 to 0.7 L/kg, a value close to the volume of distribution of intracellular and extracellular water.

Metabolism:

The major metabolic pathway (24% of the dose) is an enzymatic hydrolysis of the acetamide group. Production of this metabolite, ucb L057, is not supported by liver cytochrome P450 isoforms. Hydrolysis of the acetamide group was measurable in a large number of tissues including whole blood but not plasma. The metabolite ucb L057 is pharmacologically inactive.

Two minor metabolites were also identified. One was obtained by hydroxylation of the pyrrolidone ring (1.6% of the dose) and the other one by opening of the pyrrolidone ring (0.9% of the dose).

Other unidentified components accounted for only 0.6% of the dose.

No enantiomeric interconversion was evidenced in vivo for either levetiracetam or its major metabolite ucb L057. In vitro, levetiracetam and its primary metabolite have been shown not to inhibit the major human liver cytochrome P450 isoforms (CYP3A4, 2A6, 2C9, 2C19, 2D6, 2E1 and 1A2), glucuronyl transferase (UGT1A1 and UGT1A6) and epoxide hydroxylase activities. In addition, levetiracetam does not affect the in vitro glucuronidation of valproic acid.

In human hepatocytes in vitro, levetiracetam had no effect on CYP1A/2 or UGT isoform activities (including ethinyloestradiol conjugation). Levetiracetam caused mild induction of CYP2B6 and CYP3A4, but only at high concentrations not considered to be clinically relevant. Therefore, the interaction of levetiracetam with other substances, or vice versa, is unlikely.

Excretion: 

The plasma half-life in adults was 7.2 +/- 1.1 hours and did not vary either with dose, route of administration or repeated administration. The total body clearance was a mean of 0.96 +/- 0.14 mL/minute/kg.

The major route of excretion was via urine, accounting for a mean 95% of the dose, with approximately 93% of the dose excreted within 48 hours. Excretion via faeces accounted for only 0.3% of the dose. The cumulative urinary excretion of levetiracetam and its major metabolite (ucb L057) accounted for 66 and 24% of the dose, respectively, during the first 48 hours.

The renal clearance of levetiracetam is 0.6 mL/minute/kg, indicating that it is excreted by glomerular filtration with subsequent tubular reabsorption. The renal clearance of the major metabolite, ucb L057, is 4.2 mL/minute/kg indicating active tubular secretion in addition to glomerular filtration.

Elderly

In elderly patients, the half-life is increased by about 40% (ten to eleven hours) and is attributed to the decrease in renal function in this population (see DOSAGE AND ADMINISTRATION).

Children (4 to 12 Years of Age)

Following single dose administration (20 mg/kg) to epileptic children (6 to 12 years of age), the half-life of levetiracetam was 6.0 +/- 1.1 hours. The apparent body clearance was approximately 30% higher than in epileptic adults.

Following repeated oral dose administration (20 to 60 mg/kg/day) to epileptic children (4 to 12 years of age), levetiracetam was rapidly absorbed. Peak plasma concentration was observed 0.5 to 1.0 hour after dosing. Linear and dose proportional increases were observed for peak plasma concentrations and area under the curve. The elimination half-life was approximately five hours. The apparent body clearance was 1.1 mL/minute/kg.

Infants and Children (1 Month to 4 Years of Age)

Following single dose administration (20 mg/kg) of a 10% oral solution to epileptic children (1 month to 4 years of age), levetiracetam was rapidly absorbed and peak plasma concentrations were observed approximately one hour after dosing. The pharmacokinetic results indicated that half-life was shorter (5.3 hours) than for adults (7.2 hours) and apparent clearance was faster (1.5 mL/minute/kg) than for adults (0.96 mL/minute/kg).

Renal Impairment

The apparent body clearance of both levetiracetam and its major metabolite (ucb L057) is correlated to the creatinine clearance. It is, therefore, recommended to adjust the maintenance daily dose of levetiracetam, based on creatinine clearance in patients with moderate and severe renal impairment (see DOSAGE AND ADMINISTRATION).

In anuric endstage renal disease adult subjects the half-life was approximately 25 and 3.1 hours during interdialytic and intradialytic periods, respectively. The fractional removal of levetiracetam was 51% during a typical four hour dialysis session.

Hepatic Impairment

In subjects with mild and moderate hepatic impairment, there was no relevant modification of the clearance of levetiracetam. In most subjects with severe hepatic impairment, the clearance of levetiracetam was reduced by more than 50% due to concomitant renal impairment (see DOSAGE AND ADMINISTRATION).

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