Levetiracetam is the drug of choice for post-transplant seizures given its broad-spectrum efficacy across a broad range of seizure types throughout the lifespan, including infants, children, and adults, as well as its rapid and linear oral absorption conferring rapid efficacy; favorable side effect profile; flexible availability as oral tablet, syrup, and intravenous formulations; and lack of significant hepatic metabolism or drug–drug interactions [57, 60, 65, 66]. The CNS target for levetiracetam is binding of intravesicular synaptic vesicle protein 2A, thereby modulating neuro-transmitter release in rapidly discharging neurons [67].
Standard dosage	Initiate levetiracetam at 1,000 mg/d(2×500-mg tablets once daily) and titrate in increments of 1,000 mg every 1 to 2 weeks up to 3,000 mg/d. Intravenously, 1,000 mg infusions can be given safely and rapidly over 15 to 60 min or faster.
Contraindications	Hypersensitivity to levetiracetam.
Main drug interactions	No interactions were found between levetiracetam and 11 different drug-metabolizing enzymes [68]. Of particular relevance to transplant patients, levetiracetam does not affect cyclosporine metabolism [58].
Main side effects	Somnolence, asthenia, infection, and dizziness are the most frequent adverse effects. Behavioral abnormalities such as irritability, personality change, and psychosis, and mild leukopenia are possible. The US Food and Drug Administration has issued a class warning for antiepileptic drugs that an increase in suicidal thoughts may occur during treatment, applying generally to every AED [69].
Special points	Patients with impaired renal function may require a dosage decrease, as levetiracetam is excreted largely unchanged and almost entirely renally, and the rate of elimination correlates with creatinine clearance [42–47, 50, 60, 70, 71]. An intravenous formulation has been demonstrated as bioequivalent to the oral formulation, providing another potential option for acute seizure management, preferably for those who are not in convulsive status epilepticus, as the evidence basis for acute seizure termination remains limited and uncontrolled [72, 73]. Ongoing randomized trials of intravenous levetiracetam in status epilepticus may yield more definitive data on efficacy in the near future [74].
Cost	Expensive (especially the intravenous formulation).