Brivaracetam

BRIVIACT

What it isSV2A ligand with higher affinity than levetiracetam; focal seizures.

Why this oneLess irritability and mood disturbance than levetiracetam, which is the usual reason to switch.

What limits itSedation and dizziness. CYP2C19 variation affects exposure; Schedule V.

FDA-approved for

FDA dosing	Population	Start	Target	Max
Partial-onset seizures (monotherapy or adjunctive)	Adults & peds ≥16 yr	50 mg BID	25–100 mg BID	100 mg BID (200 mg/day)
Partial-onset seizures	Peds 1 mo–<16 yr, weight-based	Weight-based BID (e.g. 0.5–1.5 mg/kg BID)	0.5–3 mg/kg BID by weight	Up to 3 mg/kg BID (<11 kg)

Renal No adjustment needed; not recommended in ESRD/dialysis

Hepatic Reduce dose for all stages (adults: start 25 mg BID, max 75 mg BID)

Swallow tablets whole with liquid; do not chew or crush
May take with or without food
Avoid abrupt withdrawal — taper to reduce seizure/status epilepticus risk
IV injection over 2–15 min when oral temporarily not feasible; same dose and frequency
Double the dose with concomitant rifampin

Suicidal behavior and ideation
Somnolence, fatigue, dizziness, and coordination disturbance
Psychiatric reactions (psychosis, irritability, aggression, depression, anxiety)
Hypersensitivity: bronchospasm and angioedema
Serious dermatologic reactions (SJS, TEN)

Pregnancy Insufficient human data; developmental toxicity in animals. Pregnancy registry available (1-888-233-2334)

Lactation Present in human milk; insufficient data on effects

NO BOXED WARNINGS

Principal riskSedation and dizziness

Cost, est. cash$300–$2,500/month

Generic entry2025

Therapeutic safety burden2 / 4

Overdose danger2 / 4

Weight-gain liability1 / 4

Sedation liability1 / 4

QT / Torsades0 / 4

Direct muscarinic antagonism0 / 4

Embryofetal risk2 / 4

Legacy pregnancy categoryNot assigned — PLLR-era drug

Defining liabilitySomnolence and behavioral adverse effects; misuse potential is lower than many sedatives but not absent.

CYP2C19 substrate