Section 01 · Monograph

Brivaracetam

Reviewed Nov 2026FDA label

BriviactSV2A ligand

Indications

High-affinity, selective ligand for synaptic vesicle protein 2A (SV2A), the same target as levetiracetam, but with substantially greater binding affinity and selectivity in preclinical studies, which may contribute to its pharmacologic profile
Modulates synaptic vesicle release and neurotransmitter exocytosis, dampening abnormal, synchronized neuronal firing

Adults (16 years and older): initiate 50mg BID (100mg/day); no titration required, though initiation at 25mg BID may be considered based on tolerability
Maintenance range: 25-100mg BID (50-200mg/day) based on response and tolerability
Available as oral tablet, oral solution, and IV injection — IV is used when oral administration is temporarily not feasible and is dosed identically to oral (1:1 conversion), infused over 2-15 minutes

Hepatic impairment (any severity): reduce initial dose to 25mg BID, with maximum maintenance dose of 75mg BID (150mg/day)

Known hypersensitivity to brivaracetam or any component of the formulation (hypersensitivity reactions including bronchospasm and angioedema have been reported)

Rifampin decreases brivaracetam plasma concentrations substantially (~45%) — consider dose increase during coadministration
Brivaracetam inhibits epoxide hydrolase, increasing concentrations of the active carbamazepine-epoxide metabolite when coadministered with carbamazepine — monitor for carbamazepine toxicity
May increase phenytoin concentrations — monitor phenytoin levels when initiating or discontinuing brivaracetam
Minimal hepatic CYP-mediated interaction potential overall compared to older AEDs; no added therapeutic benefit demonstrated when combined with levetiracetam
High doses may minimally reduce estrogen/progestin exposure with hormonal contraceptives

Common: somnolence/sedation, dizziness, fatigue, nausea/vomiting
Psychiatric/behavioral symptoms (irritability, anxiety, nervousness, aggression, depression) occur but generally with lower reported frequency/severity than levetiracetam; rare psychotic symptoms (hallucination, paranoia, acute psychosis) have been reported
Suicidal ideation/behavior (class effect)
Hypersensitivity reactions including bronchospasm and angioedema
Serious dermatologic reactions (Stevens-Johnson syndrome, toxic epidermal necrolysis) reported rarely

Mental status for mood/behavioral changes or suicidal ideation, though generally less prominent than with levetiracetam
Neurologic effects (somnolence, dizziness) — advise caution with driving/operating machinery until effects are known
Phenytoin levels if coadministered
Skin reactions suggestive of serious dermatologic hypersensitivity

Animal studies showed developmental toxicity at exposures exceeding clinical doses; human data are insufficient to establish drug-associated risk
Encourage enrollment in the North American Antiepileptic Drug (NAAED) Pregnancy Registry (1-888-233-2334)
Brivaracetam is present in human milk; insufficient data on effects in the breastfed infant — weigh benefits of treatment against potential infant exposure