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This document is an application form for medical practitioners to request special access to the levetiracetam medication (Keppra) for patients with epilepsy, detailing the necessary information and
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How to fill out application form for levetiracetam

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How to fill out APPLICATION FORM FOR LEVETIRACETAM SPECIAL ACCESS

01
Obtain the APPLICATION FORM FOR LEVETIRACETAM SPECIAL ACCESS from the relevant health authority or hospital.
02
Fill in the patient's personal information, including name, date of birth, and contact details.
03
Provide details regarding the medical condition for which levetiracetam is being requested.
04
Include any previous treatments tried and their outcomes.
05
Specify the dosage and duration of levetiracetam treatment being requested.
06
Attach supporting documents, such as medical reports or letters from healthcare providers.
07
Sign and date the application form.
08
Submit the completed application form to the appropriate health authority or designated office.

Who needs APPLICATION FORM FOR LEVETIRACETAM SPECIAL ACCESS?

01
Patients who have a medical condition that requires levetiracetam and cannot access it through standard channels.
02
Healthcare providers seeking special access for patients who have exhausted other treatment options.
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Dosage. The usual dose of levetiracetam to treat epilepsy in: adults and older children (aged 12 years and over) is 250mg to 3,000mg a day, taken as 1 or 2 doses, but the exact dose may depend on your weight. children (aged 1 month to 11 years) varies depending on their weight.
Levetiracetam XR. XR is a different form of the same medicine. The "XR" stands for "extended-release," which means that the time it takes the pills to dissolve and release the medicine is longer. Most people need to take regular two or sometimes more times a day.
This product is available in the following dosage forms: Tablet, Extended Release. Tablet.
You can take levetiracetam with or without food. If you take it twice a day, try to space your doses evenly through the day – for example, first thing in the morning and in the evening.
The recommended dosages of for focal-onset seizures are: Starting dosage: 500 mg twice per day. Recommended maintenance dosage: 1,500 mg twice per day. Maximum dosage: 3,000 mg per day (1,500 mg twice per day)
Levetiracetam is currently only available via prescription. This means the use of this drug must be authorized by a licensed health care provider. Providers on Sesame can write a prescription – or refill an existing one – during a virtual or in-person visit.
Levetiracetam can also affect your vision. Do not drive if your vision is affected. If you have epilepsy, you're not allowed to drive until you have had no seizures for 1 year. You're also not allowed to drive for 6 months if you change your epilepsy medicine.
Levetiracetam is available in oral and intravenous (IV) formulations. The total daily dosage of IV levetiracetam is equivalent to oral. It is administered as a 15-minute infusion. There is no evidence to use a loading dose.

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The Application Form for Levetiracetam Special Access is a document that allows healthcare professionals to request access to the medication levetiracetam for patients who may not have other treatment options available.
Healthcare professionals, including physicians, are required to file the Application Form for Levetiracetam Special Access on behalf of their patients needing this medication.
To fill out the Application Form for Levetiracetam Special Access, the healthcare professional should provide patient details, medical history, previous treatments tried, and the rationale for requesting levetiracetam.
The purpose of the Application Form for Levetiracetam Special Access is to ensure that patients who require levetiracetam for their treatment can access it in a regulated manner, especially when it is not readily available.
The application must report the patient's identity, medical condition, details of previous therapies, justification for the request, and any potential benefits and risks associated with using levetiracetam.
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Relevant keywords

Levetiracetam Special Access Application Form Epilepsy Keppra PHARMAC Medical Practitioner Funding NZMC Patient Consent

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