Therapeutic choices in convulsive status epilepticus

Abstract

Introduction: Convulsive status epilepticus (SE) is one of the most frequent and severe neurological emergencies in both adults and children. A timely administration of appropriate antiepileptic drugs (AEDs) can stop seizures early and markedly improve outcome.

Areas covered: The main treatment strategies for SE are reviewed with an emphasis on initial treatments. The established first-line treatment consists of benzodiazepines, most frequently intravenous lorazepam. Benzodiazepines that do not require intravenous administration like intranasal midazolam or intramuscular midazolam are becoming more popular because of easier administration in the field. Other benzodiazepines may also be effective. After treatment with benzodiazepines, treatment with fosphenytoin and phenobarbital is usually recommended. Other intravenously available AEDs, such as valproate and levetiracetam, may be as effective and safe as fosphenytoin and phenobarbital, have a faster infusion time and better pharmacokinetic profile. The rationale behind the need for an early treatment of SE is discussed. The real-time delays of AED administration in clinical practice are described.

Expert opinion: There is limited evidence to support what the best initial benzodiazepine or the best non-benzodiazepine AED is. Recent and developing multicenter trials are evaluating the best treatment options and will likely modify the recommended treatment choices in SE in the near future. Additionally, more research is needed to understand how different treatment options modify prognosis in SE. Timely implementation of care protocols to minimize treatment delays is crucial.

Keywords:

• benzodiazepines
• epilepsy
• lorazepam
• midazolam
• seizures
• status epilepticus

Declaration of interest

I Sánchez Fernández is funded by a grant for the study of Iván Sánchez Fernández is funded by a grant for the study of Epileptic Encephalopathies from “Fundacion Alfonso Martín Escudero” and the HHV6 Foundation. Tobias Loddenkemper serves on the Laboratory Accreditation Board for Long Term (Epilepsy and Intensive Care Unit) Monitoring, on the Council of the American Clinical Neurophysiology Society, on the American Board of Clinical Neurophysiology, as an Associate Editor for Seizure, as Contributing Editor for Epilepsy Currents, and as an Associate Editor for Wyllie’s Treatment of Epilepsy 6th edition. He is part of pending patent applications to detect seizures and to diagnose epilepsy. He receives research support from the American Epilepsy Society, the Epilepsy Foundation of America, the Epilepsy Therapy Project, PCORI, the Pediatric Epilepsy Research Foundation, Cure, Danny-Did Foundation, HHV-6 Foundation, Lundbeck, Eisai, and Upsher-Smith. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

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