Treating epileptic emergencies – pharmacological advances

ABSTRACT

Introduction: Epileptic emergencies are frequently encountered and include ictal events as status epilepticus or seizure clusters, and non-ictal situations like postictal psychosis or acute drug side effects. The aim of this review was to describe recent pharmacological advances in the treatment of epileptic emergencies.

Areas covered: Based on clinically relevant questions, a literature search was performed. The search showed that most pharmacological advances have been made in management of status epilepticus, where substantial literature has accumulated on several AEDs with potentially less side-effects than the traditional choices. The use of these drugs; valproate, levetiracetam, and lacosamide, was therefore made the main focus of this review. Pharmacological advances in treatment of other epileptic emergencies were scarce, and were therefore covered more briefly in the Expert Opinion section.

Expert opinion: This section outlines our current practice in management of status epilepticus and seizures clusters. Our opinion is that valproate is an equal alternative as second line treatment to fosphenytoin, with levetiracetam considered a good choice in frail and elderly patients. Due to the lack of literature, lacosamide is used mainly as a 2^nd line drug after the failure of valproate, fosphenytoin and levetiracetam. Our review underlines the need for more research in management of epileptic emergencies.

KEYWORDS:

• Status epilepticus
• epileptic emergency
• side effects of anti-seizure drugs
• seizure clusters

Article highlights

• Epileptic emergencies can be ictal or non-ictal.

• Pharmacological advances have primarily been made in the management of status epilepticus.

• The main advance is the application of alternative AEDs like valproate, levetiracetam, and lately lacosamide in benzodiazepine-resistant SE .

• In non-ictal emergencies, like postictal psychosis, adverse events related to AEDs, or suicidality, there have been no major pharmacological advances in the last years.

• There is a need for more research on epileptic emergencies.

• Comparative trials have been published concerning the different benzodiazepine alternatives as first line AED in cluster seizures and status epilepticus.

This box summarizes key points contained in the article.

Declaration of interest

E Ben-Menachem has been involved in clinical trials for UCB Pharma, BIAL and Eisai. 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.

Additional information

Funding

This paper was not funded.