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25 years of advances in the definition, classification and treatment of status epilepticus. Seizure 2016; 44:65-73. [PMID: 27890484 DOI: 10.1016/j.seizure.2016.11.001] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 11/01/2016] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Status epilepticus (SE) requires not only urgent symptomatic treatment with antiepileptic drugs but also rapid identification and treatment of its cause. This narrative review summarizes the most important advances in classification and treatment of SE. METHOD Data sources included MEDLINE, EMBASE, ClinicalTrials.gov, and back tracking of references in pertinent studies, reviews, and books. RESULTS SE is now defined as "a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms, which lead to abnormally, prolonged seizures (after time point t1). It is a condition, which can have long-term consequences (after time point t2), including neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type and duration of seizures." A new diagnostic classification system of SE introduces four axes: semiology, aetiology, EEG correlates, and age. For the acute treatment intravenous benzodiazepines (lorazepam, diazepam, clonazepam) and intramuscular midazolam appear as most effective treatments for early SE. In children, buccal or intranasal midazolam are useful alternatives. In established SE intravenous antiepileptic drugs (phenytoin, valproate, levetiracetam, phenobarbital, and lacosamide) are in use. Treatment options in refractory SE are intravenous anaesthetics; ketamine, magnesium, steroids and other drugs have been used in super-refractory SE with variable outcomes. CONCLUSION Over the past 25 years major advances in definition, classification and understanding of its mechanisms have been achieved. Despite this up to 40% of patients in early status cannot be controlled with first line drugs. The treatment of super-refractory status is still an almost evidence free zone.
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Is intravenous lorazepam really more effective and safe than intravenous diazepam as first-line treatment for convulsive status epilepticus? A systematic review with meta-analysis of randomized controlled trials. Epilepsy Behav 2016; 64:29-36. [PMID: 27732915 DOI: 10.1016/j.yebeh.2016.09.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/16/2016] [Accepted: 09/08/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Some guidelines or expert consensus indicate that intravenous (IV) lorazepam (LZP) is preferable to IV diazepam (DZP) for initial treatment of convulsive status epilepticus (SE). We aimed to critically assess all the available data on efficacy and tolerability of IV LZP compared with IV DZP as first-line treatment of convulsive SE. METHODS Systematic search of the literature (MEDLINE, CENTRAL, EMBASE, ClinicalTrials.gov) to identify randomized controlled trials (RCTs) comparing IV LZP versus IV DZP used as first-line treatment for convulsive SE (generalized or focal). Inverse variance, Mantel-Haenszel meta-analysis to obtain risk ratio (RR) with 95% confidence intervals (CI) of following outcomes: seizure cessation after drug administration; continuation of SE requiring a different drug; seizure cessation after a single dose of medication; need for ventilator support; clinically relevant hypotension. RESULTS Five RCTs were included, with a total of 656 patients, 320 randomly allocated to IV LZP and 336 to IV DZP. No statistically significant differences were found between IV LZP and IV DZP for clinical seizure cessation (RR 1.09; 95% CI 1.00 to 1.20), continuation of SE requiring a different drug (RR 0.76; 95% CI 0.57 to 1.02), seizure cessation after a single dose of medication (RR 0.96; 95% CI 0.85 to 1.08), need for ventilator support RR 0.93; 95% CI 0.61 to 1.43, and clinically relevant hypotension. CONCLUSION Despite its favorable pharmacokinetic profile, a systematic appraisal of the literature does not provide evidence to strongly support the preferential use of IV LZP as first-line treatment of convulsive SE over IV DZP.
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Mawasi H, Bibi D, Shekh-Ahmad T, Shaul C, Blotnik S, Bialer M. Pharmacokinetic-Pharmacodynamic Correlation and Brain Penetration of sec-Butylpropylacetamide, a New CNS Drug Possessing Unique Activity against Status Epilepticus. Mol Pharm 2016; 13:2492-6. [PMID: 27218460 DOI: 10.1021/acs.molpharmaceut.6b00221] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
sec-Butylpropylacetamide (SPD) is the amide derivative of valproic acid (VPA). SPD possess a wide-spectrum anticonvulsant profile better than that of VPA and blocks status epilepticus (SE) induced by pilocarpine and organophosphates. The activity of SPD on SE is better than that of benzodiazepines (BZDs) in terms of the ability to block SE when given 20-60 min after the beginning of a seizure. However, intraperitoneal (i.p.) administration to rats cannot be extrapolated to humans. Consequently, in the current study a comparative pharmacokinetic (PK)-pharmacodynamic analysis of SPD was conducted following i.p., intramuscular (i.m.), and intravenous (i.v.) administrations to rats. SPD brain and plasma levels were quantified at various times after dosing following i.p. (60 mg/kg), i.v. (60 mg/kg), and i.m. administrations (120 mg/kg) to rats, and the major PK parameters of SPD were estimated. The antiseizure (SE) efficacies of SPD and its individual stereoisomers were assessed in the pilocarpine-induced BZD-resistant SE model following i.p. and i.m. administrations to rats at 30 min after seizure onset. The absolute bioavailabilities of SPD following i.p. and i.m. administrations were 76% (i.p.) and 96% (i.p.), and its clearance and half-life were 1.8-1.5 L h(-1) kg(-1) and 0.5-1.7 h, respectively. The SPD brain-to-plasma AUC ratios were 1.86 (i.v.), 2.31 (i.p.), and 0.77 (i.m.). Nevertheless, the ED50 values of SPD and its individual stereoisomers were almost identical in the rat pilocarpine-induced SE model following i.p. and i.m. administrations. In conclusion, in rats SPD is completely or almost completely absorbed after i.m. and i.p. administration and readily penetrates into the brain. Consequently, in spite of PK differences, the activities of SPD in the BZD-resistant SE model following i.m. and i.p. administrations are similar.
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Affiliation(s)
- Hafiz Mawasi
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem , Jerusalem 91120, Israel
| | - David Bibi
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem , Jerusalem 91120, Israel
| | - Tawfeeq Shekh-Ahmad
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem , Jerusalem 91120, Israel
| | - Chanan Shaul
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem , Jerusalem 91120, Israel.,Clinical Pharmacology Unit, Division of Medicine, Hadassah University Hospital , Jerusalem 91120, Israel
| | - Simcha Blotnik
- Clinical Pharmacology Unit, Division of Medicine, Hadassah University Hospital , Jerusalem 91120, Israel
| | - Meir Bialer
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem , Jerusalem 91120, Israel.,David R. Bloom Center for Pharmacy, The Hebrew University of Jerusalem , Jerusalem 91120, Israel
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Höfler J, Rohracher A, Kalss G, Zimmermann G, Dobesberger J, Pilz G, Leitinger M, Kuchukhidze G, Butz K, Taylor A, Novak H, Trinka E. (S)-Ketamine in Refractory and Super-Refractory Status Epilepticus: A Retrospective Study. CNS Drugs 2016; 30:869-76. [PMID: 27465262 PMCID: PMC4996879 DOI: 10.1007/s40263-016-0371-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The aim was to describe the safety and efficacy of (S)-ketamine [(S)-KET] in a series of patients with refractory and super-refractory status epilepticus (RSE and SRSE) in a specialized neurological intensive care unit (NICU). METHODS We retrospectively analyzed the data of patients with RSE and SRSE treated with (S)-KET in the NICU, Salzburg, Austria, from 2011 to 2015. Data collection included demographic features, clinical presentation, diagnosis, electroencephalogram (EEG) data, anticonvulsant treatment, timing, and duration of treatment with (S)-KET. Outcomes were seizure control and death. RESULTS A total of 42 patients (14 women) with RSE and SRSE were treated with (S)-KET. The median duration of status epilepticus (SE) was 10 days [first quartile (Q1) 5.0, Q3 21.0]; the median latency from SE onset to the first administration of (S)-KET was 3 days (Q1 2.0, Q3 6.8). Prior to (S)-KET administration, patients had received a median of two (Q1 2.0, Q3 3.0) anesthetics and three (Q1 2.0, Q3 4.0) antiepileptic drugs. Forty percent of patients (17/42) received propofol: 65 % prior to (S)-KET; 35 % at the same time with (S)-KET. Seven patients received a median bolus of (S)-KET of 200 mg (Q1 200, Q3 250) followed by a continuous infusion, while 35 started with a continuous infusion (maximum rate median 2.55 mg/kg/h; Q1 2.09, Q3 3.22). In 64 % of patients (27/42), (S)-KET was the last drug before SE cessation; in five patients, it was given with propofol at the same time. Median duration of administration was 4 days (Q1 2.0, Q3 6.8). Overall (S)-KET treatment was well tolerated, adverse effects were not observed, and overall mortality was 45.2 %. CONCLUSIONS Treatment of SRSE in adult patients with (S)-KET led to resolution of status in 64 %. No adverse events were found, indicating a favorable safety profile.
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Affiliation(s)
- Julia Höfler
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Alexandra Rohracher
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Georg Zimmermann
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria ,Department of Mathematics, Paris Lodron University, Salzburg, Austria
| | - Judith Dobesberger
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Georg Pilz
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Markus Leitinger
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Giorgi Kuchukhidze
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria ,Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Kevin Butz
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria ,Department of Psychology, Paris Lodron University, Salzburg, Austria
| | - Alexandra Taylor
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria ,Department of Psychology, Paris Lodron University, Salzburg, Austria
| | - Helmut Novak
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria ,Centre for Cognitive Neuroscience, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University of Salzburg, Ignaz-Harrer-Str. 79, 5020, Salzburg, Austria. .,Centre for Cognitive Neuroscience, Salzburg, Austria.
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