Assessment of benzodiazepine dosing strategies for the management of status epilepticus in the emergency department

Indications for the use of intravenous second-line antiseizure medications in an emergency room setting

BACKGROUND

Second-line iv antiseizure medications (ASMs) are used to treat status epilepticus (SE), but in the emergency room setting, there might be other intended and unintended indications for administration. We wanted to explore these different indications and assess the actual usage of first- and second-line ASMs for SE with reference to other uses, such as for SE mimics.

METHODS

In this retrospective study, we searched the electronic patient registry with the following terms: "epilepsy", "SE", and "seizure", during 2015. Patients at least 16 years old and treated with iv second-line ASMs were further analysed. We reassessed the indications for the use of iv ASMs based on clinical features and examinations performed.

RESULTS

A total of 166 episodes from 136 patients with a median age of 66 years were evaluated, constituting the following indication categories: ongoing SE (48.2%), recurrent seizures (19.3%), postictal (12.1%), seizure mimics (10.2%) and prophylactic use of ASMs (10.2%). Ongoing SE included the following subgroups: convulsive SE, focal aware SE, nonconvulsive SE (NCSE) and NCSE with coma. The seizure mimics group had a preexisting epilepsy diagnosis more often than the ongoing SE group (73% vs. 44%, p = 0.039). Ischaemic stroke was the most frequent seizure mimic. EEG was performed during hospital admission in 78% of patients with ongoing SE, 50% of patients with recurrent seizures, 75% of patients with postictal state, 53% of seizure mimic episodes and 12% of the prophylactic group. In NCSE and comatose NCSE, the diagnosis was made, and treatment was initiated only after an EEG in 52% and 30% of cases, respectively. The use of newer second-line ASMs (levetiracetam and lacosamide) was frequent in our study population. Immediate side effects of ASMs were infrequent.

CONCLUSIONS

Even though most of the use of ASMs was justified and administered for SE, it is a diagnostic challenge where a prior diagnosis of epilepsy can be a misleading factor, and EEG is an essential tool when clinical features are often overlapping with other acute seizure disorders. Side effects of the newer second-line ASMs after a single dose are infrequent.

Clonazepam Loading Dose in Status Epilepticus: Is More Always Better?

BACKGROUND AND OBJECTIVES

Benzodiazepines are the first treatment line in status epilepticus (SE). Despite their well-established benefit, benzodiazepines are frequently underdosed with potential detrimental consequences. In some European countries, clonazepam (CLZ) is commonly used as the first line treatment. The aim of this study was to explore the correlation between CLZ loading doses and SE outcome.

METHODS

This study included a retrospective analysis of a prospective registry in Lausanne, Switzerland (CHUV Lausanne University Hospital), including all SE episodes treated between February 2016 and February 2021. Only adults (> 16 years old) were included with CLZ used as the first treatment line. Post-anoxic SE were excluded because of significant differences in physiopathology and prognosis. Patient characteristics, SE features, the validated SE severity score (STESS), and treatment characteristics were prospectively recorded. We considered loading doses of 0.015 mg/kg or higher (following commonly recommended loading doses) as high doses. We analyzed outcome in terms of number of treatment lines after the CLZ, proportion of refractory episodes, intubation for airways protection, intubation for SE treatment, and mortality. We performed univariable analyses to investigate the association between loading doses and clinical response. A multivariable stepwise backward binary logistic regression was applied for adjusting for potential confounders. Multivariable linear regression was similarly used to analyze CLZ dose as a continuous variable.

RESULTS

We collected 251 SE episodes in 225 adult patients. Median CLZ loading dose was 0.010 mg/kg. CLZ high doses were used in 21.9% of SE episodes (in 43.8% for > 80% of the high dose). Thirteen percent of patients with SE were intubated for airways control, while intubation was needed in 12.7% for SE treatment. High CLZ loading doses were independently associated with younger age (median 62 versus 68 years old, p = 0.002), lesser weight (65 kg versus 75 kg, p = 0.001) and more frequent intubation for airways protection (23% vs 11%, p = 0.013), but differing CLZ dose was not associated with any outcome parameter.

CONCLUSION

CLZ high doses were more frequently used for SE treatment in younger patients with healthy weight and were more often associated with intubation for airways protection, probably as an adverse event. Varying CLZ dose did not alter outcome in SE, raising the possibility that commonly recommended doses are above what is needed, at least in some patients. Our results suggest that CLZ doses in SE may be individualized depending on the clinical setting.

Optimizing Status Epilepticus Management in the Emergency Department: It's About Time

Status epilepticus (SE) is a frequent medical emergency that requires expedited treatment to avoid the ensuing high incidence of morbidity and mortality associated with prolonged seizures. Protracted seizure duration itself has the potential to result in maladaptive neuronal responses that can not only further increase seizure duration and worsen clinical outcomes but also lead to reduced responsiveness to pharmacotherapy. Benzodiazepines are consistently recommended as first-line treatment due to their rapid onset and efficacy in terminating seizures, followed by the emergent administration of an antiepileptic drug (AED). Various benzodiazepine and AED options are recommended and can be utilized in this setting, all with their own unique advantages and challenges. With time at a premium, agents should be selected that can be rapidly administered and have an advantageous pharmacokinetic profile in order to limit seizure duration and optimize outcomes. The intent of this review is to provide an outline of the importance of time-to-treatment implementation in this setting, assess the landscape of options that may provide timing advantages, and examine potential strategies for deploying expeditious therapy.

Das ist neu in der Neurointensiv- und Notfallmedizin: die wichtigsten Studien des Jahres im Rück- und Überblick

Die vorliegende Übersichtsarbeit fasst wichtige klinische Studien der neurologischen Notfall- und Intensivmedizin zwischen 2020 und 2021 zusammen zu den Themen: rekanalisierende Therapie beim ischämischen Schlaganfall, Anwendbarkeit und Auswirkung eines zerebralen Sauerstoffgewebemonitorings bei Subarachnoidalblutung, Wirksamkeit induzierter Hypothermie bei Patienten mit „cardiac arrest“ (CA), Wertigkeit früher kranialer Bildgebung nach CA, Relevanz eines schnellen Managements und medikamentöser Therapie beim Status epilepticus sowie Inzidenz von Critical-illness-Polyneuropathie-Myopathie bei intensivpflichtigen COVID-Patienten.

Lack of Clinically Relevant Differences in Safety and Pharmacokinetics After Second-Dose Administration of Intranasal Diazepam Within 4 Hours for Acute Treatment of Seizure Clusters: A Population Analysis

Objective

Current diazepam nasal spray labeling requires waiting 4 h before administering a second dose. The objective of the current analyses was to examine safety and pharmacokinetic profiles of second doses of diazepam nasal spray given 0−4 h after the first dose.

Methods

Two datasets were analyzed. The first, a long‐term, repeat‐dose safety study of diazepam nasal spray, compared rates of treatment‐emergent adverse events (TEAEs), serious TEAEs, and treatment‐related TEAEs for patients receiving ≥1 second dose ≤4 h versus all second doses >4 h after the first. The second was a population pharmacokinetic analysis using data from three phase 1 studies to model drug exposure when a second dose of diazepam nasal spray was administered across multiple time points (1 min−4 h) following the first dose.

Results

In the repeat‐dose safety study, a second dose of diazepam nasal spray was administered ≤24 h after the first to treat 485 seizure clusters in 79 patients. Rates of TEAEs were similar between patients receiving ≥1 second dose in ≤4 h (89.5%, n = 38) compared with >4–24 h only (80.5%, n = 41). The most common treatment‐related TEAEs were associated with nasal discomfort, which was mild or moderate and transient. There were no reports of respiratory or cardiac depression. The pharmacokinetic simulations of second doses predicted comparable elevations of plasma diazepam concentrations with administrations across a range of intervals after the first dose (1 min−4 h).

Significance

These data indicate that the safety and pharmacokinetic profiles of a second dose of diazepam nasal spray administered within 4 h of the first dose are consistent with those associated with current labeling. This is potentially important for patients with seizure clusters who have a recurrent seizure within 4 h of first treatment and might benefit from immediate retreatment to reduce the risk of progression to status epilepticus.