An alternative perspective on the management of status epilepticus

Use of Interval Therapy with Benzodiazepines to Prevent Seizure Recurrence in Stressful Situations

Introduction: Antiseizure medications (ASMs) control 70–75% of seizures. Accepting stress as a trigger for seizures, intervention, at the time of predictable stress, should offer a therapeutic option. Mode of intervention: Intervention requires the maintenance of an accurate seizure diary to identify a recurring pattern. With a questioning approach to that diary, the clinician may intervene when stressful provocateurs occur. Benzodiazepines, such as clobazam, initiated prior to the predictable stress, and continued until after it has passed, should be short lived, making serious adverse effects unlikely. Benzodiazepines have a dual benefit, being both anxietolytic and raising the seizure threshold in patients with epilepsy. Discussion: Many patients claim stress provokes their seizures and may not be aware the stress was the provocateur, until after a seizure occurred, leading to a retrospective claim of the relationship. To confirm the relationship, permitting preventative measures, before exposure to provocative factors, often unable to be avoided, requires maintenance and review of a detailed diary. Interval temporary use of benzodiazepines, such as clobazam, or alternatively clonazepam, diazepam or nitrazepam, offers a reasonable response to obviate subsequent seizures, and should be continued, for a brief period, after the risk has abated. Subsequent review of the diary, over a period of repeated exposures to the identified stress, will confirm or refute the therapeutic effect. Conclusion: Judicious use of interval therapy, with one of the benzodiazepines, covering the period of stressful provocation, offers adjunctive treatment of possible refractory epilepsy, based upon the review of the strictly maintained epilepsy/seizure diary.

The benefits of antiepileptic drug (AED) blood level monitoring to complement clinical management of people with epilepsy

INTRODUCTION

Some argue that there is no evidence to support the use of antiepileptic drug (AED) blood level monitoring when treating people with epilepsy (PWE). This paper identifies how AED monitoring can be invaluable in such treatment. SPECIFIC EXAMPLES: (i) Compliance: Antiepileptic drug blood levels often confirm noncompliance rather than adequate seizure control, confirming subtherapeutic levels in PWE attending hospitals due to seizures. Routine monitoring of AED levels may prevent breakthrough seizures by identifying noncompliance and instituting heightened compliance measures before experiencing breakthrough seizures without modifying dosages. For PWE attending hospitals due to seizures, loading with the AED shown to be subtherapeutic may be all that is required. (ii) Cluster seizures and status epilepticus: When using long-acting AEDs to complement benzodiazepines, blood level monitoring confirms that an adequate dosage was given and, if not, a further bolus can be administered with further monitoring. This is particularly useful when using rectal administration of AEDs. (iii) Polypharmacy: Polypharmacy provokes drug interactions in which case AED monitoring helps in differentiating adequate dosing, offending AED with toxicity and free level measuring benefits when total levels are unhelpful. (iv) Generic substitution: Generic AEDs can fluctuate considerably from a parent compound, and even a parent compound, sourced from an alternative supplier, may have altered bioavailability for which blood level monitoring is very useful.

CONCLUSIONS

While therapeutic blood level monitoring is not a substitute for good clinical judgment, it offers a valuable adjunct to patient care.

Guidelines for the evaluation and management of status epilepticus

Status epilepticus (SE) treatment strategies vary substantially from one institution to another due to the lack of data to support one treatment over another. To provide guidance for the acute treatment of SE in critically ill patients, the Neurocritical Care Society organized a writing committee to evaluate the literature and develop an evidence-based and expert consensus practice guideline. Literature searches were conducted using PubMed and studies meeting the criteria established by the writing committee were evaluated. Recommendations were developed based on the literature using standardized assessment methods from the American Heart Association and Grading of Recommendations Assessment, Development, and Evaluation systems, as well as expert opinion when sufficient data were lacking.

Pharmacokinetics and tolerability of nasal versus intravenous midazolam in healthy Dutch volunteers: a single-dose, randomized-sequence, open-label, 2-period crossover pilot study

BACKGROUND

Intranasal (IN) midazolam is a potential alternative to rectal diazepam for the acute treatment of epileptic seizures.

OBJECTIVE

The purpose of this pilot study was to investigate the pharmacokinetics and tolerability of IN midazolam (50 mg/mL) compared with intravenous (IV) midazolam (2.5 mg) in healthy adult volunteers.

METHODS

In this single-dose, randomized-sequence, open-label, 2-period crossover pilot study subjects were randomly assigned to receive IN or IV midazolam, with a washout period of at least 5 days between treatments. The 50-mg/mL IN midazolam formulation consisted of 5 mg midazolam base per 0.1 mL (1 spray) and was administered once in 1 nostril. The IV midazolam solution (2.5 mg) was infused over 10 seconds. Blood samples were taken before and at regular intervals up to 240 minutes after dosing. Pharmacokinetic data (ie, C(max), T(max), t(½), and AUC) were analyzed using a 2-compartment model.

RESULTS

Of 9 volunteers screened and enrolled, 7 completed the study (mean age 34.1 [9.0] years; mean weight, 68.6 [10.4] kg, range 53-89 kg; 6 men, 3 women; all white). The mean C(max) of 78 (40) ng/mL was reached 44 minutes after IN administration, whereas the mean C(max) was 51 (5) ng/mL after IV administration. The mean estimated C(t=5 min) was 31.4 (28.1) ng/mL after IN administration. The elimination t(½) was 1.9 (0.41) hours for IN midazolam and 2.3 (0.19) hours for IV midazolam. The bioavailability of IN midazolam was 82%. There were few adverse events, with a local burning feeling in the nose being the most reported event (6 of 7 subjects).

CONCLUSIONS

In this select group of healthy volunteers, concentrations of midazolam >30 ng/mL were reached within 5 minutes of IN administration at a dose of 5 mg/0.1 mL. A burning feeling in the nostril was the main adverse effect. Additional research is needed to evaluate the safety profile, convenience, satisfaction, and efficacy of nasal midazolam in the treatment of adults with seizures. This trial is registered at www.isrctn.org, No. ISRCTN79059168.

Medical treatment of pediatric status epilepticus

Status epilepticus (SE) is a common pediatric neurologic emergency that refers to a prolonged seizure or recurrent seizures without a return to baseline mental status between seizures. Appropriate treatment strategies are necessary to prevent prolonged SE and its associated morbidity and mortality. This review discusses the importance of a rapid and organized management approach, reviews data related to commonly utilized medications including benzodiazepines, phenytoin, phenobarbital, valproate sodium, and levetiracetam, and then provides a sample SE management algorithm.

Seizures in the context of acute illness

PURPOSE OF REVIEW

Seizures during an acute illness demand immediate evaluation, as they indicate an acute central nervous system insult. There are three goals: identify and treat the precipitating cause; determine the need for antiepileptic drug therapy; and recognize nonconvulsive seizures. Management depends upon whether there is a primary or secondary central nervous system insult. Seizures may persist despite antiepileptic drugs if the precipitating cause is untreated.

RECENT FINDINGS

Seizures and epilepsy and children with neurodevelopmental disabilities comprise a significant percentage of acute care in children. A continuum exists from a single seizure and escalating seizures to status epilepticus. Seizure treatment is more successful when given earlier, and prognosis depends on the cause. Guidelines for the diagnostic evaluation and treatment of status epilepticus have been produced. Continuous electroencephalographic monitoring reveals frequent nonconvulsive seizures and nonconvulsive status epilepticus in the sick child.

SUMMARY

The recognition and rapid treatment of clinical and electrographic seizures is important during acute illness.

Intravenous midazolam in convulsive status epilepticus in children with pharmacoresistant epilepsy

Although the efficacy of midazolam in refractory status epilepticus and as a first-line agent in children with established status epilepticus has been reported, differences in starting doses, continuation method, timing of efficacy assessment, and discontinuation pose limitations in deriving a specific protocol for midazolam use. An audit of clinical experience with a protocol of midazolam as first-line agent for impending status epilepticus (defined as a continuous, generalized, convulsive seizure lasting >5 minutes) in 76 episodes of unprovoked convulsive status epilepticus in children 1-15 years old with treatment-refractory epilepsy demonstrated that: (1) repeated bolus midazolam 0.1mg/kg (every 5 minutes, maximum 5) controlled 91% of events; (2) three bolus doses controlled 89% of the episodes, with minimal chance of response beyond that; (3) treating impending status resulted in lower doses (mean 0.17 mg/kg) than reported and infrequent utilization of additional anticonvulsants (9%); and (4) adverse events were infrequent (respiratory depression 13%, assisted ventilation 3%).