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Gorecki L, Pejchal J, Torruellas C, Korabecny J, Soukup O. Midazolam - A diazepam replacement for the management of nerve agent-induced seizures. Neuropharmacology 2024; 261:110171. [PMID: 39362626 DOI: 10.1016/j.neuropharm.2024.110171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 08/27/2024] [Accepted: 09/26/2024] [Indexed: 10/05/2024]
Abstract
A benzodiazepine, diazepam, has been the leading antidote for seizures caused by nerve agents, the most toxic chemical weapons of mass destruction, since the 1960s. However, its limitations have often brought questions about its usefulness. Extensive effort has been devoted into exploring alternatives, such as other benzodiazepines, anticholinergics, or glutamate antagonists. However, only few showed clear clinical benefit. The only two options to ultimately reach clinical milestones are Avizafone, a water-soluble prodrug of diazepam adopted by the French and UK armed forces, and intramuscular midazolam, adopted by the US Army. The recently FDA-approved new intramuscular application of midazolam brought several advantages, such as rapid onset of action, short duration with predictable pharmacokinetics, increased water solubility for aqueous injectable solutions, and prolonged storage stability. Herein, we discuss the pitfalls and prospects of using midazolam as a substitute in anticonvulsant therapy with a particular focus on military purposes in combat casualty care. We have also considered and discussed several other alternatives that are currently at the experimental level. Recent studies have shown the superiority of midazolam over other benzodiazepines in the medical management of poisoned casualties. While its use in emergency care is straightforward, the proper dose for soldiers under battlefield conditions is questionable due to its sedative effects.
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Affiliation(s)
- Lukas Gorecki
- University of Defence, Military Faculty of Medicine, Department of Toxicology and Military Pharmacy, Trebesska 1575, 500 01, Hradec Kralove, Czech Republic; University Hospital Hradec Kralove, Biomedical Research Centre, Sokolska 581, 500 05, Hradec Kralove, Czech Republic.
| | - Jaroslav Pejchal
- University of Defence, Military Faculty of Medicine, Department of Toxicology and Military Pharmacy, Trebesska 1575, 500 01, Hradec Kralove, Czech Republic
| | - Carilyn Torruellas
- U. S. Army CCDC Chemical Biological Center, Aberdeen Proving Ground, MD, 21010-5424, USA
| | - Jan Korabecny
- University of Defence, Military Faculty of Medicine, Department of Toxicology and Military Pharmacy, Trebesska 1575, 500 01, Hradec Kralove, Czech Republic; University Hospital Hradec Kralove, Biomedical Research Centre, Sokolska 581, 500 05, Hradec Kralove, Czech Republic
| | - Ondrej Soukup
- University of Defence, Military Faculty of Medicine, Department of Toxicology and Military Pharmacy, Trebesska 1575, 500 01, Hradec Kralove, Czech Republic; University Hospital Hradec Kralove, Biomedical Research Centre, Sokolska 581, 500 05, Hradec Kralove, Czech Republic
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Abstract
Benzodiazepines represent the first-line treatment for the acute management of epileptic seizures and status epilepticus. The emergency use of benzodiazepines must be timely, and because most seizures occur outside of the hospital environment, there is a significant need for delivery methods that are easy for nonclinical caregivers to use and administer quickly and safely. In addition, the ideal route of administration should be reliable in terms of absorption. Rectal diazepam is the only licensed formulation in the USA, whereas rectal diazepam and buccal midazolam are currently licensed in the EU. However, the sometimes unpredictable absorption with rectal and buccal administration means they are not ideal routes. Several alternative routes are currently being explored. This is a narrative review of data about delivery methods for benzodiazepines alternative to the intravenous and oral routes for the acute treatment of seizures. Unconventional delivery options such as direct delivery to the central nervous system or inhalers are reported. Data show that intranasal diazepam or midazolam and the intramuscular auto-injector for midazolam are as effective as rectal or intravenous diazepam. Head-to-head comparisons with buccal midazolam are urgently needed. In addition, the majority of trials focused on children and adolescents, and further trials in adults are warranted.
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Affiliation(s)
- Marco Mula
- Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, SW17 0QT, UK.
- Institute of Medical and Biomedical Sciences, St George's University of London, London, UK.
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Quick treatment with the most appropriate benzodiazepine formulation is vital when treating acute repetitive seizures in the outpatient setting. DRUGS & THERAPY PERSPECTIVES 2015. [DOI: 10.1007/s40267-015-0218-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Reddy SD, Reddy DS. Midazolam as an anticonvulsant antidote for organophosphate intoxication--A pharmacotherapeutic appraisal. Epilepsia 2015; 56:813-21. [PMID: 26032507 DOI: 10.1111/epi.12989] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This review summarizes the therapeutic potential of midazolam as an anticonvulsant antidote for organophosphate (OP) intoxication. METHODS Benzodiazepines are widely used to treat acute seizures and status epilepticus (SE), a neurologic emergency of persistent seizures that can lead to severe neuronal damage or death. Midazolam is a benzodiazepine hypnotic with a rapid onset and short duration of action. RESULTS Midazolam is considered the new drug of choice for persistent acute seizures and SE, including those caused by neurotoxic OPs and nerve agents. Midazolam is a positive allosteric modulator of synaptic γ-aminobutyric acid (GABA)A receptors in the brain. It potentiates GABAergic inhibition and thereby controls hyperexcitability and seizures. Midazolam is administered intravenously or intramuscularly to control acute seizures and SE. Due to its favorable pharmacokinetic features, midazolam is being considered as a replacement anticonvulsant for diazepam in the antidote kit for nerve agents. Clinical studies such as the recent Rapid Anticonvulsant Medication Prior to Arrival Trial (RAMPART) trial have confirmed the anticonvulsant efficacy of midazolam in SE in prehospital settings. SIGNIFICANCE In experimental models, midazolam is effective when given at the onset of seizures caused by nerve agents. However, benzodiazepines are less effective at terminating seizures when given 30 min or later after OP exposure or seizure onset, likely because of internalization or downregulation of synaptic, but not extrasynaptic, GABAA receptors, which can lead to diminished potency and seizure recurrence.
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Affiliation(s)
- Sandesh D Reddy
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas, U.S.A
| | - Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas, U.S.A
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Verrotti A, Milioni M, Zaccara G. Safety and efficacy of diazepam autoinjector for the management of epilepsy. Expert Rev Neurother 2015; 15:127-33. [DOI: 10.1586/14737175.2015.1003043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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McKee HR, Abou-Khalil B. Outpatient pharmacotherapy and modes of administration for acute repetitive and prolonged seizures. CNS Drugs 2015; 29:55-70. [PMID: 25583219 DOI: 10.1007/s40263-014-0219-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Acute repetitive seizures (ARS) are a serious epilepsy phenomenon, generally described as closely grouped seizures over minutes to 2 days, representing an increase in seizure frequency compared with baseline. In some instances, ARS may not stop without treatment, and evolution into status epilepticus is a significant concern. Additionally, neuronal injury may occur after even brief repeated seizures. Given the substantial risks that may be involved with ARS, it is crucial to develop appropriate protocols for identification and management of this seizure phenomenon. This article focuses on pharmacotherapy and, in particular, different modes of administering medication for ARS in the outpatient setting. Our aim was to present a review of data from non-randomized and randomized, controlled trials to evaluate the efficacy, safety and tolerability of out-of-hospital ARS treatments. Several of the studies included patients with ARS, as well as patients with prolonged seizures. Prolonged seizures, or seizures lasting greater than 5 min, have similar risks and treatment options to those of ARS; therefore, this discussion also includes treatment trials and recommendations for prolonged seizures. All trials used benzodiazepines, a class of drugs that are ideal for the ARS and prolonged seizure populations because of their rapid onset of action and minimal adverse effects. Rectal diazepam is currently the only formulation approved by the US Food and Drug Administration (FDA) for out-of-hospital treatment. Oral benzodiazepines are appropriate only for mild ARS. Intramuscular diazepam autoinjection has shown success against ARS in clinical trials. Intranasal midazolam and diazepam are in testing. Other treatments have also been explored--specifically, buccal midazolam (approved in the European Union), sublingual lorazepam and intranasal lorazepam.
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Affiliation(s)
- Heather Ravvin McKee
- Department of Neurology, University of Cincinnati, 222 Piedmont Avenue, Cincinnati, OH, 45219, USA,
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Rogin J, Wheless J, Abou-Khalil B, Wolter KD, Pixton GC, Sherman NA, Shukla RB, Roland CL, Sommerville KW. Safety and effectiveness of long-term treatment with diazepam auto-injector administered by caregivers in an outpatient setting for the treatment of acute repetitive seizures. Epilepsia 2014; 55:1444-51. [DOI: 10.1111/epi.12685] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Joanne Rogin
- Minneapolis Clinic of Neurology; Midwest Center for Seizure Disorders; Golden Valley Minnesota U.S.A
| | - James Wheless
- University of Tennessee Health Science Center and Le Bonheur Children's Hospital; Memphis Tennessee U.S.A
| | | | | | | | | | | | | | - Kenneth W. Sommerville
- Pfizer, Inc.; Durham North Carolina U.S.A
- Duke University Medical Center; Durham North Carolina U.S.A
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Abou-Khalil B, Wheless J, Rogin J, Wolter KD, Pixton GC, Shukla RB, Sherman NA, Sommerville K, Goli V, Roland CL. A double-blind, randomized, placebo-controlled trial of a diazepam auto-injector administered by caregivers to patients with epilepsy who require intermittent intervention for acute repetitive seizures. Epilepsia 2013; 54:1968-76. [DOI: 10.1111/epi.12373] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | - James Wheless
- University of Tennessee Health Science Center and LeBonheur Children's Hospital; Memphis Tennessee U.S.A
| | - Joanne Rogin
- Midwest Center for Seizure Disorders; Minneapolis Clinic of Neurology; Golden Valley Minnesota U.S.A
| | | | | | | | | | - Kenneth Sommerville
- Pfizer, Inc.; Cary North Carolina U.S.A
- Duke University Medical Center; Cary North Carolina U.S.A
| | - Veeraindar Goli
- Pfizer, Inc.; Cary North Carolina U.S.A
- Duke University Medical Center; Cary North Carolina U.S.A
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Wu Z, Hassan D, Shaw JP. In-vitro prediction of bioavailability following extravascular injection of poorly soluble drugs: an insight into clinical failure and the role of delivery systems. J Pharm Pharmacol 2013; 65:1429-39. [DOI: 10.1111/jphp.12114] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 06/18/2013] [Indexed: 11/29/2022]
Abstract
Abstract
Objectives
To investigate the feasibility of using an in-vitro model to simulate the incidence of post-injection drug precipitation (PDP), and to identify the roles of drug properties and delivery systems in its occurrence.
Methods
A literature review on incomplete absorption following extravascular injection (subcutaneous and intramuscular) was conducted. Six model drugs in nine different formulations were studied for an in-vitro/in-vivo correlation. A rapid in-vitro dilution method using a 96-well plate was used for predicting PDP by dilution with a physiological buffer. New formulations based on hydroxypropyl-β-cyclodextrin (CD), with and without co-solvents or pH control, were developed and tested on the in-vitro model.
Key findings
The occurrence of precipitation detected from the in-vitro dilution model appeared to be correlated with clinical reports and animal studies. The formulation components played an important role in determining the potential for drug precipitation on dilution or pH neutralization. CD was found to reduce the tendency for precipitation. The addition of co-solvents may reduce the effect of CD, depending on the solvent used.
Conclusions
The in-vitro model can be used as a cost-effective screening tool in injectable formulation development for safe and effective delivery of poorly soluble drugs. PDP can be circumvented with a well-designed formulation.
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Affiliation(s)
- Zimei Wu
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
| | - Dalia Hassan
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
| | - John P Shaw
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
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Reichard DW, Atkinson AJ, Hong SP, Burback BL, Corwin MJ, Johnson JD. Human Safety and Pharmacokinetic Study of Intramuscular Midazolam Administered by Autoinjector. J Clin Pharmacol 2013; 50:1128-35. [DOI: 10.1177/0091270009358083] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Lamson MJ, Sitki-Green D, Wannarka GL, Mesa M, Andrews P, Pellock J. Pharmacokinetics of Diazepam Administered Intramuscularly by Autoinjector versus Rectal Gel in Healthy Subjects. Clin Drug Investig 2011; 31:585-597. [DOI: 10.2165/11590250-000000000-00000] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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GIRI TK, SA B. Statistical Evaluation of Influence of Polymers Concentration on Disintegration Time and Diazepam Release from Quick Disintegrating Rapid Release Tablet. YAKUGAKU ZASSHI 2009; 129:1069-75. [DOI: 10.1248/yakushi.129.1069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Tapan Kumar GIRI
- Centre for Advanced Research in Pharmaceutical Sciences, Department of Pharmaceutical Technology
| | - Biswanath SA
- Centre for Advanced Research in Pharmaceutical Sciences, Department of Pharmaceutical Technology
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