Plasmapheresis for refractory status epilepticus Part II: A scoping systematic review of the pediatric literature

Zeiler, Frederick A.; Matuszczak, Maria; Teitelbaum, Jeanne; Kazina, Colin; Gillman, Lawrence M.

doi:10.1016/j.seizure.2016.11.010

Cited by 18 publications

(6 citation statements)

References 22 publications

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“…Though there may be increasing willingness to try immunotherapy early, there is no consensus or good quality data to suggest that one particular medication or therapy is better than others. Various immunotherapies are suggested and summarized in Table 5 (adapted from Zaccara et al) [ 36 , 37 , 106 ].…”

Section: Treatmentmentioning

confidence: 99%

“…Initial laboratory evaluation to look for serum and CSF autoantibodies should be completed before initiation of immunomodulating therapies. If first-line treatment fails, one can consider either additional doses of the first-line treatment or PLEX [ 106 , 111 ]. However, if IVIg is used initially, deploying PLEX is likely to negate its effects as it is likely to wash out immunoglobulins given prior.…”

Section: Treatmentmentioning

confidence: 99%

See 1 more Smart Citation

Updates in Refractory Status Epilepticus

Marawar

Basha

Mahulikar

et al. 2018

Critical Care Research and Practice

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Refractory status epilepticus is defined as persistent seizures despite appropriate use of two intravenous medications, one of which is a benzodiazepine. It can be seen in up to 40% of cases of status epilepticus with an acute symptomatic etiology as the most likely cause. New-onset refractory status epilepticus (NORSE) is a recently coined term for refractory status epilepticus where no apparent cause is found after initial testing. A large proportion of NORSE cases are eventually found to have an autoimmune etiology needing immunomodulatory treatment. Management of refractory status epilepticus involves treatment of an underlying etiology in addition to intravenous anesthetics and antiepileptic drugs. Alternative treatment options including diet therapies, electroconvulsive therapy, and surgical resection in case of a focal lesion should be considered. Short-term and long-term outcomes tend to be poor with significant morbidity and mortality with only one-third of patients reaching baseline neurological status.

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Section: Treatmentmentioning

confidence: 99%

Section: Treatmentmentioning

confidence: 99%

Updates in Refractory Status Epilepticus

Marawar

Basha

Mahulikar

et al. 2018

Critical Care Research and Practice

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“…Reasons to exclude publications from this review included the unavailability of a version in English, French, German, Italian, or Spanish. Available reviews with a total of over 300 enrolled subjects for the use of a single ASD or other therapeutic options were used to cross-check the selected publications [26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41]. Processed data (e.g.…”

Section: Characteristics Of the Reviewmentioning

confidence: 99%

Therapeutic Options for Patients with Refractory Status Epilepticus in Palliative Settings or with a Limitation of Life-Sustaining Therapies: A Systematic Review

et al. 2020

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Background Refractory status epilepticus (RSE) represents a serious medical condition requiring early and targeted therapy. Given the increasing number of elderly or multimorbid patients with a limitation of life-sustaining therapy (LOT) or within a palliative care setting (PCS), guidelines-oriented therapy escalation options for RSE have to be omitted frequently. Objectives This systematic review sought to summarize the evidence for fourth-line antiseizure drugs (ASDs) and other minimally or non-invasive therapeutic options beyond guideline recommendations in patients with RSE to elaborate on possible treatment options for patients undergoing LOT or in a PCS. Methods A systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, focusing on fourth-line ASDs or other minimally or non-invasive therapeutic options was performed in February and June 2020 using the MEDLINE, EMBASE and Cochrane databases. The search terminology was constructed using the name of the specific ASD or therapy option and the term 'status epilepticus' with the use of Boolean operators, e.g. "(brivaracetam) AND (status epilepticus)". The respective Medical Subject Headings (MeSH) and Emtree terms were used, if available. ResultsThere is currently no level 1, grade A evidence for the use of ASDs in RSE. The best evidence was found for the use of lacosamide and topiramate (level 3, grade C), followed by brivaracetam, perampanel (each level 4, grade D) and stiripentol, oxcarbazepine and zonisamide (each level 5, grade D). Regarding non-medicinal options, there is little evidence for the use of the ketogenic diet (level 4, grade D) and magnesium sulfate (level 5, grade D) in RSE. The broad use of immunomodulatory or immunosuppressive treatment options in the absence of a presumed autoimmune etiology cannot be recommended; however, if an autoimmune etiology is assumed, steroid pulse, intravenous immunoglobulins and plasma exchange/plasmapheresis should be considered (level 4, grade D). Even if several studies suggested that the use of neurosteroids (level 5, grade D) is beneficial in RSE, the current data situation indicates that there is formal evidence against it. Conclusions RSE in patients undergoing LOT or in a PCS represents a challenge for modern clinicians and epileptologists. The evidence for the use of ASDs in RSE beyond that in current guidelines is low, but several effective and well-tolerated options are available that should be considered in this patient population. More so than in any other population, advance care planning, advance directives, and medical ethical aspects have to be considered carefully before and during therapy.

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“…Additionally, a systematic review of 37 children with RSE who received plasmapheresis found that 24% (9/37) of patients responded to plasmapheresis; seven (19%) with seizure resolution and two (5%) with partial reduction. However, given that a minority of patients responded, it was concluded that plasmapheresis incurs little to no benefit in RSE [63].…”

Section: Immunomodulatory Therapiesmentioning

confidence: 99%

Pharmacotherapy for Pediatric Convulsive Status Epilepticus

2019

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Convulsive status epilepticus (CSE) is one of the most common pediatric neurological emergencies. Ongoing seizure activity is a dynamic process and may be associated with progressive impairment of gamma-aminobutyric acid (GABA)-mediated inhibition due to rapid internalization of GABA A receptors. Further hyperexcitability may be caused by AMPA (alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) and NMDA (N-methyl-d-aspartic acid) receptors moving from subsynaptic sites to the synaptic membrane. Receptor trafficking during prolonged seizures may contribute to difficulties treating seizures of longer duration and may provide some of the pathophysiological underpinnings of established and refractory SE (RSE). Simultaneously, a practice change toward more rapid initiation of first-line benzodiazepine (BZD) treatment and faster escalation to second-line non-BZD treatment for established SE is in progress. Early administration of the recommended BZD dose is suggested. For second-line treatment, non-BZD anti-seizure medications (ASMs) include valproate, fosphenytoin, or levetiracetam, among others, and at this point there is no clear evidence that any one of these options is better than the others. If seizures continue after second-line ASMs, RSE is manifested. RSE treatment consists of bolus doses and titration of continuous infusions under continuous electro-encephalography (EEG) guidance until electrographic seizure cessation or burst-suppression. Ultimately, etiological workup and related treatment of CSE, including broad spectrum immunotherapies as clinically indicated, is crucial. A potential therapeutic approach for future studies may entail consideration of interventions that may accelerate diagnosis and treatment of SE, as well as rational and early polytherapy based on synergism between ASMs by utilizing medications targeting different mechanisms of epileptogenesis and epileptogenicity.

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Plasmapheresis for refractory status epilepticus Part II: A scoping systematic review of the pediatric literature

Abstract: Oxford level 4, GRADE D evidence exists to suggest little to no benefit of PE in pediatric RSE. Routine application of PE for pediatric RSE cannot be recommended at this time.

Cited by 18 publications

References 22 publications

Updates in Refractory Status Epilepticus

Updates in Refractory Status Epilepticus

Therapeutic Options for Patients with Refractory Status Epilepticus in Palliative Settings or with a Limitation of Life-Sustaining Therapies: A Systematic Review

Pharmacotherapy for Pediatric Convulsive Status Epilepticus

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