Anticonvulsant therapy for status epilepticus

Prasad, Manya; Krishnan, Prasad; Sequeira, Reginald P.; Al‐Roomi, Khaldoon

doi:10.1002/14651858.cd003723.pub3

Cited by 90 publications

(45 citation statements)

References 25 publications

(46 reference statements)

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“…This pharmacologic advantage has been clinically substantiated in randomized, controlled trials comparing IV lorazepam with placebo [ 40 ], IV diazepam [ 41 – 43 ], and IM midazolam [ 44 ]. In a meta-analysis, lorazepam was better than placebo for risk of non-cessation of seizures (relative risk (RR) 0.52; 95 % confidence interval (CI) 0.38–0.71), better than diazepam for reducing risk of non-cessation of seizures (RR 0.64; 95 % CI 0.45–0.90), and had a lower risk for continuation of SE requiring a different drug or general anesthesia (RR 0.63; 95 % CI 0.45–0.88) [ 36 , 45 ]. There was no statistically significant difference between lorazepam and diazepam administered intravenously in terms of respiratory failure/depression, or hypotension [ 36 , 45 ].…”

Section: Early Status Epilepticus: Stage Imentioning

confidence: 99%

Pharmacotherapy for Status Epilepticus

Trinka

Höfler

Leitinger

et al. 2015

Drugs

170

138

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Status epilepticus (SE) represents the most severe form of epilepsy. It is one of the most common neurologic emergencies, with an incidence of up to 61 per 100,000 per year and an estimated mortality of 20 %. Clinically, tonic-clonic convulsive SE is divided into four subsequent stages: early, established, refractory, and super-refractory. Pharmacotherapy of status epilepticus, especially of its later stages, represents an “evidence-free zone,” due to a lack of high-quality, controlled trials to inform clinical decisions. This comprehensive narrative review focuses on the pharmacotherapy of SE, presented according to the four-staged approach outlined above, and providing pharmacological properties and efficacy/safety data for each antiepileptic drug according to the strength of scientific evidence from the available literature. Data sources included MEDLINE and back-tracking of references in pertinent studies. Intravenous lorazepam or intramuscular midazolam effectively control early SE in approximately 63–73 % of patients. Despite a suboptimal safety profile, intravenous phenytoin or phenobarbital are widely used treatments for established SE; alternatives include valproate, levetiracetam, and lacosamide. Anesthetics are widely used in refractory and super-refractory SE, despite the current lack of trials in this field. Data on alternative treatments in the later stages are limited. Valproate and levetiracetam represent safe and effective alternatives to phenobarbital and phenytoin for treatment of established SE persisting despite first-line treatment with benzodiazepines. To date there are no class I data to support recommendations for most antiepileptic drugs for established, refractory, and super-refractory SE. Limiting the methodologic heterogeneity across studies is required and high-class randomized, controlled trials to inform clinicians about the best treatment in established and refractory status are needed.

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Section: Early Status Epilepticus: Stage Imentioning

confidence: 99%

Pharmacotherapy for Status Epilepticus

Trinka

Höfler

Leitinger

et al. 2015

Drugs

170

138

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“…SE therapy constitutes an emergency for which an early aggressive therapeutic approach is required in order to avoid systemic and neurological complications [ 3 , 6 , 7 ]. Nevertheless the therapeutic management of prolonged SE remains a terra incognita with regard to evidence-based medicine [ 1 , 8 , 9 ]. The prognosis of RSE has long been considered as poor, including high mortality rates and severe neurological impairment, which may raise ethical concerns on the usefulness of prolonged full treatment in the ICU.…”

Section: Introductionmentioning

confidence: 99%

Functional outcome of prolonged refractory status epilepticus

et al. 2015

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IntroductionTo characterize etiology, clinical course and outcomes of patients in prolonged refractory status epilepticus (PRSE) and looking for prognostic factors.MethodsRetrospective study conducted in patients hospitalized from January 1, 2001 to December 31, 2011 in 19 polyvalent intensive care units in French university and general hospitals. Patients were adults with a generalized convulsive refractory status epilepticus that lasted more than seven days, despite treatment including an anesthetic drug and mechanical ventilation. Patients with anoxic encephalopathy were excluded. Follow-up phone call was used to determine functional outcome using modified Rankin Scale (mRS) with mRS 0–3 defining good and mRS 4–6 poor outcome.Results78 patients (35 female) were included. Median age was 57 years. Causes of status epilepticus were various, mainly including prior epilepsy (14.1%), CNS infection (12.8%), and stroke (12.8%). No etiology was found in 27 (34.6%) patients. PRSE was considered controlled in only 53 (67.9%) patients after a median duration of 17 (IQR 12–26) days. The median length of ICU stay was 28 (19–48) days. Forty-one (52.5%) patients died in the ICU, 26 from multiple organ failure, 8 from care withdrawal, 2 from sudden cardiac arrest, 1 from brain death and 4 from unknown causes. PRSE was previously resolved in 20 patients who died in the ICU. At one-year follow-up, there were 12 patients with good outcome and 58 with poor outcome and 8 lost of follow-up. On multivariate analysis, only vasopressor use was a predictor of poor outcome (OR 6.54; 95%CI 1.09-39.29; p = 0.04).ConclusionPoor outcome was observed in about 80% of this population of PRSE. Most patients died from systemic complications linked to their ICU stay. Some patients can recover satisfactorily over time though we did not identify any robust factor of good outcome.

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“…4 Mortality is estimated at 20% to 30%, 2,4 and up to 23% of patients will deteriorate in neurological function. 6 Additionally, its estimated annual direct inpatient costs in the United Status are >$4 billion.…”

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confidence: 99%

Timing is everything: Where status epilepticus treatment fails

Hill

Parikh

Ellis

et al. 2017

Annals of Neurology

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Status epilepticus is an emergency; however, prompt treatment of patients with status epilepticus is challenging. Clinical trials, such as the ESETT (Established Status Epilepticus Treatment Trial), compare effectiveness of antiepileptic medications, and rigorous examination of effectiveness of care delivery is similarly warranted. We reviewed the medical literature on observed deviations from guidelines, clinical significance, and initiatives to improve timely treatment. We found pervasive, substantial gaps between recommended and “real-world” practice with regard to timing, dosing, and sequence of antiepileptic therapy. Applying quality improvement methodology at the institutional level can increase adherence to guidelines and may improve patient outcomes.

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Anticonvulsant therapy for status epilepticus

Cited by 90 publications

References 25 publications

Pharmacotherapy for Status Epilepticus

Pharmacotherapy for Status Epilepticus

Functional outcome of prolonged refractory status epilepticus

Timing is everything: Where status epilepticus treatment fails

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