From the Guidelines
Midazolam is the preferred medication for subcutaneous administration to manage seizures in palliative care patients, with a recommended dose of 2.5-5 mg subcutaneously as needed for seizure activity, and a continuous subcutaneous infusion of 10-30 mg over 24 hours for ongoing seizure management, as supported by the evidence from 1. The subcutaneous route is particularly valuable in palliative care when oral administration is difficult or impossible.
- The dose can be repeated after 20-30 minutes if seizures continue, and rescue doses of 5-10 mg can be ordered for breakthrough seizures when using continuous infusions.
- Midazolam works by enhancing the effect of the inhibitory neurotransmitter GABA in the brain, which reduces neuronal excitability and helps control seizure activity.
- Side effects include sedation, respiratory depression, and hypotension, so monitoring is important, though respiratory concerns are often balanced against symptom control goals in end-of-life care, as noted in 1 and 1. For patients who have been on benzodiazepines previously or who have severe seizures, higher doses may be required, and the dose should be titrated based on response. The evidence from 1 provides a clear guideline for the use of midazolam in palliative care, and it is the most recent and highest quality study available, making it the preferred choice for guiding clinical practice.
From the Research
Midsole Subcutaneous Dosing for Seizures in Palliative Patients
- The term "midsole subcutaneous" is not a standard medical term, however, it can be inferred that the question is referring to the subcutaneous administration of midazolam for seizures in palliative patients.
- According to the study 2, midazolam can be administered subcutaneously using a syringe driver, but this may cause sedation.
- The study 3 discusses the use of midazolam in palliative care, but does not provide specific dosing information for subcutaneous administration.
- However, the study 2 mentions that brivaracetam can be administered subcutaneously with a 1:1 conversion from oral:subcutaneous, with syringe driver doses ranging from 150 mg to 300 mg/24 hours, but this is not directly relevant to midazolam dosing.
Alternative Subcutaneous Dosing for Seizures in Palliative Patients
- The study 4 reports the use of subcutaneous levetiracetam and sodium valproate in palliative care patients, with doses ranging from 500 to 3000 mg/d of levetiracetam and 500 to 2500 mg/d of sodium valproate.
- The study 5 discusses the use of alternative AED administration routes, including subcutaneous, for effective and individualized AED therapy in palliative care patients.
- The study 6 recommends choosing AEDs with a low interaction potential and which can be administered by the parenteral route, preferably intravenously, but does not provide specific dosing information for subcutaneous administration.