What is the recommended dosing of benzodiazepines (benzos) for status epilepticus?

From the Guidelines

For status epilepticus, the recommended first-line benzodiazepine treatment is intravenous lorazepam at a dose of 0.1 mg/kg (typically 4 mg for adults), administered at 2 mg/min. This recommendation is based on the clinical policy for critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures, as outlined in the Annals of Emergency Medicine 1. The policy suggests that benzodiazepines, such as lorazepam, are effective in terminating seizure activity by enhancing GABA-mediated inhibition in the brain.

Some key points to consider when administering benzodiazepines for status epilepticus include:

• If IV access is unavailable, alternatives include intramuscular midazolam (10 mg for adults >40 kg) 1
• Rectal diazepam (0.2-0.5 mg/kg) or buccal midazolam (10 mg for adults) can also be used in certain situations
• Diazepam can be given intravenously at 0.15-0.2 mg/kg (typically 10 mg for adults) if lorazepam is unavailable
• These medications should be administered promptly, as delays in treatment increase the risk of refractory status epilepticus
• Respiratory monitoring is essential during benzodiazepine administration due to the risk of respiratory depression, particularly in patients with compromised respiratory function or when multiple doses are required.

It is essential to note that if seizures continue after the initial dose, a second dose may be given, but persistent seizures after two adequate doses of benzodiazepines indicate the need to progress to second-line agents such as fosphenytoin, valproate, or levetiracetam. The clinical policy was created after careful review and critical analysis of the medical literature, including searches of MEDLINE, MEDLINE InProcess, Cochrane Systematic Review Database, and Cochrane Database of Clinical Trials 1.

From the FDA Drug Label

For the treatment of status epilepticus, the usual recommended dose of lorazepam injection is 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures cease, no additional lorazepam injection is required. If seizures continue or recur after a 10- to 15-minute observation period, an additional 4 mg intravenous dose may be slowly administered.

The recommended dosing of benzodiazepines, specifically lorazepam, for status epilepticus is:

• Initial dose: 4 mg given slowly (2 mg/min) for patients 18 years and older 2
• Additional dose: If seizures continue or recur after a 10- to 15-minute observation period, an additional 4 mg intravenous dose may be slowly administered 2
• Key considerations:
  • The treatment of status epilepticus requires more than just the administration of an anticonvulsant agent.
  • Ventilatory support must be readily available.
  • Patients who are susceptible to further seizure episodes should receive adequate maintenance antiepileptic therapy.
  • Experience with further doses of lorazepam is very limited 2

From the Research

Benzodiazepine Dosing for Status Epilepticus

• The recommended dosing of benzodiazepines for status epilepticus includes:
  • Lorazepam: 2-8 mg/70kg 3, 0.1 mg/kg 4
  • Diazepam: 5-20 mg/70kg 3
  • Midazolam: 8-20 mg followed by an infusion at 4-30 mg/hour 3

Refractory Status Epilepticus Treatment

• For refractory status epilepticus, the following benzodiazepine dosing may be considered:
  • High-dose intravenous lorazepam: 0.3 to 9 mg/hr 5
  • Midazolam infusion: 4-30 mg/hour 3

First-Line Therapy

• Benzodiazepines, such as lorazepam or diazepam, are recommended as first-line therapy for status epilepticus 3, 6, 7
• Phenytoin is also recommended as first-line therapy in combination with benzodiazepines 3, 6