From the Guidelines
Benzodiazepines are generally not administered to patients with partial seizures who remain conscious. The preferred first-line treatment for ongoing partial seizures with preserved consciousness (also called focal aware seizures) is oral or intravenous antiepileptic drugs such as levetiracetam, lacosamide, or carbamazepine rather than benzodiazepines 1. Benzodiazepines like lorazepam, diazepam, or midazolam are typically reserved for emergency treatment of generalized seizures or partial seizures that have progressed to impaired consciousness or convulsions. This is because benzodiazepines can cause significant sedation, respiratory depression, and cognitive impairment, which would be particularly problematic in an already conscious patient.
Some key points to consider when managing patients with seizures include:
- The use of levetiracetam, fosphenytoin, or valproate can result in cessation of seizures in approximately half of all patients with benzodiazepine-resistant status epilepticus 1.
- The primary safety outcome of life-threatening hypotension or cardiac arrhythmia occurring within 60 minutes after start of medication infusion was not significantly different among the studied anticonvulsants 1.
- The focus for patients with recurrent partial seizures who remain conscious should be on optimizing their maintenance antiepileptic medication regimen under the guidance of a neurologist, rather than administering as-needed benzodiazepines.
In terms of specific treatment options, some studies have shown that:
- Levetiracetam, fosphenytoin, and valproate are effective in terminating seizures in patients with benzodiazepine-resistant status epilepticus 1.
- The use of these anticonvulsants can lead to cessation of seizures in roughly half of all patients receiving one of the three medications 1.
Overall, the management of patients with partial seizures who remain conscious should prioritize the use of antiepileptic drugs over benzodiazepines, with a focus on optimizing maintenance medication regimens and minimizing the risk of adverse effects.
From the Research
Administration of Benzodiazepines in Partial Seizures
- Benzodiazepines (BZDs) are commonly used in the treatment of epilepsy, particularly in the management of status epilepticus and acute seizures 2, 3, 4, 5.
- The use of BZDs in patients with partial seizures who remain conscious is not explicitly stated in the provided studies, but it is mentioned that BZDs can be used as an adjunct treatment in refractory epilepsies 3.
- Clonazepam and clobazam are considered useful as an adjunct treatment in refractory epilepsies, but the clinical use of BZDs for the prophylactic treatment of epilepsy is associated with potential side-effects and the risk of development of tolerance 3.
Routes of Administration and Efficacy
- BZDs can be administered via several routes, including intravenous, intramuscular, rectal, intranasal, and intrapulmonary 4, 5.
- The efficacy of BZDs in the treatment of seizures and status epilepticus is well-established, with rapid onset of action and high efficacy rates 2, 4, 5.
- However, the potential shortcomings of BZDs include tolerance, withdrawal symptoms, adverse events, and drug interactions 4.
Specific Benzodiazepines and Their Uses
- Clobazam, clonazepam, clorazepate, diazepam, lorazepam, and midazolam are commonly used BZDs in the management of seizures and epilepsy 4.
- Clorazepate has a unique profile with a long half-life of its active metabolite and slow onset of tolerance, but larger studies are needed to further examine its role in the treatment of patients with epilepsy 4.
- Diazepam, clonazepam, and lorazepam are considered first-line agents in the emergency management of acute seizures and status epilepticus 3.