What is the treatment for status epilepticus (seizures lasting one minute or longer, occurring one after another)?

From the Guidelines

Status epilepticus should be treated with intravenous benzodiazepines as the first-line treatment, followed by valproate (20-30 mg/kg at a rate of 40 mg/min) as a second-line agent if seizures continue, due to its effectiveness and lower risk of adverse effects compared to phenytoin and fosphenytoin 1. The treatment of status epilepticus involves several key steps, with the primary goal of stopping the seizure as quickly as possible to prevent neuronal damage and other complications.

• The first-line treatment is intravenous benzodiazepines, specifically lorazepam (0.1 mg/kg) or diazepam (0.15-0.2 mg/kg), which should be administered as soon as possible.
• If IV access is unavailable, midazolam can be given intramuscularly (10 mg for adults) or buccally.
• If seizures continue after 5-10 minutes, a second dose of benzodiazepines should be given, followed by an anti-epileptic drug such as valproate (20-30 mg/kg at a rate of 40 mg/min), which has been shown to be effective in stopping seizures with potentially fewer adverse effects than phenytoin and fosphenytoin 1.
• For refractory status epilepticus, general anesthesia with propofol, midazolam, or pentobarbital may be necessary.
• Throughout treatment, vital signs should be monitored, airway management ensured, and underlying causes investigated.
• The choice of second-line agent is crucial, and valproate has been recommended as an acceptable treatment option for refractory status epilepticus due to its safety and effectiveness 1.
• The most recent evidence suggests that the use of levetiracetam, fosphenytoin, or valproate will result in cessation of seizures in approximately half of all patients with benzodiazepine-resistant status epilepticus, with limited harms 1.

From the FDA Drug Label

The treatment of status, however, requires far more than the administration of an anticonvulsant agent. It involves observation and management of all parameters critical to maintaining vital function and the capacity to provide support of those functions as required. 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 treatment for status epilepticus involves:

• Administration of an anticonvulsant agent, such as lorazepam injection at a dose of 4 mg given slowly (2 mg/min) for patients 18 years and older.
• Observation and management of vital functions.
• Support of vital functions as required.
• Additional interventions (e.g., concomitant intravenous administration of phenytoin) may be necessary.
• Ventilatory support must be readily available.
• Correction of any underlying metabolic or toxic derangement.
• Consideration of maintenance antiepileptic therapy for patients susceptible to further seizure episodes.
• Possible consultation with a neurologist if the patient fails to respond to treatment 2.

From the Research

Treatment for Status Epilepticus

The treatment for status epilepticus, which is characterized by seizures lasting one minute or longer, occurring one after another, involves several steps and medications.

• Initial first aid measures should be accompanied by establishing intravenous access if possible and administering thiamine and glucose if required 3.
• High-quality evidence supports the use of benzodiazepines for initial treatment, with midazolam (buccal, intranasal, or intramuscular) being a suitable option when intravenous access is not available 3, 4.
• Lorazepam or diazepam are suitable intravenous agents, with speed of administration and adequate initial dosing being more important than the choice of drug 3.
• For established status epilepticus, phenytoin and phenobarbitone are licensed options, but levetiracetam and valproate are also supported by evidence and international consensus as alternatives 3.
• A recent study found that levetiracetam was non-inferior to fosphenytoin as a second-line treatment after diazepam for adult convulsive status epilepticus, with similar efficacy and higher safety 5.
• Other studies have compared the efficacy of different anticonvulsant therapies, including intravenous lorazepam, diazepam, and phenytoin, with varying results 6, 7.

Medication Options

Some key medication options for status epilepticus include:

• Benzodiazepines (e.g., midazolam, lorazepam, diazepam) for initial treatment 3, 4
• Phenytoin and phenobarbitone for established status epilepticus 3
• Levetiracetam and valproate as alternative options for established status epilepticus 3, 5
• Fosphenytoin as a second-line treatment after diazepam for adult convulsive status epilepticus 5

Administration Routes

Different administration routes may be used for status epilepticus treatment, including:

• Intravenous (e.g., lorazepam, diazepam, phenytoin) 3, 6, 7
• Intramuscular (e.g., midazolam) 3, 4
• Rectal (e.g., diazepam) 4