Is Nayzilam (midazolam) more effective than intranasal diazepam for seizures?

Nayzilam (Midazolam) vs. Intranasal Diazepam for Seizures

Intranasal midazolam (Nayzilam) is more effective than intranasal diazepam for seizures, with faster administration time, quicker seizure cessation, and fewer respiratory side effects. 1, 2

Comparative Efficacy

• Intranasal midazolam has demonstrated superior efficacy compared to rectal diazepam, with significantly shorter time from drug administration to seizure cessation 1
• Meta-analysis data shows that midazolam by any route is superior to diazepam by any route for seizure cessation (relative risk = 1.52) 2
• Buccal midazolam specifically is superior to rectal diazepam in achieving seizure control (relative risk = 1.54) 2
• Intranasal midazolam has been proven safe and effective for acute seizures in children, making it a revolutionary alternative when intravenous administration isn't possible 3

Administration Advantages

• Intranasal midazolam can be administered more quickly than diazepam (mean difference = 2.46 minutes), which is critical since rapid treatment of status epilepticus is associated with better outcomes 2
• The intranasal route allows for easier administration by non-medical personnel, making it more accessible and user-friendly during seizure events 3
• Mean time from arrival of doctor to drug administration was significantly shorter for intranasal midazolam (50.6 seconds) compared to rectal diazepam (68.3 seconds) 1

Safety Profile

• Respiratory complications requiring intervention are similar between midazolam and diazepam, regardless of administration route 2
• Serious side effects such as respiratory depression occur in only about 1% of cases with intranasal midazolam 4
• Local mucosal irritation occurs in less than one-third of cases with intranasal midazolam 4
• Midazolam has a more rapid onset of action and shorter duration of effect compared to diazepam, with onset within 1-2 minutes and peak effect within 3-4 minutes 5

Dosing Considerations

• Standard dosing for intranasal midazolam is 0.2 mg/kg body weight, compared to 0.3 mg/kg for rectal diazepam 1
• For seizures, intramuscular midazolam can be administered at 0.2 mg/kg (maximum: 6 mg per dose) and may be repeated every 10-15 minutes 5
• When using midazolam for refractory status epilepticus, a loading dose of 0.15-0.20 mg/kg followed by continuous infusion may be required 5

Recent Evidence

• A 2024 randomized controlled trial found no significant differences in efficacy between intranasal, buccal, and intramuscular midazolam routes for acute seizures in children, with intranasal midazolam showing success rates of 93.3% in home settings and 88.2% in emergency room settings 6
• The intranasal route showed the highest satisfaction rate among caregivers compared to other administration routes 6

Clinical Considerations and Cautions

• Be prepared to provide respiratory support regardless of administration route, as there is an increased incidence of apnea when midazolam is combined with other sedative agents 5
• Monitor oxygen saturation during and after administration 5
• Flumazenil may be administered to reverse life-threatening respiratory depression caused by midazolam; however, it will also reverse the anticonvulsant effects and may precipitate seizures 5
• Midazolam clearance is reduced in the elderly, obese, and those with hepatic or renal impairment, so dose adjustments may be necessary in these populations 5