From the Guidelines
Status epilepticus should be treated with intravenous benzodiazepines as first-line therapy, followed by second-line therapy with valproate (40mg/kg IV over 10 minutes), levetiracetam (60mg/kg IV over 15 minutes), or fosphenytoin (20mg PE/kg IV at 150mg/min) if seizures persist. The management of status epilepticus involves stabilizing the patient by securing the airway, ensuring adequate breathing, and maintaining circulation. First-line treatment is intravenous benzodiazepines: lorazepam 4mg IV (preferred), diazepam 10mg IV, or midazolam 10mg IM if IV access is unavailable 1. If seizures persist after 5-10 minutes, second-line therapy includes valproate, levetiracetam, or fosphenytoin. Valproate has been shown to be at least as effective as phenytoin for refractory status epilepticus, with potentially fewer adverse effects 1. Levetiracetam has also been found to be effective in treating status epilepticus, with a potential role as treatment for status epilepticus refractory to benzodiazepines 1. For refractory status epilepticus, continuous infusions of midazolam, propofol, or pentobarbital may be necessary with EEG monitoring in an ICU setting. Identifying and treating the underlying cause (infection, stroke, metabolic disturbance, medication withdrawal, etc.) is crucial, as prolonged status epilepticus can cause neuronal damage through excitotoxicity and increased metabolic demands, leading to permanent brain injury, making rapid intervention essential to prevent long-term complications 1. Key points to consider in the management of status epilepticus include:
- Stabilizing the patient by securing the airway, ensuring adequate breathing, and maintaining circulation
- First-line treatment with intravenous benzodiazepines
- Second-line therapy with valproate, levetiracetam, or fosphenytoin if seizures persist
- Identifying and treating the underlying cause of status epilepticus
- Considering continuous infusions of midazolam, propofol, or pentobarbital for refractory status epilepticus.
From the FDA Drug Label
Lorazepam injection is indicated for the treatment of status epilepticus. 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.
Status Epilepticus Treatment with Lorazepam:
- The recommended dose is 4 mg given slowly (2 mg/min) for patients 18 years and older.
- If seizures cease, no additional dose 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 2.
- Lorazepam injection is indicated for the treatment of status epilepticus 2.
From the Research
Status Epilepticus Overview
- Status epilepticus (SE) is a medical emergency that requires prompt and aggressive treatment 3
- The goal of treatment is to stabilize the airway, breathing, and circulation, and to terminate seizures as quickly as possible 3
Treatment Options
- Intravenous benzodiazepines, such as diazepam, midazolam, or lorazepam, are commonly used as first-line treatments for SE 3, 4
- Phenytoin is also a commonly used medication for SE, although it may have a higher risk of adverse effects compared to other options 4, 5
- Levetiracetam and valproate are also effective treatments for SE, and may be considered as alternative options 4, 6, 7
- The choice of medication may depend on the individual patient's needs and medical history, as well as the severity of the SE episode 4, 6, 7
Efficacy of Treatment Options
- Studies have shown that levetiracetam, fosphenytoin, and valproate are all effective treatments for SE, with similar efficacy and safety profiles 6, 7
- A randomized controlled trial found that levetiracetam, fosphenytoin, and valproate all led to seizure cessation and improved alertness in approximately half of patients with benzodiazepine-refractory convulsive SE 7
- Another study found that intravenous lorazepam was better than intravenous diazepam or phenytoin for cessation of seizures, and had a lower risk of continuation of SE requiring a different drug or general anesthesia 5
Age-Related Considerations
- Studies have shown that children, adults, and older adults with established SE respond similarly to levetiracetam, fosphenytoin, and valproate, with treatment success in approximately half of patients 6
- However, the efficacy and safety of these medications may vary depending on the individual patient's age and medical history, and should be carefully considered when selecting a treatment option 6, 7