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Sunday, November 15, 2009

When faced with a seizure that is going on for prolonged periods, neurologists are forced to often consider intravenous medications to break what is called “status epilepticus”. This terrifying but infrequent situation can occur to almost any patient with epilepsy, and requires emergency intervention often in an intensive care unit. Medications typically used are phenytoin (Dilantin), lorazepam (Ativan), diazepam (Valium), and phenobarbital. Fortunately, most of the time these medications work quickly and the seizure stops, but sometimes it doesn’t, requiring high doses of sedating anticonvulsants to create a planned comatose state. Even then, seizures may not stop. What should a neurologist do then?

Ambulance

Over the past few months, three articles have suggested in small, case reports that dietary treatments might be valuable in this situation. It is logical to consider this as

  1. patients have to have nutrition anyway and the ketogenic diet can be provided as a formula through a feeding tube,
  2. it is very effective when medications fail,
  3. the ketogenic and modified Atkins diets usually work quickly (sometimes within a few days), and
  4. it should not interact with other anticonvulsants or antibiotics given by the intensive care unit.

The idea of using the ketogenic diet as a treatment for status epilepticus first was published in February 2008, in an article by Dr. Bodenant and colleagues from Lille, France. This French-language article describes the response of a 54-year-old man who had his partial focus status epilepticus stop 7 days after starting a ketogenic diet. In an article by a different group from France published this past April, it was reported that children with recently worsened epilepsy (within the past month) did better than those who had a more “stable” seizure pattern over the past month. Specifically in this study, four out of five children with status epilepticus responded to the ketogenic diet within 7 days. Just this September, Dr. Kumada and his group from Shiga, Japan reported similarly quick results in two children with nonconvulsive status epilepticus within 5 and 10 days of starting the diet, but in this case series the modified Atkins diet led to this success.

A new article, just published by Dr. Wusthoff from Philadelphia this month in Epilepsia, continues to add evidence that diets can help status epilepticus which has not responded to medications. They report the results from using KetoCal™ formula in two adults (ages 29 and 34 years) who had nonconvulsive status epilepticus for 101 and 18 days, respectively. Both improved after just over a week of treatment and stayed on the ketogenic diet for at least one year according to the article.

There certainly appears to be great interest in this idea, perhaps as many of the anticonvulsants we have for treating status epilepticus are very sedating and there is always a need for new and possibly better treatments. There is no doubt that patients can become acidotic (low serum bicarbonate) on the ketogenic diet, and this has been mentioned (and treated) in most of these articles. A dietitian also needs to be involved to make sure all medications are carbohydrate-free and also that weight and nutrition are being carefully monitored. It is likely the use of diets for status epilepticus will only be done rarely and at large hospitals with ketogenic diet programs, but if evidence continues to grow, it may become more popular in the future.

REFERENCES

  • Bodenant M, Moreau C, Sejourne´ C, et al. Interest of the ketogenic diet in a refractory status epilepticus in adults. Rev Neurol (Paris) 2008; 164: 194–99
  • Villeneuve N, Pinton F, Bahi-Buisson N, et al. The ketogenic diet improves recently worsened focal epilepsy. Dev Med Child Neurol. 2009;51:276-81.
  • Wusthoff CJ, Kranick SM, Morley JF, Bergqvist AGC. The ketogenic diet in treatment of two adults with prolonged nonconvulsive status epilepticus. Epilepsia 2009 (online early).
  • Kumada T, Miyajima T, Kimura, et al. Modified Atkins Diet for the Treatment of Nonconvulsive Status Epilepticus in Children. J Child Neurol 2009 (online early).
Authored by: Eric Kossoff, MD on 11/2009
Reviewed by: Robert Fisher MD PhD on 10/2009
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