A New Trial of Medications for Status Epilepticus

• Benzodiazepines, like lorazepam or midazolam, are the first medicines to treat status epilepticus, a seizure emergency. Yet these do not work to stop status in 1 out of 3 people.
• A new study looked at the best seizure medicine to use for status epilepticus if benzodiazepines do not work.
• The study found that levetiracetam, phenytoin, and valproate all had similar results when used to treat status.

What is status epilepticus?

Status epilepticus is a condition that occurs when a seizure lasts for more than 5 minutes or when seizures are so close together that a person does not recover in between them. Status epilepticus is important because the longer a seizure goes on, the more likely it will need medication to stop. This is typically why doctors will tell their patients to call emergency services or give a rescue medicine if seizures last longer than 5 minutes.

Several studies have shown that benzodiazepines (like lorazepam or midazolam) have worked the best to stop the seizure when given as the first medicine to treat status epilepticus. However, in about 1 out of 3 people with status epilepticus, benzodiazepines don't work.

Is there new information about treating status?

For many years, it has been debated what the next best medicine should be. A recent study published in the New England Journal of Medicine set out to determine what is the best medicine if status epilepticus continues despite treatment with a benzodiazepine.

• This study collected information on the 3 most common seizure medicines used in this situation: levetiracetam, phenytoin, and valproate.
• The goal was to see if one of these medicines was clearly better than the others or if one was clearly worse.
• Nearly 400 people with status epilepticus were enrolled in this study from 57 emergency departments across the country.
• People were randomly give 1 of the 3 medicines if a benzodiazepine medicine didn't work.
• Treatment with the seizure medicine was considered successful if the seizures stopped within 60 minutes.

What did the study find?

• All of the seizure medicines were very similar in their success.
• Almost half of people responded to each of these medications (levetiracetam 47%, phenytoin 45%, and valproate 46%).
• The study was stopped early because enrolling more people would not show any significant difference between any of the medicines.
• There was no significant difference in the safety or side effects of the medicines.

Why is this important?

This study has finally shown that none of these seizure medicines are better than the other in treating status epilepticus. Health care providers taking care of people experiencing status epilepticus can now confidently use any of these medications.

The choice of seizure medicine for treating status should now be based on the individual person and situation.

What’s next?

There are several issues that have still not been resolved from this study.

• Although the 3 medicines studied are the most common ones used, there are many other medications. New ones are also being developed. We still do not know whether some of these other medications may be just as helpful as the three studied.
• Also, only half of the people responded to these medicines. We still do not know what is the best medicine to use if one of these doesn’t work.

Summary

This study by Kapur and colleagues shows no difference between levetiracetam, phenytoin, or valproate in treating status epilepticus. Health care providers can now confidently use any of these medications, tailoring the choice to each specific situation.