For people with seizures who experience status epilepticus (prolonged or recurrent seizures), getting the earliest possible treatment is important. The availability of treatments at home, before emergency medical services (EMS) arrive or before being treated in an emergency room, is currently limited, but crucial. The importance of fast treatment was highlighted during a session at the recent London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held this past spring.

When considering early treatments for status epilepticus, which can be given by family members or bystanders, the medication used needs to be effective at stopping seizures, and the delivery method needs to be easy to use, reliable, and able to quickly get the drug into the blood stream and brain.

At this time, only the rectal form of diazepam (Diastat) is FDA approved for at-home treatment of cluster seizures. Though this is widely available, the route of administration is problematic in many circumstances.

Oral formulations are available for clonazepam, diazepam, and lorazepam, though this route of administration has a relatively longer time to onset of action. These medications are also available at most pharmacies with a prescription.  

Intranasal (within the nose) therapies, such as midazolam or diazepam, have a lot of promise, due to rapid absorption and relative ease of administration once the caregiver receives some training. Intranasal diazepam is currently undergoing clinical trials for acute treatment of cluster seizures.

Intramuscular (within the muscle) medications can be rapidly administered, but absorption can be unreliable and there is a risk of complications at the injection site.

Intrapulmonary (within the lung) administration allows the medication to be taken up directly into the pulmonary capillaries, which then go to the heart with direct blood flow into the brain. This route is very fast, though currently available drugs do not have the properties to be absorbed in the lungs. This requires that researches modify the drugs so they can be reliably absorbed and still have an effect on seizures.

Cluster seizures or status epilepticus are serious medical events and having an available rescue medication allows for the earliest possible treatment. The delivery routes described above all allow for rapid administration of medication. Many have been shown to have faster administration that IV medication since special medical training is not required. Though options are limited at this time, there is excitement in the field of epilepsy when it comes to emerging acute treatments and the benefits they will offer people with epilepsy.

  Advantages Disadvantages Currently Available
Oral Currently available, portable. May be difficult to administer during a seizure.
Relatively longer time to onset of action.
Clonazepam wafers, other benzodiazepine liquid and tablet formations.
Rectal FDA approved.
Faster time to action than oral administration.
Difficult to administer in many settings. Rectal diazepam is FDA approved.
Intramuscular Easy administration. Complications at injection site. Unreliable absorption. Only under medical supervision.
Nasal Rapid absorption.
Can be given from any position.
Administration does require minimal training. Risk of injury to nasal cavity. Nasal diazepam in clinical trials.
Intrapulmonary Fastest absorption. Currently available drugs not able to be absorbed through lungs. Intrapulmonary propofol hemisuccinate under investigation.
Authored By: 
Amy Z. Crepeau MD
Authored Date: