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Evidence summaries

Anticonvulsants for Status Epilepticus

For cessation of seizures in status epilepticus, intravenous (iv.) lorazepam may be better than iv. diazepam or iv. phenytoin. For pre-hospital treatment, intramuscular midazolam is probably at least as good as iv. lorazepam. Level of evidence: "C"

Comment: The quality of evidence is downgraded by inconsistency (heterogeneity in patients and start of treaments) and impresice results (few studies in each comparison).

A Cochrane review [Abstract] 1 included 18 studies with a total of 2755 subjects. Ten studies included only adults and 6 only children, 2 studies included both. The type of status epilepticus included varied from study to study, time-since-onset also was variable, from minutes to hours in the different studies.Few studies used the same interventions.

  • Intravenous (iv.) diazepam vs. placebo (one trial, n=139): diazepam was better in reducing the risk of non-cessation of seizures (RR 0.73, 95% CI 0.57 to 0.92), requirement for ventilatory support (RR 0.39, 95% CI 0.16 to 0.94), or continuation of status epilepticus requiring use of a different drug or general anaesthesia (RR 0.73, 95% CI 0.57 to 0.92).
  • Iv. lorazepam vs. placebo (one trial, n=139): lorazepam was better for risk of non-cessation of seizures (RR 0.52, 95% CI 0.38 to 0.71) and for risk of continuation of status epilepticus requiring a different drug or general anaesthesia (RR 0.52, 95% CI 0.38 to 0.71).
  • Iv. lorazepam vs. iv. diazepam (3 trials, n=264): lorazepam was better for reducing the risk of non-cessation of seizures (RR 0.64, 95% CI 0.45 to 0.90) and had a lower risk for continuation of status epilepticus requiring a different drug or general anaesthesia (RR 0.63, 95% CI 0.45 to 0.88).
  • Iv. lorazepam vs. iv. phenytoin (one trials, n=198): lorazepam was better for risk of non-cessation of seizures (RR 0.62, 95% CI 0.45 to 0.86).
  • Diazepam gel vs. placebo gel (2 trials, n=165): diazepam was better in reducing the risk of non-cessation of seizures (RR 0.43 95% CI 0.30 to 0.62).
  • Intramuscular midazolam vs. iv. lorazepam for pre-hospital treatment (one trial, n=893): midazolam was at least as effective as (probably more effective than) in control of seizures (RR1.16, 95% CI 1.06 to 1.27) and frequency of hospitalisation (RR 0.88, 95% CI 0.79 to 0.97) or intensive care admissions (RR 0.79, 95% CI 0.65 to 0.96).
  • Iv. valproate vs. iv. phenytoin (one trial, n=100): It was uncertain whether there were any differences between them in reducing risk of non-cessation of seizures (RR 0.75, 95% CI 0.28 to 2.00).
  • Iv. levetiracetam vs iv. lorazepam (one trial, n=97): they were equally effective in aborting seizures (RR 0.97, 95% CI 0.44 to 2.13).

Results for other comparisons of anticonvulsant therapies were uncertain due to single studies with few participants.

References

  • Prasad M, Krishnan PR, Sequeira R et al. Anticonvulsant therapy for status epilepticus. Cochrane Database Syst Rev 2014;9():CD003723. [PubMed]

Primary/Secondary Keywords