New evidence will renew debate about which medication to use for status epilepticus patients who DON’T respond to a benzodiazepine. Continue to first optimize the benzodiazepine dose, such as giving up to 8 mg of lorazepam (drug of choice; duration of action 12–24 hours). There are several recommended options to try next, but many hospitals use IV fosphenytoin (prodrug of phenytoin) due to long-standing experience. Now evidence suggests fosphenytoin, levetiracetam (Keppra, Tiratam, Tiralepsy), and valproic acid are equally effective at stopping convulsive status epilepticus including in the elderly and kids age 2 and older.
Standardize practice and use the agent you can access the fastest. The longer status epilepticus continues, the more likely it is to be unresponsive to medications and cause neurological damage. Consider using levetiracetam. Storing its commercially available premade bags or vials for IV push on the unit can save time, instead of having to prep loading doses of other medications. Plus levetiracetam has fewer interactions or adverse effects.
If you know a patient has missed doses of their maintenance antiepileptic, it’s okay to use that agent. But feel comfortable giving a dose of levetiracetam acutely if you can start it faster. Use high doses for status epilepticus. For example, give levetiracetam 60 mg/kg (up to 4500 mg). Feel comfortable infusing this dose over as little as 10 minutes, based on recent evidence. But administration can be challenging, since many adults will need 3 premade 1500 mg levetiracetam bags or 9 vials. Use EHR alerts to help avoid errors, such as inadvertently giving just 1 bag.
If an antiepileptic doesn’t work, don’t generally try a different one, they’re not often effective third-line. Instead, typically move to a propofol (2 mg/kg as IV bolus, followed by infusion at 2-15 mg/kg/hr, depending on response) or midazolam infusion (0.05-0.2 mg/kg/hr) to stop seizures.
REFERENCES
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Kapur, J., Elm, J., Chamberlain, J.M., Barsan, W., Cloyd, J., Lowenstein, D., Shinnar, S., Conwit, R., Meinzer, C., Cock, H., Fountain, N., Connor, J.T. and Silbergleit, R. (2019). Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. New England Journal of Medicine, 381(22), pp.2103–2113. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa1905795
Glauser T, Shinnar S, Gloss D, Alldredge B, Arya R, Bainbridge J, Bare M, Bleck T, Dodson WE, Garrity L, Jagoda A, Lowenstein D, Pellock J, Riviello J, Sloan E, Treiman DM. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016 Jan-Feb;16(1):48-61. Available at: https://pubmed.ncbi.nlm.nih.gov/26900382
Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, Laroche SM, Riviello JJ Jr, Shutter L, Sperling MR, Treiman DM, Vespa PM; Neurocritical Care Society Status Epilepticus Guideline Writing Committee. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012 Aug;17(1):3-23. Available at: https://pubmed.ncbi.nlm.nih.gov/22528274