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Reviewed by Gretchen M. Brophy, Pharm.D., FCCP, BCPS; Matthew J. Korobey, Pharm.D. BCCCP; and
You Min Sohn, Pharm.D., M.S., BCPS, BCCCP
LEARNING OBJECTIVES
1. Evaluate factors that may affect treatment success in patients with status epilepticus.
2. Distinguish gaps in the literature related to optimal status epilepticus treatment.
3. Evaluate therapeutic strategies for super-refractory status epilepticus.
4. Assess the impact of timing of status epilepticus treatment initiation, and develop strategies to optimize effective treatment.
Diazepam 5–20 mg rectally Preferred to intranasal midazolam for CNS depression None
infants and small children
Midazolam 5–10 mg (0.2 mg/kg) Must use atomizer adapter with syringe; CNS depression None
intranasally may not be ideal for infants and small
children because of difficult drug delivery
Urgent Loading Dose Administration Notes Potential Adverse Diluents
Therapies Effects
Levetiracetam 1000–3000 mg IV or May infuse over 15–30 min Irritability, behavioral None
30mg/kg changes
Phenobarbitala 20 mg/kg IV Max infusion rate 100 mg/min Hypotension Propylene glycol
Goal concentration 10-40 mcg/ml CNS depression
Ketamineb 1 mg/kg IV push, Should also include sedative infusion Dissociative psychosis None
then 1–10 mg/kg/hr to limit dissociative psychosis Increased ICP?
infusion Hypertension
Pentobarbitalb 10 mg/kg × 1 IV, then 1–5 mg/kg/hr infusion range; serum CNS depression Propylene glycol
6 mg/kg/hr × 3 hr concentration does not typically Hypotension
IV, then 1 mg/kg/hr correlate with burst suppression Cardiac suppression
infusion Ileus
Extended half-life with
prolonged use
Propofolb 20 mcg/kg/min, max High dose (> 80 mcg/kg/min) for CNS depression Lipid emulsion
200 mcg/ kg/min prolonged duration (> 48 hr) is Hypotension (1.1 kcal/mL)
associated with PRIS Hypertriglyceridemia
PRIS
a
Consider obtaining serum concentration within 2–4 hr of loading dose.
b
Typically titrated to EEG targets (seizure cessation, burst suppression).
IV = intravenous(ly); PE = phenytoin equivalents; PRIS = propofol-related infusion syndrome.
Although many of the options for urgent therapy have urgent therapy in benzodiazepine-refractory status epilep-
clinical data supporting their use, no clinical trials defini- ticus (the ESETT trial) (Kapur 2016). The results of this trial
tively support the use of one antiepileptic drug over another may help practitioners prioritize specific agents in urgent
on the basis of efficacy (Brophy 2012). Studies investigating therapy. Before moving on to refractory therapy options that
the preferred urgent therapy suggest that the response to require the patient to be intubated and mechanically venti-
any of these options alone is often suboptimal. For instance, lated, clinicians should use additional urgent therapy agents
patients receiving phenytoin or phenobarbital for in-hospi- if the initial medication chosen fails to abort seizure activity.
tal status epilepticus have less than a 50% overall response Despite the lack of a recommendation on the basis of agent
rate (i.e., seizure cessation) (Treiman 1998). Other studies efficacy, the characteristics of each agent must be carefully
suggest the response rate is 70%–88% for patients receiving considered from the safety perspective. Traditional urgent ther-
valproate early in status epilepticus (compared with a 25%– apy options such as phenobarbital and (fos)phenytoin are often
84% response to phenytoin) (Misra 2006, Agarwal 2007). With avoided because of prolonged infusion times. Phenobarbital is
the lack of consistent benefit, continued research is of utmost well known to cause hypotension and respiratory depression
importance. A clinical trial is currently under way to compare at intravenous loading and at high infusion rates. Often, endo-
the use of levetiracetam, fosphenytoin, and valproate for tracheal intubation is needed to protect the patient’s airway
Lorazepam
Figure 1-1. Proposed algorithm for treating status epilepticus according to available evidence. Lorazepam is the drug
of choice for initial therapy, followed by an antiepileptic drug such as phenytoin, valproate, or levetiracetam. Additional
therapies may depend on the patient’s need for intubation and other patient-specific factors.
Figure 1-2. Receptor changes in prolonged status epilepticus. Under normal conditions (left), neurons have
homeostasis with respect to excitatory (blue circles = glutamate, blue receptors = NMDA) and inhibitory (red circles =
GABA, red receptors = GABA) stimuli. After prolonged status epilepticus (right), NMDA receptors up-regulate on the
postsynaptic surface, causing increased excitation. Concomitantly, GABA receptors also undergo endocytosis, further
perpetuating the excitatory imbalance.
GABA = g-aminobutyric acid; NMDA = N-methyl-D-aspartate.
1. Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012;17:3-23.
2. Lackner TE. Interaction of dexamethasone with phenytoin. Pharmacotherapy 1991;11:344-7.
Table 1-2. Ancillary Agents Used for the Etiological Treatment of Status Epilepticus
Induction of Hepatic Metabolism (Inducing Inhibition of Hepatic Metabolism Clinical Impact (additive effects)
agent inducer ↔ Drug with reduced (Inhibiting agent ↔ Drug with
exposure) increased exposure)
Phenytoin ↔ Lamotrigine
Phenytoin ↔ Metronidazole
Phenytoin ↔ Midazolam
Phenytoin ↔ Nimodipine
Phenytoin ↔ Quetiapine
Phenytoin ↔ Tolvaptan
Phenytoin ↔ Topiramate
Phenytoin ↔ Valproate
Phenytoin ↔ Warfarin
Carbamazepine ↔ Midazolam
Carbamazepine ↔ Phenytoin
Carbamazepine ↔ Valproate
Carbamazepine ↔ Warfarin
Dexamethasone/corticosteroids
↔ Phenytoin
a
Drug interactions with phenobarbital are similar to those with pentobarbital.
and oncology, for which combinations of agents have been GI residence of phenytoin, together with phenytoin’s potential
studied and additive or synergistic activity has been shown, interactions with components of enteral nutrition products,
evidence is sparse to guide practitioners on optimal com- may lead to impaired enteral absorption and reduced serum
binations of antiepileptic drugs. Clinicians are left to select phenytoin concentrations. One study that evaluated the phar-
agents with differing mechanisms of action or, often, avoid macokinetics of various phenytoin formulations (chewable
combinations for which the site of action is similar or adverse tablet and suspension) in a simulated drug-nutrient interac-
effects overlap. Combinations such as phenytoin and car- tion model suggested that phenytoin recovery was less than
bamazepine may provide less additive benefit because they 40% when combined with standard enteral nutrition prod-
are mechanistically similar, with action on the fast-acting ucts (Hennessy 2003, Suzuki 2016). Of interest, the amount
sodium channel. Benzodiazepines and less commonly used of phenytoin recovered differed when comparing formulas
agents (e.g., clobazam) may have similar effects on the GABA with different protein sources. Significantly greater phenytoin
receptor, which may not be additive. Agents with relatively recovery was evident when phenytoin was combined with
unique mechanisms of action such as lacosamide, leve- whey protein isolates (82%) than with casein-based isolates
tiracetam, valproate, or topiramate may be beneficial to pair (48%). Other studies have postulated that phenytoin binding
with other agents because their mechanisms are distinct and to protein in the nutrition product or with the enteral nutrition
more likely to be complimentary. tubing reduces bioavailability, though more recent studies
Drug-drug interactions may dictate preferable combina- with the injectable products given enterally do not suggest
tions of agents in patients with status epilepticus (Table 1-3). this. Use of the intravenous phenytoin sodium formula-
Most antiepileptic drugs have notable drug-drug interactions tion by tube does not appear to affect overall bioavailability
that complicate therapy, ranging from abnormal absorption compared with suspension in combination with nasogastric
to changes in protein binding, metabolism, and elimination. In feeding in healthy volunteers. The Cmax and Tmax for the
many cases, these agents interact with each other, complicat- intravenous solution were greater than with the suspension
ing matters for clinicians given that adding new agents may (Doak 1998). Fosphenytoin solution for injection also appears
alter the pharmacokinetics of the current treatment regimen. to be quite well absorbed orally and may be another option
Several drug-disease or drug-nutrient interactions may occur for enteral use, when necessary (Kaucher 2015). In gen-
as well. Clinicians should be consistent and complete in eval- eral, enteral administration of phenytoin products should
uating the potential drug-drug interactions that may occur in be avoided in patients with status epilepticus. If conversion
patients who are receiving several antiepileptic drugs in the from intravenous to oral or enteral use is necessary, clini-
ICU environment. cians should consider separating the phenytoin dose from
Classically, phenytoin has been associated with reduced enteral nutrition products by at least 1 hour before and after
bioavailability in patients receiving enteral nutrition (Bauer administering or using intravenous formulations enterally (if
1982, Gilbert 1996). Many potential mechanisms for this this can be done in a way that avoids medication errors and
interaction have been suggested, though none has defini- inadvertent intravenous administration), as well as frequently
tively been proven as the primary factor. Published evidence monitoring serum to ensure adequate phenytoin concen-
supports this interaction in patients and in in vitro models, trations. Clinicians should modify enteral nutrition goals to
but not in simulated clinical scenarios with healthy volun- ensure patients receive the appropriate amount of calories,
teers (Yeung 2000). Phenytoin has a prolonged GI transit time despite holding nutrition for phenytoin therapy.
and Tmax for absorption, particularly with increasing doses The enteral absorption of carbamazepine and levetiracetam
(notably over 400 mg per dose) (Jung 1980). This increased has also been investigated. According to the package insert
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increase P.R.’s risk of drug-induced seizures? M.R. is a 32-year-old man (height 74 inches [188 cm], weight
80 kg) who presented with a severe TBI after a motor vehi-
A. Dexamethasone use
cle collision. He has no contributory medical history other
B. Meropenem use
than social anxiety disorder. On admission, M.R. was taken
C. Vancomycin use
to the operating room for a subdural hematoma evacuation;
D. Age
since then, he has convalesced in the ICU. He was initiated
8. Which one of the following best describes the combina- on phenytoin for posttraumatic seizure prophylaxis. On ICU
tion of phenytoin with P.R.’s current meningitis regimen? day 3, M.R.’s neurologic examination worsened subtly; hence,
A. It is likely to accumulate if vancomycin causes the neurocritical care team obtained a CT of his head and a
nephrotoxicity. continuous EEG. The EEG revealed nonconvulsive status
B. Its metabolism is inhibited by meropenem, and it will epilepticus. M.R. was given an intravenous benzodiazepine,
have higher total concentrations. and a total phenytoin concentration was obtained. On ICU
C. Its metabolism is induced by dexamethasone, and it day 3, his vital signs and laboratory values are as follows:
will have lower total concentrations. temperature 98.4°F (36.9°C), heart rate 88 beats/minute, blood
D. It will have altered protein binding because of pressure 100/49 mm Hg, respiratory rate 18 breaths/minute
concomitant vancomycin. (ventilator rate 12), Sao2 99%, serum sodium 145 mEq/L, serum
potassium 3.8 mEq/L, BUN 10 mg/dL, SCR 0.89 mg/dL, glucose
Questions 9 and 10 pertain to the following case. 153 mg/dL, serum magnesium 2.1 mg/dL, serum phosphorus
2.7 mg/dL, arterial pH 7.34, Pco2 33 mm Hg, Po2 126 mm Hg,
J.B. is a 64-year-old woman who presents with a 2-week his-
HCO3 24 mEq/L, Fio2 40%, and total phenytoin 11.2 mg/L.
tory of progressive neurologic decline after a fall. She was
brought to the hospital by her family, who noted that J.B. 11. Which one of the following is best to recommend for
could not open doors or hold utensils with her right hand. M.R.’s refractory status epilepticus?
A CT reveals a left temporal chronic subdural hematoma. A. Valproate 30-mg/kg load plus 1-mg/kg/hour infusion
J.B. has a medical history of hypothyroidism, atrial fibrilla- B. Propofol 50-mcg/kg/minute infusion
tion, hyperlipidemia, and hypertension. She was adherent C. Midazolam 0.05-mg/kg/hour infusion
to her home drugs: metoprolol, levothyroxine, apixaban, and D. Ketamine 100-mg load plus 1-mg/kg/hour infusion
aspirin. J.B. undergoes a burr hole washout to evacuate her
12. Which one of the following would best monitor the effi-
chronic subdural hematoma. On hospital day 2, just after eat-
cacy of pentobarbital therapy in M.R.?
ing lunch, she has a generalized tonic-clonic seizure for about
7 minutes, which is treated with lorazepam 4 mg intravenously A. Serum pentobarbital concentrations
× 1. She is currently postictal and unable to communicate. Her B. Continuous EEG
neurosurgeons wish to initiate an intravenous antiepileptic C. Bispectral index
drug to prevent further seizures. J.B.’s vital signs and labo- D. Glasgow Coma Score
ratory values are as follows: temperature 99°F (37.2°C), heart
rate 63 beats/minute (normal sinus), blood pressure 126/65 Questions 13–15 pertain to the following case.
mm Hg, respiratory rate 14 breaths/minute, and Sao2 97%. D.B. is a 42-year-old woman (weight 70 kg) with a history
9. Which one of the following is best to initiate as urgent of treatment-refractory epilepsy. Her current home antiep-
therapy for J.B.? ileptic regimen consists of lamotrigine 100 mg twice daily,
clonazepam 1 mg twice daily, and phenytoin 300 mg once
A. Phenytoin
daily. While D.B. was at work, emergency medical services
B. Valproate
was called because of intermittent seizure activity.
C. Levetiracetam
D. Lacosamide 13. Which one of the following agents would be best as
emergency status epilepticus therapy for D.B.?
10. Which one of the following statements best describes add-
ing antiepileptic drugs if J.B.’s status epilepticus continues? A. Levetiracetam 1000 mg intravenously × 1
B. Fosphenytoin 20 mg/kg intravenously × 1
A. Agents for urgent therapy should be added rapidly.
C. Ketamine 1 mg/kg intravenously × 1
B. Urgent therapy agents with overlapping
D. Lorazepam 4 mg intravenously × 1
mechanisms should be used preferentially.
C. Escalation to agents used for refractory therapy is 14. D.B.’s home antiepileptic regimen is reinitiated, and she
necessary if the initial urgent therapy fails. is given the therapy you selected from the previous ques-
D. Benzodiazepine therapy should not be repeated tion; however, she continues to have seizure on EEG.
after the initial emergency therapy period. The neurologists would like to initiate valproate. Which