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Wang D, Li M, Pan Y, Lin Z, Ji Z, Zhang X, Tan M, Pan S, Wu Y, Wang S. Risk factors for super-refractory and mortality in generalized convulsive status epilepticus: a 10-year retrospective cohort study. Ther Adv Neurol Disord 2023; 16:17562864231214846. [PMID: 38152090 PMCID: PMC10752052 DOI: 10.1177/17562864231214846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 11/01/2023] [Indexed: 12/29/2023] Open
Abstract
Background Generalized convulsive status epilepticus (GCSE) is one of the most challenging life-threatening neurological emergencies. If GCSE becomes super-refractory, it is associated with significant mortality. Although aggressive management of prolonged status epilepticus was conducted, the mortality has not decreased since the late 1990s. Objectives The present study aimed to explore the risk factors for progression to super-refractory in patients with generalized convulsive status epilepticus (GCSE). Moreover, we illustrated the risk factors for mortality in GCSE patients. Design An observational retrospective cohort study. Methods We conducted a retrospective study of patients with GCSE admitted to our neurocritical unit, in Guangzhou, China, from October 2010 to February 2021. The data of sociodemographic information, etiology, laboratory results, treatment, and prognosis were collected and analyzed. Results A total of 106 patients were enrolled; 51 (48%) of them developed super-refractory status epilepticus (SRSE). Multivariate logistic regression analysis demonstrated that patients with autoimmune encephalitis (p = 0.015) and intracranial infection (p = 0.019) are likely to progress to SRSE. The in-hospital mortality was 11.8% and 9.1% for patients in the SRSE and non-SRSE groups, respectively (p = 0.652). Multivariate logistic regression analysis showed that neutrophil-to-lymphocyte ratios (NLR) at admission were independently associated with in-hospital mortality. Up to 31.4% of SRSE patients and 29.1% of non-SRSE patients died within 6 months after discharge (p = 0.798). Multivariate logistic regression analysis showed that plasma exchange (PE) was a protective factor for 6-month mortality. A high NLR at discharge was a risk factor for 6-month mortality. Conclusion In the current study, about 48% of GCSE patients progressed to SRSE. Regarding etiology, autoimmune encephalitis or intracranial infection was prone to SRSE. No significant differences were observed in the in-hospital and 6-month mortality between SRSE and non-SRSE groups. Multivariate logistic regression analysis showed that NLR at admission and discharge was an independent predictor of in-hospital and 6-month mortality, respectively. Moreover, PE significantly reduced the 6-month mortality.
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Affiliation(s)
- Dongmei Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Meirong Li
- Department of Dermatology and Venereology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yue Pan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Zhenzhou Lin
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Zhong Ji
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Xiaomei Zhang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Miaoqin Tan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Suyue Pan
- Department of Neurology, Nanfang Hospital, Southern Medical University, 1838 Northern Guangzhou Avenue, Guangzhou, Guangdong 510515, China
| | - Yongming Wu
- Department of Neurology, Nanfang Hospital, Southern Medical University, 1838 Northern Guangzhou Avenue, Guangzhou, Guangdong 510515, China
| | - Shengnan Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, 1838 Northern Guangzhou Avenue, Guangzhou, Guangdong 510515, China
- Department of Critical Care Medicine, Baiyun Branch of Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
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Jain P, Aneja S, Cunningham J, Arya R, Sharma S. Treatment of benzodiazepine-resistant status epilepticus: Systematic review and network meta-analyses. Seizure 2022; 102:74-82. [DOI: 10.1016/j.seizure.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/06/2022] [Accepted: 09/25/2022] [Indexed: 10/31/2022] Open
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Why won't it stop? The dynamics of benzodiazepine resistance in status epilepticus. Nat Rev Neurol 2022; 18:428-441. [PMID: 35538233 DOI: 10.1038/s41582-022-00664-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/08/2022]
Abstract
Status epilepticus is a life-threatening neurological emergency that affects both adults and children. Approximately 36% of episodes of status epilepticus do not respond to the current preferred first-line treatment, benzodiazepines. The proportion of episodes that are refractory to benzodiazepines is higher in low-income and middle-income countries (LMICs) than in high-income countries (HICs). Evidence suggests that longer episodes of status epilepticus alter brain physiology, thereby contributing to the emergence of benzodiazepine resistance. Such changes include alterations in GABAA receptor function and in the transmembrane gradient for chloride, both of which erode the ability of benzodiazepines to enhance inhibitory synaptic signalling. Often, current management guidelines for status epilepticus do not account for these duration-related changes in pathophysiology, which might differentially impact individuals in LMICs, where the average time taken to reach medical attention is longer than in HICs. In this Perspective article, we aim to combine clinical insights and the latest evidence from basic science to inspire a new, context-specific approach to efficiently managing status epilepticus.
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Olivola M, Civardi S, Damiani S, Cipriani N, Silva A, Donadeo A, Politi P, Brondino N. Effectiveness and safety of intravenous valproate in agitation: a systematic review. Psychopharmacology (Berl) 2022; 239:339-350. [PMID: 34783884 DOI: 10.1007/s00213-021-06009-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
RATIONALE The use of intravenous valproate is not approved for clinical practice in psychiatry. Literature data pointed out for a potential usefulness of this route of administration for valproate, but there is no actual consensus. OBJECTIVES The aim of the present systematic review is to assess the effectiveness of intravenous valproate in agitation as well as general safety. METHODS A systematic review of studies evaluating the use of intravenous valproate in agitation was conducted. Additionally, safety was evaluated in all randomized trials involving the use of intravenous valproate in all medical conditions (epilepsy, migraine and psychiatric conditions). RESULTS For the systematic review on effectiveness in agitation, the search yielded 965 articles overall. After removing duplicates, 9411 articles were screened by title and abstract, and 39 of these were evaluated at a full-text level. Six studies were considered eligible for qualitative synthesis: one RCT and case report (n = 3), followed by cohort studies (n = 2). For the systematic review on safety, twenty-two RCTs were considered eligible for quantitative synthesis. CONCLUSION Intravenous valproate seems efficacious in reducing agitation in psychiatric patients; it generally appears safe compared to other neuroleptics or antiepileptics. However, the evidence is still not strong as it relies mainly on open-label studies or case series.
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Affiliation(s)
- Miriam Olivola
- ASST Pavia, Pavia, Italy. .,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.
| | - Serena Civardi
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Stefano Damiani
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Nicolo Cipriani
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genova, Italy
| | - Andrea Silva
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Alberto Donadeo
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Pierluigi Politi
- ASST Pavia, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Natascia Brondino
- ASST Pavia, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
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Benzodiazepines in the Management of Seizures and Status Epilepticus: A Review of Routes of Delivery, Pharmacokinetics, Efficacy, and Tolerability. CNS Drugs 2022; 36:951-975. [PMID: 35971024 PMCID: PMC9477921 DOI: 10.1007/s40263-022-00940-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 02/05/2023]
Abstract
Status epilepticus (SE) is an acute, life-threatening medical condition that requires immediate, effective therapy. Therefore, the acute care of prolonged seizures and SE is a constant challenge for healthcare professionals, in both the pre-hospital and the in-hospital settings. Benzodiazepines (BZDs) are the first-line treatment for SE worldwide due to their efficacy, tolerability, and rapid onset of action. Although all BZDs act as allosteric modulators at the inhibitory gamma-aminobutyric acid (GABA)A receptor, the individual agents have different efficacy profiles and pharmacokinetic and pharmacodynamic properties, some of which differ significantly. The conventional BZDs clonazepam, diazepam, lorazepam and midazolam differ mainly in their durations of action and available routes of administration. In addition to the common intravenous, intramuscular and rectal administrations that have long been established in the acute treatment of SE, other administration routes for BZDs-such as intranasal administration-have been developed in recent years, with some preparations already commercially available. Most recently, the intrapulmonary administration of BZDs via an inhaler has been investigated. This narrative review provides an overview of the current knowledge on the efficacy and tolerability of different BZDs, with a focus on different routes of administration and therapeutic specificities for different patient groups, and offers an outlook on potential future drug developments for the treatment of prolonged seizures and SE.
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6
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Abbaskhanian A, Sheidaee K, Charati JY. Comparison of the effect of continuous intravenous infusion of sodium valproate and midazolam on management of status epilepticus in children. Arch Pediatr 2021; 28:696-701. [PMID: 34706856 DOI: 10.1016/j.arcped.2021.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/09/2021] [Accepted: 09/28/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Status epilepticus as a pediatric emergency requires rapid seizure control in order to prevent subsequent disabilities. Therefore, the present study was conducted to compare the efficacy and side effects of continuous intravenous infusion of sodium valproate versus midazolam as a third-line treatment of status epilepticus in children. METHODOLOGY This randomized clinical trial study included all children with convulsive and non-convulsive status epilepticus admitted to the pediatric intensive care unit (PICU) of the Bu-Ali Sina Hospital in Sari City (Mazandaran Province, Iran) who had not responded to first-line treatment with diazepam and second-line treatment with phenytoin or phenobarbital. They were consequently treated with continuous intravenous infusion of sodium valproate or midazolam to control persistent seizures. RESULTS The study comprised 70 patients who were randomly assigned to two equal groups of sodium valproate or midazolam treatment. The mean age of patients in group A (sodium valproate) and group B (midazolam) was 3.97 ± 3.33 and 3.84 ± 2.93 years, respectively. In the present study, the most common etiology of status epilepticus was remote symptomatic, accounting for 35% of cases in the two groups. Sodium valproate was effective in controlling status epilepticus in 91.4% of patients, while midazolam was found to be effective in 85.7% of patients (p > 0.05). Patients who received sodium valproate had shorter seizure duration after administration of the drug compared to those who received midazolam (p = 0.01). Eight patients in the midazolam group and two patients in the sodium valproate group were intubated (p = 0.023). The mean duration of stay in the PICU was 3.2 ± 1.4 and 5.6 ± 2.8 days in groups A and B, respectively, showing a significant difference (p = 0.001). CONCLUSION According to our findings, intravenous infusion of sodium valproate can be used as an effective and relatively safe treatment in children with all types of status epilepticus, especially in challenging situations such as lack of intensive care units or respiratory problems.
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Affiliation(s)
- Ali Abbaskhanian
- Department of Pediatric Neurology, Bu-Ali Sina Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Kobra Sheidaee
- Department of Pediatric Neurology, Bu-Ali Sina Hospital, Mazandaran University of Medical Sciences, Sari, Iran.
| | - Jamshid Yazdani Charati
- Department of Epidemiology and Biostatistics, School of Health, Mazandaran University of Medical Sciences, Sari, Iran
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Su Y, Huang H, Jiang M, Pan S, Ding L, Zhang L, Jiang W, Zhuang X. Phenobarbital versus valproate for generalized convulsive status epilepticus in adults (2): A multicenter prospective randomized controlled trial in China (China 2-P vs. V). Epilepsy Res 2021; 177:106755. [PMID: 34517272 DOI: 10.1016/j.eplepsyres.2021.106755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/29/2021] [Accepted: 09/07/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A multicenter study of phenobarbital versus valproate (i.e., the China 2-P vs. V study) was conducted to compare the efficacy and safety of phenobarbital and valproate for generalized convulsive status epilepticus (SE) in a multicenter trial design. METHODS Three improvements (uniform intravenous pumping, pump speed adjustment according to adverse events and blood drug level monitoring) over a previous study were made regarding an intravenous regimen of phenobarbital and valproate in a multicenter, prospective, randomized, controlled study. Long-term electroencephalography (EEG) monitoring was performed after initial drug treatment. Termination, relapse, adverse event and poor prognosis rates in patients with generalized convulsive status epilepticus (GCSE) were compared. RESULTS The rate of GCSE termination within one hour were significantly higher in the phenobarbital group (33 cases) than in the valproate group (36 cases) (84.8 % vs. 63.9 %, P = 0.048), but the rates of nontermination of EEG epileptic discharge within one hour were similar between the two groups (12.1 % vs. 8.3 %, P = 0.702). The relapse and adverse event rates were not significantly different between groups, but 3 hypoventilation events and 1 hypotension event occurred in the phenobarbital group compared to 0 in the valproate group. There were no cases of epileptiform EEG discharge relapse in the phenobarbital group, compared to 1 case in the valproate group. CONCLUSIONS The phenobarbital regimen evaluated in this study has a higher GCSE termination rate than the valproate regimen, indicating that the former is suitable for countries, regions and individuals with limited access to new antiepileptic drugs or limited economic means.
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Affiliation(s)
- Yingying Su
- Neurocritical Care Committee of the Chinese Society of Neurology (CSN/NCC) and the Neurocritical Care Committee of the China Neurologist Association (CNA/NCC), Neurointensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.
| | - Huijin Huang
- Neurointensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Mengdi Jiang
- Neurointensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Suyue Pan
- Department of Neurology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China
| | - Li Ding
- Department of Neurology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming 654100, China
| | - Le Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Xiaorong Zhuang
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, 200032, China
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8
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Ghasemian M, Owlia MB, Mosaddegh MH, nejad MN, Sohrevardi SM. Evaluation of sodium valproate low dose efficacy in radicular pain management and it's relation with pharmacokinetics parameters. Biomedicine (Taipei) 2020; 10:33-40. [PMID: 33854925 PMCID: PMC7721468 DOI: 10.37796/2211-8039.1039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/28/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Radiculopathy due to lumbar or cervical disc disease is the most common chronic neuropathic pain in adults. The aim of present study was evaluation of low dose of sodium valproate (VPA) on radicular pain and determining VPA pharmacokinetics. MATERIALS AND METHODS In this double blind randomized placebo control clinical study, 80 patients with established lumbar or cervical radicular pain, have been randomly allocated into two study groups: 40 have received sodium valproate 200 mg/day and Celecoxib 100 mg/day and acetaminophen 500 mg PRN as rescue medication, and second group has received placebo, Celecoxib and acetaminophen. Quantitative assessment of pain was done by visual analogue scale (VAS) prior to perform the intervention and after ten days (treatment duration). Blood sample has been taken for determining mean through concentration after five half-lives. Evaluation of plasma concentration of VPA and that of efficacy on pain score relationship by comparing VAS before and after the therapy was done. RESULTS Group A and B have demonstrated significant alleviation in mean VAS score; -21.97 ± 25.41, -14.39 ± 23.03 respectively (P < 0.001). The mean plasma concentration of VPA in group A was: 26.9 ± 13.5 mg/L. Moreover, no significant correlation was seen between pain score with age, gender, and weight (p > 0.05). CONCLUSION Low dose of sodium valproate especially together with NSAIDs demonstrated good efficacy in lumbar and cervical radicular pain management.
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Affiliation(s)
- Mona Ghasemian
- Department of Clinical Pharmacy, Shahid Sadoughi University of Medical Sciences, Yazd,
Iran
| | - Mohammad Bagher Owlia
- Department of Internal Medicine, Shahid Sadoughi University of Medical Sciences, Yazd,
Iran
| | | | - Masoud Nakhaie nejad
- Department of Pharmaceutical Sciences, Shahid Sadoughi University of Medical Sciences, Yazd,
Iran
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Brigo F, Del Giovane C, Nardone R, Trinka E, Lattanzi S. Second-line treatments in benzodiazepine-resistant convulsive status epilepticus: An updated network meta-analysis including the ESET Trial - What did change? Epilepsy Behav 2020; 106:107035. [PMID: 32213452 DOI: 10.1016/j.yebeh.2020.107035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 03/05/2020] [Indexed: 01/23/2023]
Affiliation(s)
- Francesco Brigo
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Bolzano, Italy.
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Raffaele Nardone
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Bolzano, Italy; Department of Neurology, Christian Doppler Klinik, University Hospital Paracelsus Medical University, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, University Hospital Paracelsus Medical University, Salzburg, Austria; Institute of Public Health, Medical Decision Making and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, UMIT, Hall in Tyrol, Austria
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
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Liampas I, Siokas V, Brotis A, Zintzaras E, Stefanidis I, Dardiotis E. Intravenous sodium valproate in status epilepticus: review and Meta-analysis. Int J Neurosci 2020; 131:70-84. [DOI: 10.1080/00207454.2020.1732967] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Ioannis Liampas
- Department of Neurology, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Vasileios Siokas
- Department of Neurology, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Alexandros Brotis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Elias Zintzaras
- Department of Biomathematics, School of Medicine, University of Thessaly, Larissa, Greece
- Center for Clinical Evidence Synthesis, the Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Ioannis Stefanidis
- Department of Nephrology, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
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Minicucci F, Ferlisi M, Brigo F, Mecarelli O, Meletti S, Aguglia U, Michelucci R, Mastrangelo M, Specchio N, Sartori S, Tinuper P. Management of status epilepticus in adults. Position paper of the Italian League against Epilepsy. Epilepsy Behav 2020; 102:106675. [PMID: 31766004 DOI: 10.1016/j.yebeh.2019.106675] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/30/2019] [Accepted: 10/30/2019] [Indexed: 01/15/2023]
Abstract
Since the publication of the Italian League Against Epilepsy guidelines for the treatment of status epilepticus in 2006, advances in the field have ushered in improvements in the therapeutic arsenal. The present position paper provides neurologists, epileptologists, neurointensive care specialists, and emergency physicians with updated recommendations for the treatment of adult patients with status epilepticus. The aim is to standardize treatment recommendations in the care of this patient population.
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Affiliation(s)
- Fabio Minicucci
- Epilepsy Center, Unit of Neurophysiology, Neurological Department, IRCCS San Raffaele Hospital, Milan, Italy.
| | - Monica Ferlisi
- Division of Neurology A, Azienda Ospedaliera Universitaria Integrata, Verona, Italy.
| | - Francesco Brigo
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Italy; Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy
| | - Oriano Mecarelli
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy.
| | - Stefano Meletti
- Department of Biomedical, Metabolic and Neural Sciences, Center for Neurosciences and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, OCB Hospital, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy.
| | - Umberto Aguglia
- Epilepsy Center, Department of Medical and Surgical Sciences Regional, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Roberto Michelucci
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Unit of Neurology, Bellaria Hospital, Bologna, Italy.
| | - Massimo Mastrangelo
- Pediatric Neurology Unit, "V. Buzzi" Children's Hospital, Pediatrics Department, ASST Fatebenefratelli Sacco, Milan, Italy.
| | - Nicola Specchio
- Department of Neuroscience, IRCCS Bambino Gesù Children's Hospital, Rome, Italy.
| | - Stefano Sartori
- Paediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy.
| | - Paolo Tinuper
- IRCCS Istituto delle Scienze Neurologiche, Bellaria Hospital, Bologna, Italy; Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy.
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Brigo F, Del Giovane C, Nardone R, Trinka E, Lattanzi S. Intravenous antiepileptic drugs in adults with benzodiazepine-resistant convulsive status epilepticus: A systematic review and network meta-analysis. Epilepsy Behav 2019; 101:106466. [PMID: 31462385 DOI: 10.1016/j.yebeh.2019.106466] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 07/28/2019] [Indexed: 12/19/2022]
Abstract
AIM The aim of this study was to estimate the comparative efficacy and safety of antiepileptic drugs (AEDs) in adults with benzodiazepine-resistant convulsive status epilepticus (SE). METHODS MEDLINE, CENTRAL, ClinicalTrials.gov, and Opengrey.eu were searched (from inception to 3rd April, 2018) for randomized controlled trials (RCTs) of AEDs used intravenously to treat benzodiazepine-resistant SE in adults. Efficacy outcomes were SE cessation within 1 h from drug administration and seizure freedom at 24 h. Safety outcomes were respiratory depression and hypotension. Effect sizes were estimated by network meta-analyses within a frequentist framework. The hierarchy of competing interventions was established using the surface under the cumulative ranking curve (SUCRA) and mean ranks. RESULTS Five RCTs were considered, involving 349 patients. Included interventions were valproate (VPA; 20-30 mg/kg), phenytoin (PHT; 20 mg/kg), diazepam (DZP; 0.2 mg/kg, then 4 mg/h), phenobarbital (PHB; 20 mg/kg, then 100 mg every 6 h), lacosamide (LCM; 400 mg), and levetiracetam (LEV; 20 mg/kg); PHB was superior to PHT, VPA, DZP, LEV, and LCM with respect to SE cessation and performed better than VPA, DZP, and LCM in the achievement of seizure freedom at 24 h. No differences were noted between drugs in the occurrence of respiratory depression and hypotension. According to SUCRA, PHB had the greatest probabilities of being best in the achievement of SE control and seizure freedom, whereas VPA and LCM ranked best for the safety outcomes. CONCLUSIONS Our study suggests that high-dose PHB is effective in controlling SE and preventing seizure recurrence, and LCM and VPA could be better tolerated options. Further head-to-head comparative studies are strongly required to provide more definitive evidence. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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Affiliation(s)
- Francesco Brigo
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Bolzano, Italy; Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy.
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Raffaele Nardone
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, Bolzano, Italy; Department of Neurology, Christian Doppler Klinik, University Hospital Paracelsus Medical University, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, University Hospital Paracelsus Medical University, Salzburg, Austria; Institute of Public Health, Medical Decision Making and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, UMIT, Hall in Tyrol, Austria
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
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Nelson SE, Varelas PN. Status Epilepticus, Refractory Status Epilepticus, and Super-refractory Status Epilepticus. Continuum (Minneap Minn) 2019; 24:1683-1707. [PMID: 30516601 DOI: 10.1212/con.0000000000000668] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Status epilepticus, refractory status epilepticus, and super-refractory status epilepticus can be life-threatening conditions. This article presents an overview of the three conditions and discusses their management and outcomes. RECENT FINDINGS Status epilepticus was previously defined as lasting for 30 minutes or longer but now is more often defined as lasting 5 minutes or longer. A variety of potential causes exist for status epilepticus, refractory status epilepticus, and super-refractory status epilepticus, but all three ultimately involve changes at the cellular and molecular level. Management of patients with status epilepticus generally requires several studies, with EEG of utmost importance given the pathophysiologic changes that can occur during the course of status epilepticus. Status epilepticus is treated with benzodiazepines as first-line antiepileptic drugs, followed by phenytoin, valproic acid, or levetiracetam. If status epilepticus does not resolve, these are followed by an IV anesthetic and then alternative therapies based on limited data/evidence, such as repetitive transcranial magnetic stimulation, therapeutic hypothermia, immunomodulatory agents, and the ketogenic diet. Scores have been developed to help predict the outcome of status epilepticus. Neurologic injury and outcome seem to worsen as the duration of status epilepticus increases, with outcomes generally worse in super-refractory status epilepticus compared to status epilepticus and sometimes also to refractory status epilepticus. SUMMARY Status epilepticus can be a life-threatening condition associated with multiple complications, including death, and can progress to refractory status epilepticus and super-refractory status epilepticus. More studies are needed to delineate the best management of these three entities.
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Sánchez Fernández I, Gaínza-Lein M, Lamb N, Loddenkemper T. Meta-analysis and cost-effectiveness of second-line antiepileptic drugs for status epilepticus. Neurology 2019; 92:e2339-e2348. [DOI: 10.1212/wnl.0000000000007503] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/17/2019] [Indexed: 02/07/2023] Open
Abstract
ObjectiveCompare the cost and effectiveness of nonbenzodiazepine antiepileptic drugs (non-BZD AEDs) for treatment of BZD-resistant convulsive status epilepticus (SE).MethodsDecision analysis model populated with effectiveness data from a systematic review and meta-analysis of the literature, and cost data from publicly available prices. The primary outcome was cost per seizure stopped ($/SS). Sensitivity analyses evaluated the robustness of the results across a wide variation of the input parameters.ResultsWe included 24 studies with 1,185 SE episodes. The most effective non-BZD AED was phenobarbital (PB) with a probability of SS of 0.8 (95% confidence interval [CI]: 0.69–0.88), followed by valproate (VPA) (0.71 [95% CI: 0.61–0.79]), lacosamide (0.66 [95% CI: 0.51–0.79]), levetiracetam (LEV) (0.62 [95% CI: 0.5–0.73]), and phenytoin/fosphenytoin (PHT) (0.53 [95% CI: 0.39–0.67]). In pairwise comparisons, PB was more effective than PHT (p = 0.002), VPA was more effective than PHT (p = 0.043), and PB was more effective than LEV (p = 0.018). The most cost-effective non-BZD AED was LEV (incremental cost-effectiveness ratio [ICER]: $18.55/SS), followed by VPA (ICER: $94.44/SS), and lastly PB (ICER: $847.22/SS). PHT and lacosamide were not cost-effective compared to the other options. Sensitivity analyses showed marked overlap in cost-effectiveness, but PHT was consistently less cost-effective than LEV, VPA, and PB.ConclusionVPA and PB were more effective than PHT for SE. There is substantial overlap in the cost-effectiveness of non-BZD AEDs for SE, but available evidence does not support the preeminence of PHT, neither in terms of effectiveness nor in terms of cost-effectiveness.
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Abstract
Patients with prolonged seizures that do not respond to intravenous benzodiazepines and a second-line anticonvulsant suffer from refractory status epilepticus and those with seizures that do not respond to continuous intravenous anesthetic anticonvulsants suffer from super-refractory status epilepticus. Both conditions are associated with significant morbidity and mortality. A strict pharmacological treatment regimen is urgently required, but the level of evidence for the available drugs is very low. Refractory complex focal status epilepticus generally does not require anesthetics, but all intravenous non-anesthetizing anticonvulsants may be used. Most descriptive data are available for levetiracetam, phenytoin and valproate. Refractory generalized convulsive status epilepticus is a life-threatening emergency, and long-term clinical consequences are eminent. Administration of intravenous anesthetics is mandatory, and drugs acting at the inhibitory gamma-aminobutyric acid (GABA)A receptor such as midazolam, propofol and thiopental/pentobarbital are recommended without preference for one of those. One in five patients with anesthetic treatment does not respond and has super-refractory status epilepticus. With sustained seizure activity, excitatory N-methyl-d-aspartate (NMDA) receptors are increasingly expressed post-synaptically. Ketamine is an antagonist at this receptor and may prove efficient in some patients at later stages. Neurosteroids such as allopregnanolone increase sensitivity at GABAA receptors; a Phase 1/2 trial demonstrated safety and tolerability, but randomized controlled data failed to demonstrate efficacy. Adjunct ketogenic diet may contribute to termination of difficult-to-treat status epilepticus. Randomized controlled trials are needed to increase evidence for treatment of refractory and super-refractory status epilepticus, but there are multiple obstacles for realization. Hitherto, prospective multicenter registries for pharmacological treatment may help to improve our knowledge.
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Affiliation(s)
- Martin Holtkamp
- Epilepsy-Center Berlin-Brandenburg, Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
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Morano A, Iannone L, Palleria C, Fanella M, Giallonardo AT, De Sarro G, Russo E, Di Bonaventura C. Pharmacology of new and developing intravenous therapies for the management of seizures and epilepsy. Expert Opin Pharmacother 2018; 20:25-39. [PMID: 30403892 DOI: 10.1080/14656566.2018.1541349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Antiepileptic drugs (AEDs) are administered orally for chronic use. Parenteral formulations might be necessary when the oral route is not feasible (e.g. an impairment of consciousness, trauma, dysphagia, gastrointestinal illness) or for treatment of seizure emergencies. At present, few intravenous (IV) formulations are available on the market. AREAS COVERED The purpose of this review is to summarize the pharmacological characteristics and clinical applications of IV medications that have been recently introduced to the armamentarium of epilepsy therapy or are currently being developed. Apart from AEDs, other compounds belonging to different pharmacological classes (e.g. diuretics, anesthetics), which have shown potential effectiveness in seizure control, are taken into consideration, and the pathophysiological premises supporting their use for epilepsy treatment are illustrated. The authors give particular focus to immunomodulatory and immunosuppressive agents, which have become the therapeutic cornerstones for immune-mediated epilepsies, despite regulatory obstacles. EXPERT OPINION In several circumstances, especially in the case of seizure-related emergencies, clinical practice seems not match literature-based evidence, and several IV AEDs are still used off-label. Strong evidence derived from randomized clinical trials (RCTs) is needed to support the effectiveness and tolerability of any therapeutic approach, however common and "accepted' it may be, in order to guarantee patient safety and well-being.
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Affiliation(s)
- Alessandra Morano
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
| | - Luigi Iannone
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Caterina Palleria
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Martina Fanella
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
| | - Anna Teresa Giallonardo
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
| | - Giovambattista De Sarro
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Emilio Russo
- b Science of Health Department, School of Medicine , University of Catanzaro , Catanzaro , Italy
| | - Carlo Di Bonaventura
- a Neurology Unit, Department of Neurosciences, Mental Health , "Sapienza" University , Rome , Italy
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Recommendations for Electroencephalography Monitoring in Neurocritical Care Units. Chin Med J (Engl) 2018; 130:1851-1855. [PMID: 28748859 PMCID: PMC5547838 DOI: 10.4103/0366-6999.211559] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Zhou C, Sui Y, Zhao W, Dong C, Ren L, Song P, Xu B, Sun X. The critical interaction between valproate sodium and warfarin: case report and review. BMC Pharmacol Toxicol 2018; 19:60. [PMID: 30285858 PMCID: PMC6167846 DOI: 10.1186/s40360-018-0251-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Valproic acid (VPA) and warfarin are commonly prescribed for patients with epilepsy and concomitant atrial fibrillation (AF). When VPA and warfarin are prescribed together, clinically important interactions may occur. VPA may replace warfarin from the protein binding sites and result in an abnormally increased anticoagulation effect. This is commonly underrecognized. CASE PRESENTATION In our case, we report a 78-year-old woman with a glioma who presented with status epilepticus. The patient was on warfarin to prevent cardiogenic embolism secondary to AF. Intravenous loading dose of VPA was administered, but international normalized ratio (INR) increased significantly to 8.26. Intravenous vitamin K1 was then given and the patient developed no overt bleeding during the hospitalization. CONCLUSION By reviewing the literature and discussing the critical interaction between valproate sodium and warfarin, we conclude that intravenous VPA and the co-administrated warfarin may develop critical but underrecognized complications due to effects on the function of hepatic enzymes and displacement of protein binding sites.
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Affiliation(s)
- Chenguang Zhou
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yi Sui
- Department of Neurology, Shenyang First People's Hospital, Shenyang Brain Institute, Shenyang Medical College Affiliated Shenyang Brain Hospital, Shenyang, China.
| | - Weijin Zhao
- Department of Neurology, Shenyang First People's Hospital, Shenyang Brain Institute, Shenyang Medical College Affiliated Shenyang Brain Hospital, Shenyang, China
| | - Chunyao Dong
- Department of Neurology, Shenyang First People's Hospital, Shenyang Brain Institute, Shenyang Medical College Affiliated Shenyang Brain Hospital, Shenyang, China
| | - Li Ren
- Department of Neurology, Shenyang First People's Hospital, Shenyang Brain Institute, Shenyang Medical College Affiliated Shenyang Brain Hospital, Shenyang, China
| | - Pingmei Song
- Department of Diagnostic Sonography, Shenyang First People's Hospital, Shenyang Brain Institute, Shenyang Medical College Affiliated Shenyang Brain Hospital, Shenyang, China
| | - Bing Xu
- Department of Neurology, Shenyang First People's Hospital, Shenyang Brain Institute, Shenyang Medical College Affiliated Shenyang Brain Hospital, Shenyang, China
| | - Xiaohong Sun
- Department of Neurology, the Fourth Affiliated Hospital, China Medical University, Shenyang, China
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Chen W, Su Y, Jiang M, Liu G, Tian F, Ren G. Status epilepticus associated with acute encephalitis: long‐term follow‐up of functional and cognitive outcomes in 72 patients. Eur J Neurol 2018; 25:1228-1234. [PMID: 29751371 DOI: 10.1111/ene.13678] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 05/03/2018] [Indexed: 11/29/2022]
Affiliation(s)
- W. Chen
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Y. Su
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - M. Jiang
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - G. Liu
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - F. Tian
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - G. Ren
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
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Wang RF, Xue GF, Hölscher C, Tian MJ, Feng P, Zheng JY, Li DF. Post-treatment with the GLP-1 analogue liraglutide alleviate chronic inflammation and mitochondrial stress induced by Status epilepticus. Epilepsy Res 2018; 142:45-52. [PMID: 29549796 DOI: 10.1016/j.eplepsyres.2018.03.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 12/06/2017] [Accepted: 03/08/2018] [Indexed: 12/11/2022]
Abstract
Glucagon-like peptide-1(GLP-1) is a growth factor that has neuroprotective and anti-inflammatory properties. The protease resistant GLP-1 analogue liraglutide has been shown to be neuroprotective in previous studies in animal models of Alzheimer's disease or Parkinson's disease. Status epilepticus (SE) is a complex disorder, involving many underlying pathological processes, including excitotoxic and chronic inflammatory events. The present pilot study aims to investigate whether liraglutide alleviates the chronic inflammation response and mitochondrial stress induced by SE in the lithium-pilocarpine animal model. We found that treatment with 25nmol/kg. i.p. once-daily after the induction of SE for 7 days reduced chronic inflammation as shown by reduced numbers of activated microglia and astrocytes, and reduced levels of TNF-α and IL-1ß in the hippocampus. The mitochondrial stress marker BAX was reduced and the survival factor Bcl-2 was enhanced by liraglutide. Blood glucose levels were not affected by liraglutide. We show for the first time that liraglutide can reduce the chronic inflammation and mitochondrial stress induced by SE, and the results suggest that GLP-1 receptor agonists such as liraglutide have restorative and protective effects in the brain after SE and could serve as a potential treatment.
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Affiliation(s)
- Rui-Fang Wang
- Department of Neurology, The Second Affiliated Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan 030001, Shanxi Province, China
| | - Guo-Fang Xue
- Department of Neurology, The Second Affiliated Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan 030001, Shanxi Province, China.
| | - Christian Hölscher
- Department of Neurology, The Second Affiliated Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan 030001, Shanxi Province, China; Division of Biomedical and Life Science, Faculty of Health and Medicine, Lancaster University, Lancaster LA14YQ, UK
| | - Miao-Jing Tian
- Department of Neurology, The Second Affiliated Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan 030001, Shanxi Province, China
| | - Peng Feng
- Department of Neurology, The Second Affiliated Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan 030001, Shanxi Province, China
| | - Ji-Ying Zheng
- Department of Neurology, The Second Affiliated Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan 030001, Shanxi Province, China
| | - Dong-Fang Li
- Department of Neurology, The Second Affiliated Hospital of Shanxi Medical University, No. 382 Wuyi Road, Taiyuan 030001, Shanxi Province, China.
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Challenges in the treatment of convulsive status epilepticus. Seizure 2017; 47:17-24. [DOI: 10.1016/j.seizure.2017.02.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 01/09/2023] Open
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Abstract
Status epilepticus is a neurologic and medical emergency manifested by prolonged seizure activity or multiple seizures without return to baseline. It is associated with substantial medical cost, morbidity, and mortality. There is a spectrum of severity dependent on the type of seizure, underlying pathology, comorbidities, and appropriate and timely medical management. This chapter discusses the evolving definitions of status epilepticus and multiple patient and clinical factors which influence outcome. The pathophysiology of status epilepticus is reviewed to provide a better understanding of the mechanisms which contribute to status epilepticus, as well as the potential long-term effects. The clinical presentations of different types of status epilepticus in adults are discussed, with emphasis on the hospital course and management of the most dangerous type, generalized convulsive status epilepticus. Strategies for the evaluation and management of status epilepticus are provided based on available evidence from clinical trials and recommendations from the Neurocritical Care Society and the European Federation of Neurological Societies.
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Affiliation(s)
- M Pichler
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - S Hocker
- Division of Critical Care Neurology, Mayo Clinic, Rochester, MN, USA.
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Phenobarbital Versus Valproate for Generalized Convulsive Status Epilepticus in Adults: A Prospective Randomized Controlled Trial in China. CNS Drugs 2016; 30:1201-1207. [PMID: 27878767 DOI: 10.1007/s40263-016-0388-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Although generalized convulsive status epilepticus (GCSE) is a life-threatening emergency, evidence-based data to guide initial drug treatment choices are lacking in the Chinese population. We conducted this prospective, randomized, controlled trial to evaluate the relative efficacy and safety of intravenous phenobarbital and valproate in patients with GCSE. METHODS After the failure of first-line diazepam treatment, Chinese adult patients with GCSE were randomized to receive either intravenous phenobarbital (standard doses, low rate) or valproate (standard). Successful treatment was considered when clinical and electroencephalographic seizure activity ceased. Adverse events following treatment, as well as the neurological outcomes at discharge and 3 months later, were also evaluated. RESULTS Overall, 73 cases were enrolled in the study. Intravenous phenobarbital was successful in 81.1% of patients, and intravenous valproate was successful in 44.4% of patients (p < 0.05). The relapse rate of status epilepticus within 24 h of receiving phenobarbital (6.7%) was significantly lower than that in patients receiving valproate (31.3%), and the total number of adverse events did not differ significantly between the two groups (p > 0.05). In the phenobarbital group, two patients (5.4%) required ventilation and two patients (5.4%) developed serious hypotension. The neurological outcomes of the phenobarbital group were generally better than those of the valproate group; however, no significant differences were observed between phenobarbital and valproate with respect to mortality (8.1 vs. 16.6%) at discharge, or mortality (16.2 vs. 30.5%) and post-symptomatic epilepsy (26.3 vs. 42.8%) at 3-month follow-up. CONCLUSIONS Intravenous phenobarbital appears to be more effective than intravenous valproate for Chinese adult patients with GCSE. The occurrence of serious respiratory depression and hypotension caused by phenobarbital was reduced by decreasing the intravenous infusion rate; however, even at a lower infusion rate than typically used in other institutions, intravenous phenobarbital resulted in more serious adverse events than intravenous valproate. The better outcomes in the phenobarbital group compared with the valproate group suggest that phenobarbital should be considered for the early successful treatment of GCSE.
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Diazepam sorption to PVC- and non-PVC-based tubes in administration sets with quantitative determination using a high-performance liquid chromatographic method. Int J Pharm 2016; 506:414-9. [DOI: 10.1016/j.ijpharm.2016.04.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Revised: 03/26/2016] [Accepted: 04/15/2016] [Indexed: 11/17/2022]
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Pandey S, Rathore C, Michael BD. Antiepileptic drugs for the primary and secondary prevention of seizures in viral encephalitis. Cochrane Database Syst Rev 2016; 2016:CD010247. [PMID: 27209627 PMCID: PMC7087433 DOI: 10.1002/14651858.cd010247.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Viral encephalitis is characterised by diverse clinical and epidemiological features. Seizures are an important clinical manifestation and are associated with increased mortality and morbidity. Patients may have seizures during the acute illness or they may develop after recovery. There are no recommendations regarding the use of antiepileptic drugs for the primary or secondary prevention of seizures in patients with viral encephalitis.This is an updated version of the original Cochrane review published in The Cochrane Library 2014, Issue 10. OBJECTIVES To assess the efficacy and tolerability of antiepileptic drugs for the primary and secondary prophylaxis of seizures in viral encephalitis. We had intended to answer the following questions.1. Do antiepileptic drugs used routinely as primary prophylaxis for all patients with suspected or proven viral encephalitis reduce the risk of seizures during the acute illness and reduce neurological morbidity and mortality?2. Do antiepileptic drugs used routinely as secondary prophylaxis for all patients who have had at least one seizure due to suspected or proven viral encephalitis reduce the risk of further seizures during the acute illness and reduce neurological morbidity and mortality? SEARCH METHODS For the latest version of this review, we searched the Cochrane Epilepsy Group Specialized Register (11 April 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO, 11 April 2016), MEDLINE (Ovid 1946 to 11 April 2016), the WHO International Clinical Trials Registry Platform (ICTRP, 11 April 2016), and ClinicalTrials.gov (11 April 2016). We did not impose any language restrictions. SELECTION CRITERIA Randomised and quasi-randomised controlled trials in which patients were assigned to a treatment or control group (placebo or no drug). DATA COLLECTION AND ANALYSIS One review author (SP) searched the publications by title, abstract and keywords, and decided on their suitability for the review. For any studies where their suitability was unclear, the co-authors (CR, BM) were consulted. The co-authors (CR, BM) independently evaluated the selected studies. Since there were no included studies, we carried out no data analysis. MAIN RESULTS We did not find any randomised or quasi-randomised controlled trials that compared the effects of antiepileptic drugs with placebo (or no drug) for the primary or secondary prevention of seizures in viral encephalitis. We identified two studies from the literature search where different antiepileptic drugs were used in patients with viral encephalitis, however both failed to meet the inclusion criteria. AUTHORS' CONCLUSIONS There is insufficient evidence to support or refute the routine use of antiepileptic drugs for the primary or secondary prevention of seizures in viral encephalitis. There is a need for adequately powered randomised controlled trials in patients with viral encephalitis to assess the efficacy and tolerability of antiepileptic drugs for the primary and secondary prophylaxis of seizures, which is an important clinical problem.
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Affiliation(s)
- Sanjay Pandey
- G.B. Pant HospitalDepartment of NeurologyNew DelhiIndia110002
| | - Chaturbhuj Rathore
- Sree Chitra Tirunal Institute for Medical Sciences and TechnologyDepartment of NeurologyTrivandrumKeralaIndia695011
| | - Benedict D Michael
- University of LiverpoolInstitute of Infection and Global Health8 West Derby StreetLiverpoolMerseysideUKL69 7BE
- The Walton Centre NHS Foundation TrustLiverpoolUK
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Falco-Walter JJ, Bleck T. Treatment of Established Status Epilepticus. J Clin Med 2016; 5:jcm5050049. [PMID: 27120626 PMCID: PMC4882478 DOI: 10.3390/jcm5050049] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 03/29/2016] [Accepted: 04/19/2016] [Indexed: 11/30/2022] Open
Abstract
Status epilepticus is the most severe form of epilepsy, with a high mortality rate and high health care costs. Status epilepticus is divided into four stages: early, established, refractory, and super-refractory. While initial treatment with benzodiazepines has become standard of care for early status epilepticus, treatment after benzodiazepine failure (established status epilepticus (ESE)) is incompletely studied. Effective treatment of ESE is critical as morbidity and mortality increases dramatically the longer convulsive status epilepticus persists. Phenytoin/fosphenytoin, valproic acid, levetiracetam, phenobarbital, and lacosamide are the most frequently prescribed antiseizure medications for treatment of ESE. To date there are no class 1 data to support pharmacologic recommendations of one agent over another. We review each of these medications, their pharmacology, the scientific evidence in support and against each in the available literature, adverse effects and safety profiles, dosing recommendations, and limitations of the available evidence. We also discuss future directions including the established status epilepticus treatment trial (ESETT). Substantial further research is urgently needed to identify these patients (particularly those with non-convulsive status epilepticus), elucidate the most efficacious antiseizure treatment with head-to-head randomized prospective trials, and determine whether this differs for convulsive vs. non-convulsive ESE.
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Affiliation(s)
- Jessica J Falco-Walter
- Department of Neurology, Rush University Medical Center, 1725 West Harrison Street, Suite 885, Chicago, IL 60612, USA.
| | - Thomas Bleck
- Department of Neurology, Rush University Medical Center, 1725 West Harrison Street, Suite 885, Chicago, IL 60612, USA.
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Trinka E, Höfler J, Leitinger M, Rohracher A, Kalss G, Brigo F. Pharmacologic treatment of status epilepticus. Expert Opin Pharmacother 2016; 17:513-34. [DOI: 10.1517/14656566.2016.1127354] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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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; 16:48-61. [PMID: 26900382 PMCID: PMC4749120 DOI: 10.5698/1535-7597-16.1.48] [Citation(s) in RCA: 673] [Impact Index Per Article: 84.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
CONTEXT The optimal pharmacologic treatment for early convulsive status epilepticus is unclear. OBJECTIVE To analyze efficacy, tolerability and safety data for anticonvulsant treatment of children and adults with convulsive status epilepticus and use this analysis to develop an evidence-based treatment algorithm. DATA SOURCES Structured literature review using MEDLINE, Embase, Current Contents, and Cochrane library supplemented with article reference lists. STUDY SELECTION Randomized controlled trials of anticonvulsant treatment for seizures lasting longer than 5 minutes. DATA EXTRACTION Individual studies were rated using predefined criteria and these results were used to form recommendations, conclusions, and an evidence-based treatment algorithm. RESULTS A total of 38 randomized controlled trials were identified, rated and contributed to the assessment. Only four trials were considered to have class I evidence of efficacy. Two studies were rated as class II and the remaining 32 were judged to have class III evidence. In adults with convulsive status epilepticus, intramuscular midazolam, intravenous lorazepam, intravenous diazepam and intravenous phenobarbital are established as efficacious as initial therapy (Level A). Intramuscular midazolam has superior effectiveness compared to intravenous lorazepam in adults with convulsive status epilepticus without established intravenous access (Level A). In children, intravenous lorazepam and intravenous diazepam are established as efficacious at stopping seizures lasting at least 5 minutes (Level A) while rectal diazepam, intramuscular midazolam, intranasal midazolam, and buccal midazolam are probably effective (Level B). No significant difference in effectiveness has been demonstrated between intravenous lorazepam and intravenous diazepam in adults or children with convulsive status epilepticus (Level A). Respiratory and cardiac symptoms are the most commonly encountered treatment-emergent adverse events associated with intravenous anticonvulsant drug administration in adults with convulsive status epilepticus (Level A). The rate of respiratory depression in patients with convulsive status epilepticus treated with benzodiazepines is lower than in patients with convulsive status epilepticus treated with placebo indicating that respiratory problems are an important consequence of untreated convulsive status epilepticus (Level A). When both are available, fosphenytoin is preferred over phenytoin based on tolerability but phenytoin is an acceptable alternative (Level A). In adults, compared to the first therapy, the second therapy is less effective while the third therapy is substantially less effective (Level A). In children, the second therapy appears less effective and there are no data about third therapy efficacy (Level C). The evidence was synthesized into a treatment algorithm. CONCLUSIONS Despite the paucity of well-designed randomized controlled trials, practical conclusions and an integrated treatment algorithm for the treatment of convulsive status epilepticus across the age spectrum (infants through adults) can be constructed. Multicenter, multinational efforts are needed to design, conduct and analyze additional randomized controlled trials that can answer the many outstanding clinically relevant questions identified in this guideline.
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Affiliation(s)
- Tracy Glauser
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shlomo Shinnar
- Departments of Neurology, Pediatrics, and Epidemiology and Population Health, and the Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | | | - Brian Alldredge
- School of Pharmacy, University of California, San Francisco, CA
| | - Ravindra Arya
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jacquelyn Bainbridge
- Department of Clinical Pharmacy, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Mary Bare
- Division of Neurology, Comprehensive Epilepsy Center, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | - Thomas Bleck
- Departments of Neurological Sciences, Neurosurgery, Medicine, and Anesthesiology, Rush University Medical Center, Chicago, IL
| | - W. Edwin Dodson
- Departments of Neurology and Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Lisa Garrity
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andy Jagoda
- Department of Emergency Medicine, Mount Sinai Hospital, Mount Sinai School of Medicine, New York, NY
| | - Daniel Lowenstein
- Department of Neurology, University of California, San Francisco, CA
| | - John Pellock
- Division of Pediatric Neurology, Virginia Commonwealth University, Richmond, VA
| | | | - Edward Sloan
- Department of Emergency Medicine, University of Illinois at Chicago, Chicago, IL
| | - David M. Treiman
- Division of Neurology, Barrow Neurological Institute, Phoenix, AZ
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Misra UK, Kalita J. A comparison of four antiepileptic drugs in status epilepticus: experience from India. Int J Neurosci 2015; 126:1013-9. [DOI: 10.3109/00207454.2015.1095743] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Status epilepticus (SE) represents the most severe form of epilepsy. It is one of the most common neurologic emergencies, with an incidence of up to 61 per 100,000 per year and an estimated mortality of 20 %. Clinically, tonic-clonic convulsive SE is divided into four subsequent stages: early, established, refractory, and super-refractory. Pharmacotherapy of status epilepticus, especially of its later stages, represents an "evidence-free zone," due to a lack of high-quality, controlled trials to inform clinical decisions. This comprehensive narrative review focuses on the pharmacotherapy of SE, presented according to the four-staged approach outlined above, and providing pharmacological properties and efficacy/safety data for each antiepileptic drug according to the strength of scientific evidence from the available literature. Data sources included MEDLINE and back-tracking of references in pertinent studies. Intravenous lorazepam or intramuscular midazolam effectively control early SE in approximately 63-73 % of patients. Despite a suboptimal safety profile, intravenous phenytoin or phenobarbital are widely used treatments for established SE; alternatives include valproate, levetiracetam, and lacosamide. Anesthetics are widely used in refractory and super-refractory SE, despite the current lack of trials in this field. Data on alternative treatments in the later stages are limited. Valproate and levetiracetam represent safe and effective alternatives to phenobarbital and phenytoin for treatment of established SE persisting despite first-line treatment with benzodiazepines. To date there are no class I data to support recommendations for most antiepileptic drugs for established, refractory, and super-refractory SE. Limiting the methodologic heterogeneity across studies is required and high-class randomized, controlled trials to inform clinicians about the best treatment in established and refractory status are needed.
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Affiliation(s)
- Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University Salzburg, Ignaz Harrerstrasse 79, 5020, Salzburg, Austria,
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Prager EM, Figueiredo TH, Long RP, Aroniadou-Anderjaska V, Apland JP, Braga MFM. LY293558 prevents soman-induced pathophysiological alterations in the basolateral amygdala and the development of anxiety. Neuropharmacology 2015; 89:11-8. [PMID: 25204221 PMCID: PMC4250288 DOI: 10.1016/j.neuropharm.2014.08.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 07/18/2014] [Accepted: 08/20/2014] [Indexed: 11/24/2022]
Abstract
Exposure to nerve agents can cause brain damage due to prolonged seizure activity, producing long-term behavioral deficits. We have previously shown that LY293558, a GluK1/AMPA receptor antagonist, is a very effective anticonvulsant and neuroprotectant against nerve agent exposure. In the present study, we examined whether the protection against nerve agent-induced seizures and neuropathology conferred by LY293558 translates into protection against pathophysiological alterations in the basolateral amygdala (BLA) and the development of anxiety, which is the most prevalent behavioral deficit resulting from exposure. LY293558 (15 mg/kg) was administered to rats, along with atropine and HI-6, at 20 min after exposure to soman (1.2 × LD50). At 24 h, 7 days, and 30 days after exposure, soman-exposed rats who did not receive LY293558 had reduced but prolonged evoked field potentials in the BLA, as well as increased paired-pulse ratio, suggesting neuronal damage and impaired synaptic inhibition; rats who received LY293558 did not differ from controls in these parameters. Long-term potentiation of synaptic transmission was impaired at 7 days after exposure in the soman-exposed rats who did not receive anticonvulsant treatment, but not in the LY293558-treated rats. Anxiety-like behavior assessed by the open field and acoustic startle response tests was increased in the soman-exposed rats at 30 and 90 days after exposure, while rats treated with LY293558 did not differ from controls. Along with our previous findings, the present data demonstrate the remarkable efficacy of LY293558 in counteracting nerve agent-induced seizures, neuropathology, pathophysiological alterations in the BLA, and anxiety-related behavioral deficits.
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Affiliation(s)
- Eric M Prager
- Department of Anatomy, Physiology, and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Program in Neuroscience, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Taiza H Figueiredo
- Department of Anatomy, Physiology, and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Robert P Long
- Department of Anatomy, Physiology, and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Program in Neuroscience, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Vassiliki Aroniadou-Anderjaska
- Department of Anatomy, Physiology, and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Department of Psychiatry, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Program in Neuroscience, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - James P Apland
- Neurotoxicology Branch, United States Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, MD 21010, USA.
| | - Maria F M Braga
- Department of Anatomy, Physiology, and Genetics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Department of Psychiatry, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Program in Neuroscience, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
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Pandey S, Rathore C, Michael BD. Antiepileptic drugs for the primary and secondary prevention of seizures in viral encephalitis. Cochrane Database Syst Rev 2014:CD010247. [PMID: 25300175 DOI: 10.1002/14651858.cd010247.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Viral encephalitis is characterised by diverse clinical and epidemiological features. Seizures are an important clinical manifestation and associated with increased mortality and morbidity. Patients may have seizures during the acute illness or they may develop after recovery. There are no recommendations regarding the use of antiepileptic drugs for the primary or secondary prevention of seizures in patients with viral encephalitis. OBJECTIVES To assess the efficacy and safety of antiepileptic drugs for the primary and secondary prophylaxis of seizures in viral encephalitis. We intended to answer the following questions.1. Do antiepileptic drugs used as primary prophylaxis routinely for all patients with suspected or proven viral encephalitis reduce the risk of seizures during the acute illness and reduce neurological morbidity and mortality?2. Do antiepileptic drugs used as secondary prophylaxis routinely for all patients who have had at least one seizure due to suspected or proven viral encephalitis reduce the risk of further seizures during the acute illness and reduce neurological morbidity and mortality? SEARCH METHODS We searched the Cochrane Epilepsy Group Specialised Register (13 May 2014), the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 4) (April 2014), MEDLINE (Ovid, 1946 to 13 May 2014), the WHO ICTRP search portal (13 May 2014) and ClinicalTrials.gov (13 May 2014). We did not impose any language restrictions. SELECTION CRITERIA Randomised and quasi-randomised controlled trials in which patients were assigned to a treatment or control group (placebo or no drug). DATA COLLECTION AND ANALYSIS One author (SP) searched the publications by title, abstract and keywords and decided on their suitability for inclusion in the review. For any studies where it was unclear whether they would be suitable for inclusion, the co-authors (CR, BM) were consulted. The co-authors (CR, BM) evaluated the selected studies independently. Since there were no included studies, we carried out no data analysis. MAIN RESULTS We did not find any randomised or quasi-randomised controlled trials that compared the effects of antiepileptic drugs with placebo (or no drug) for the primary or secondary prevention of seizures in viral encephalitis. We identified two studies from the literature search where different antiepileptic drugs were used in patients with viral encephalitis, however both failed to meet the inclusion criteria. The first study included children with viral encephalitis where antiepileptic drugs were given. However, it is not clear how the diagnosis was established or the aetiologies. In addition, the randomisation and blinding method is not disclosed; the patients received a diverse and ill-defined range of antiepileptic drugs and adjunctive therapies, and none of the primary or secondary outcome measures was assessed. In the second study, adults with status epilepticus (of whom a proportion had viral encephalitis), who had failed to respond to two initial boluses of diazepam, were randomised to either valproate or diazepam. The study was open-label and the randomisation methodology was not disclosed; none of the primary or secondary outcomes were reported. Data on treatment response between the two arms for those patients with viral encephalitis are not presented for subgroup analysis; the Cochrane Epilepsy Group have contacted the authors for these data but have yet to receive a response. AUTHORS' CONCLUSIONS There is insufficient evidence to support the routine use of antiepileptic drugs for the primary or secondary prevention of seizures in viral encephalitis. There is a need for adequately powered randomised controlled trials in viral encephalitis patients to assess the efficacy and safety of antiepileptic drugs for the primary and secondary prophylaxis of seizures, which is an important clinical problem.
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Affiliation(s)
- Sanjay Pandey
- Department of Neurology, G.B. Pant Hospital, New Delhi, India, 110002
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Abstract
BACKGROUND Status epilepticus is a medical emergency associated with significant mortality and morbidity that requires immediate and effective treatment. OBJECTIVES (1) To determine whether a particular anticonvulsant is more effective or safer to use in status epilepticus compared to another and compared to placebo.(2) To delineate reasons for disagreement in the literature regarding recommended treatment regimens and to highlight areas for future research. SEARCH METHODS For the latest update of this review, the following electronic databases were searched on 15/08/2013: the Cochrane Epilepsy Group's Specialized Register, CENTRAL The Cochrane Library July 2013, Issue 7, and MEDLINE (Ovid) 1946 to 15/08/2013. SELECTION CRITERIA Randomised controlled trials of participants with premonitory, early, established or refractory status epilepticus using a truly random or quasi-random allocation of treatments were included. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, assessed trial quality and extracted data. MAIN RESULTS Eighteen studies with 2755 participants were included. Few studies used the same interventions. Intravenous diazepam was better than placebo in reducing the risk of non-cessation of seizures (risk ratio (RR) 0.73, 95% confidence interval (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). Intravenous lorazepam was better than placebo 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). Intravenous lorazepam was better than intravenous diazepam 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). Intravenous lorazepam was better than intravenous phenytoin for risk of non-cessation of seizures (RR 0.62, 95% CI 0.45 to 0.86). Diazepam gel was better than placebo gel in reducing the risk of non-cessation of seizures (RR 0.43 95% CI 0.30 to 0.62)For pre-hospital treatment, intramuscular midazolam is at least as effective as (probably more effective than) intravenous lorazepam 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). It was uncertain whether Intravenous valproate was better than intravenous phenytoin in reducing risk of non-cessation of seizures (RR 0.75, 95% CI 0.28 to 2.00). Both levetiracetam and lorazepam 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.The body of randomised evidence to guide clinical decisions is small. It was uncertain whether any anticonvulsant therapy was better than another in terms of adverse effects, due to few studies and participants identified. The quality of the evidence from the included studies is not strong but appears acceptable. We were unable to make judgements for risk of bias domains incomplete outcome reporting (attrition bias) and selective outcome reporting (selection bias) due to unclear reporting by the study authors. AUTHORS' CONCLUSIONS Intravenous lorazepam is better than intravenous diazepam or intravenous phenytoin alone for cessation of seizures. Intravenous lorazepam also carries a lower risk of continuation of status epilepticus requiring a different drug or general anaesthesia compared with intravenous diazepam. Both intravenous lorazepam and diazepam are better than placebo for the same outcomes. For pre hospital management, midazolam IM seemed more effective than lorazepam IV for cessation of seizures, frequency of hospitalisation and ICU admissions however,it was unclear whether the risk of recurrence of seizures differed between treatments. The results of other comparisons of anticonvulsant therapies versus each other were also uncertain. Universally accepted definitions of premonitory, early, established and refractory status epilepticus are required. Diazepam gel was better than placebo gel in reducing the risk of non-cessation of seizures. Results for other comparisons of anticonvulsant therapies were uncertain due to single studies with few participants.
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Affiliation(s)
- Manya Prasad
- All India Institue of Medical SciencesDepartment of NeurologyC‐II/7Ansari Nagar EastAIIMS CampusAnsarinagarNew DelhiIndia110029
| | - Pudukode R Krishnan
- Fortis Healthcare Ltd.Clinical Neurosciences154/9 Bannerghatta RoadOpp IIMBBangaloreIndia560076
| | - Reginald Sequeira
- The Arabian Gulf UniversityDepartment of Pharmacology and TherapeuticsManamaBahrain
| | - Khaldoon Al‐Roomi
- The Arabian Gulf UniversityDepartment of Family and Community MedicineManamaBahrain
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Trinka E, Höfler J, Zerbs A, Brigo F. Efficacy and safety of intravenous valproate for status epilepticus: a systematic review. CNS Drugs 2014; 28:623-39. [PMID: 24806973 PMCID: PMC4078236 DOI: 10.1007/s40263-014-0167-1] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The effectiveness of valproate (VPA) in the treatment of focal and generalized epilepsies is well established. The drug has a wide spectrum of action, good tolerability, and has been available as an injectable formulation since 1993. Despite the lack of class A evidence, it has been used extensively in various forms of status epilepticus (SE). AIM Our aim was to present a systematic review of data from randomized and non-randomized controlled trials to evaluate the efficacy and safety of intravenous VPA for the treatment of SE. METHODS Data sources included MEDLINE, back tracing of references in pertinent studies, and contact with the manufacturer of VPA (Sanofi-Aventis). RESULTS Overall, the search strategy yielded 433 results (425 MEDLINE, seven congress abstracts, one unpublished study); after excluding duplicate publications and case reports, 30 studies were identified (the earliest was published in 1993, the most recent in 2012); ten were controlled (six randomized controlled trials, four non-randomized controlled studies), and 20 uncontrolled trials (eight prospective observational studies, 12 retrospective case series). The cumulative literature describes the experiences of 860 patients with various forms of SE treated with intravenous VPA. The overall response rate to abrogate SE was 70.9% (601/848; 95% confidence interval [CI] 67.8-73.9). Response rates to intravenous VPA were better in children than in adults and did not differ between the SE types. The most commonly reported effective doses were between 15 and 45 mg/kg in bolus (6 mg/kg/min) followed by 1-3 mg/kg/h infusion. Safety studies of intravenous VPA administration in patients with SE showed a low incidence of adverse events overall (<10%), mainly dizziness, thrombocytopenia, and mild hypotension, which was independent of infusion rates. Of note, good cardiovascular and respiratory tolerability was observed in these studies, even at high doses and fast infusion rates (up to 30 mg/kg at 10 mg/kg/min), despite multiple morbidities or other antiepileptic drugs. The most serious concern relates to the possibility of acute encephalopathy, sometimes related to hepatic abnormalities or hyperammonemia. CONCLUSIONS The published experience is consistent with VPA being a safe and effective therapeutic option for patients with established SE who have previously failed conventional first-line treatment with benzodiazepines, but high-quality randomized controlled trials are needed to inform clinicians on its comparative effectiveness in SE.
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Affiliation(s)
- Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Centre for Cognitive Neuroscience Salzburg, Paracelsus Medical University Salzburg, Ignaz Harrerstrasse 79, 5020, Salzburg, Austria,
| | - Julia Höfler
- Department of Neurology, Christian Doppler Klinik, Centre for Cognitive Neuroscience Salzburg, Paracelsus Medical University Salzburg, Ignaz Harrerstrasse 79, 5020 Salzburg, Austria ,Christian Doppler Medical Centre, Salzburg, Austria
| | - Alexander Zerbs
- Department of Neurology, Christian Doppler Klinik, Centre for Cognitive Neuroscience Salzburg, Paracelsus Medical University Salzburg, Ignaz Harrerstrasse 79, 5020 Salzburg, Austria ,Christian Doppler Medical Centre, Salzburg, Austria
| | - Francesco Brigo
- Department of Neurological and Movement Sciences, University of Verona, Verona, Italy
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Neuman MG, Nanau RM, Shekh-Ahmad T, Yagen B, Bialer M. Valproic acid derivatives signal for apoptosis and repair in vitro. Clin Biochem 2013; 46:1532-7. [DOI: 10.1016/j.clinbiochem.2013.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 06/17/2013] [Accepted: 07/02/2013] [Indexed: 11/26/2022]
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RSE prediction by EEG patterns in adult GCSE patients. Epilepsy Res 2013; 105:174-82. [DOI: 10.1016/j.eplepsyres.2013.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 01/24/2013] [Accepted: 02/16/2013] [Indexed: 11/22/2022]
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Sarkar P, Ibitoye RT, Sturman S, Sarkar PK. First seizure in the adult: management in the emergency department. Br J Hosp Med (Lond) 2013; 74:18-23. [PMID: 23593669 DOI: 10.12968/hmed.2013.74.1.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Pamela Sarkar
- Department of Infectious Diseases/Genito-Urinary Medicine, St George's Hospital NHS Trust, London SW17 0QT.
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Brigo F, Storti M, Del Felice A, Fiaschi A, Bongiovanni LG. IV Valproate in generalized convulsive status epilepticus: a systematic review. Eur J Neurol 2011; 19:1180-91. [PMID: 22182304 DOI: 10.1111/j.1468-1331.2011.03606.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Aim of this review was to evaluate efficacy and safety of intravenous valproate (IV VPA) in the treatment of generalized convulsive status epilepticus (GCSE) in patients of any age, synthesizing available evidences from randomized controlled trials (RCTs). RCTs on IV VPA administered in patients (no age restriction) for GCSE at any stage were searched in MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials. Studies were selected and data independently extracted. Following outcomes were considered: clinical seizure cessation after drug administration, seizure freedom at 24 h, and adverse effects. Outcomes were assessed using standard methods to calculate risk ratio (RR) with 95% confidence intervals. Five trials met inclusion criteria. Two different comparisons were available (IV VPA versus phenytoin (PHT), IV VPA versus IV Diazepam), but only the former included more than one study with enough information to permit a meta-analysis. Compared with PHT, VPA had statistically lower risk of adverse effects (RR 0.31, 95% CI 0.12-0.85), with no differences in GCSE cessation after drug administration (RR 1.31, 95% CI 0.93-1.84) and in seizure freedom at 24 h (RR 0.96, 95% CI 0.88-1.06). This review suggests that IV VPA has a better tolerability than PHT in treatment of GCSE, without any statistically significant differences in terms of efficacy. More rigorous RCTs of VPA versus an appropriate comparator, in a well-defined population with a systematic definition of SE, are however required to conclude about efficacy and tolerability of VPA in clinical practice.
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Affiliation(s)
- F Brigo
- Department of Neurological, Neuropsychological, Morphological and Movement Sciences, Section of Clinical Neurology, University of Verona, Verona, Italy.
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