Nasal rather than rectal benzodiazepines in the management of acute childhood seizures?

Midazolan nasal no tratamento de crises convulsivas

Pacientes com crises agudas incluindo estado de mal epiléptico, podem apresentar dificuldades no tratamento que geralmente envolve um benzodiazepínico. As drogas mais amplamente utilizadas em pacientes com crises agudas incluem diazepam, lorazepam e midazolam. Nós revisamos a eficácia e a segurança das diversas formas de administração do midazolam. A administração intranasal e bucal do midazolam pode ser uma alternativa a administração retal e intravenosa do diazepam.

Buccal midazolam or rectal diazepam for treatment of residential adult patients with serial seizures or status epilepticus

OBJECTIVES

To compare the efficacy and tolerability of buccal midazolam with rectal diazepam as emergency treatment in residential adults with convulsive or non-convulsive serial seizures or status epilepticus (SE), and ascertain the preference between the two treatment options among the patients and the nursing staff.

MATERIALS AND METHODS

  The nursing staff of our residential epilepsy centre treated 80 episodes of serial seizures or SE lasting more than 5 min alternating with rectal diazepam or buccal midazolam. The dose of each study drug was tailored individually. The primary outcome measure was defined as cessation of seizure activity within 10 min without seizure relapse within 2 h.

RESULTS

Convulsive SE was treated promptly, after a mean of 6.2 min, and terminated faster with buccal midazolam than with rectal diazepam; i.e. after a mean of 2.8 vs 5.0 min, respectively (n = 0.012). The other subcategories of emergency situations were treated after a mean of 25.0 min, and the seizure activity ceased after a mean of 7.4 min in the diazepam group and 7.6 min in the midazolam group (NS). The success rate was 83.3% in the diazepam group and 74.4% in the midazolam group (NS). The difference was mostly due to slightly more seizure relapses during the first 2 h in the midazolam group. Both treatment options were well tolerated, temporary tiredness being the most frequently occurring adverse effect. All the nursing staff and six of the seven patients who gained experience with both treatment options favoured the buccal route.

CONCLUSIONS

  Buccal midazolam appeared to be at least as effective as rectal diazepam with little or no side effects. The buccal administration was easy to handle and socially more acceptable than the rectal route.

Intranasal midazolam as an alternative to general anaesthesia in the management of children with oral and maxillofacial trauma

The study assessed the dosage, clinical sedative effect, and safety of intranasal midazolam in 32 children. Data were complete for 29 patients (21 with lacerations and 8 cases of dental trauma). Sedation was adequate to ensure successful completion of treatment under local with or without topical anaesthetic in 22 of the 29 cases (76%). They became sedated at a mean (SD) of 14 (5) minutes, with completion of treatment at 20 (13) minutes. Sedation was achieved with a mean (SD) of 5 (2)mg of midazolam. There were no signs of respiratory depression or of oxygen desaturation below 94% on pulse oximetry. No supplemental oxygen was required and there were no other complications. We conclude that intranasal midazolam is a safe and effective alternative to general anaesthesia in the definitive treatment of children with oral and maxillofacial injuries.

Is intranasal midazolam an effective rescue medication in adolescents and adults with severe epilepsy?

The aim of this study was to determine whether intranasal midazolam is a safe and effective rescue medication in adolescent and adult patients with severe epilepsy. This field trial was designed to test the feasibility of the use of intranasal midazolam as an alternative to rectal diazepam in a cohort of patients with severe epilepsy who require rescue medication as part of their treatment. A dose of intranasal midazolam (5 mg if the patient weighed less than 50 kg and 10 mg if the patient weighed over 50 kilograms) was prescribed for those who had previously responded to other rescue medication. Midazolam was prescribed buccally if excessive head movement accompanied seizures. The protocol reverted to the usual rescue medication if there was no response to midazolam within 10 minutes. Vital signs were monitored for half an hour following the administration of the treatment. Twenty-two patients received 84 treatment episodes and 79 of these were considered clinically effective. Five treatment failures were recorded, three due to poor technique in delivering the midazolam. Two patients were successfully retried on midazolam and a third is awaiting a retrial of this drug. The two other treatment failures received the drug buccally. In the first patient the clinical opinion was that this was possibly a psychogenic non-epileptic seizure. The other patient responded initially, but within an hour had another seizure requiring further rescue treatment. No significant adverse effects were reported. Our study shows that intranasal midazolam, when used appropriately, is an effective treatment in those who require rescue treatment. There are clear advantages in the use of midazolam over diazepam in the treatment of acute seizures. These include the favourable pharmacokinetic and pharmacodynamic properties of midazolam as well as the potential of a more acceptable and dignified administration route.

Comparison of intranasal midazolam with intravenous diazepam for treating febrile seizures in children: prospective randomised study

OBJECTIVE

To compare the safety and efficacy of midazolam given intranasally with diazepam given intravenously in the treatment of children with prolonged febrile seizures.

DESIGN

Prospective randomised study.

SETTING

Paediatric emergency department in a general hospital.

SUBJECTS

47 children aged six months to five years with prolonged febrile seizure (at least 10 minutes) during a 12 month period.

INTERVENTIONS

Intranasal midazolam (0.2 mg/kg) and intravenous diazepam (0.3 mg/kg).

MAIN OUTCOME MEASURES

Time from arrival at hospital to starting treatment and cessation of seizures.

RESULTS

Intranasal midazolam and intravenous diazepam were equally effective. Overall, 23 of 26 seizures were controlled with midazolam and 24 out of 26 with diazepam. The mean time from arrival at hospital to starting treatment was significantly shorter in the midazolam group (3.5 (SD 1.8) minutes, 95% confidence interval 3.3 to 3.7) than the diazepam group (5.5 (2.0), 5.3 to 5.7). The mean time to control of seizures was significantly sooner (6.1 (3.6), 6.3 to 6.7) in the midazolam group than the diazepam group (8.0 (0.5), 7. 9 to 8.3). No significant side effects were observed in either group.

CONCLUSION

Seizures were controlled more quickly with intravenous diazepam than with intranasal midazolam, although midazolam was as safe and effective as diazepam. The overall time to cessation of seizures after arrival at hospital was faster with intranasal midazolam than with intravenous diazepam. The intranasal route can possibly be used not only in medical centres but in general practice and, with appropriate instructions, by families of children with recurrent febrile seizures at home.

Buccal midazolam and rectal diazepam for treatment of prolonged seizures in childhood and adolescence: a randomised trial

BACKGROUND

Convulsive status epilepticus is the most common neurological medical emergency and has high morbidity and mortality. Early treatment before admission to hospital is best with an effective medication that can be administered safely. We aimed to find out whether there are differences in efficacy and adverse events between buccal administration of liquid midazolam and rectal administration of liquid diazepam in the acute treatment of seizures.

METHODS

At a residential school with on-site medical facilities 42 young people with severe epilepsy were enrolled. Continuous seizures of more than 5 min duration were randomly treated with buccal midazolam or rectal diazepam. If the seizure did not stop within 10 min additional medication chosen by the attending physician was administered. We monitored oxygen saturation and blood pressure for 30 min after treatment. The main outcome measures were efficacy, time from arrival of the nurse to drug administration, time from drug administration to end of seizure, and incidence of adverse cardiorespiratory events.

FINDINGS

Buccal midazolam was used to treat 40 seizures in 14 students, and rectal diazepam 39 seizures in 14 students. Midazolam stopped 30 (75%) of 40 seizures and diazepam 23 (59%) of 39 (p=0.16). The median time from arrival of the nurse to administration of medication was 2 min. Time from administration to end of seizure did not differ significantly between the two treatments. No clinically important adverse cardiorespiratory events were identified in the two groups. Buccal midazolam was universally acceptable to the nursing and care staff.

INTERPRETATION

Buccal midazolam is at least as effective as rectal diazepam in the acute treatment of seizures. Administration via the mouth is more socially acceptable and convenient and may become the preferred treatment for long seizures that occur outside hospital.

Midazolam via the intranasal route: an effective rescue medication for severe epilepsy in adults with learning disability

People with a learning disability are often disadvantaged due to the nature of their disability. Up to a third are likely to have concomitant epilepsy which adds to the health loss experienced by this group. It is important to manage their epilepsy in such a way as to limit the debilitating effects of both the illness and the medication. Rectal diazepam remains the gold standard rescue medication for prolonged, recurrent seizures or seizures associated with hypoxia. Some of the drawbacks are highlighted in this paper and we go on to explore a novel means of treating these seizures. Midazolam, via the intranasal route, has been used extensively in children, mostly as a sedative but also in the treatment of epilepsy. We present two cases, both are adults with a learning disability, who have benefited significantly from the use of intranasal midazolam. Ongoing research into the safe use of this form of treatment, training of staff and carers and the impact on the individual is being conducted.

Buccal absorption of midazolam: pharmacokinetics and EEG pharmacodynamics

PURPOSE

To determine whether buccal/sublingual administration of midazolam (MDL) would lead to detectable venous concentrations and EEG changes in 10 healthy volunteers.

METHODS

The study consisted of an open-label and a double-blind phases. Subjects held 10 mg MDL in 2 ml peppermint-flavored fluid or peppermint-flavored placebo in their mouth for 5 min and then spat it out. Cardiorespiratory and EEG monitoring was performed in all subjects.

RESULTS

Venous MDL concentrations measured on 10 occasions from 5 to 600 min after administration showed a rapid increase for the first 20-30 min. However, changes in the 8- to 30-Hz frequencies identified by spectral analysis of the EEG showed changes in < or = 5-10 min in test but not in control subjects--more rapid than were expected from the venous absorption data. There were no significant adverse effects.

CONCLUSIONS

Our data provide direct evidence of the speed of cerebral effect of a drug. Our results suggest that the buccal/sublingual route of administration should be tested in emergency treatment of seizures as an alternative to the rectal route, over which it has clear practical advantages.

Status epilepticus in children and adults

Status epilepticus (SE) in children and adults is one of the most common neurology problems confronting the intensivist. Recognition of SE is usually straightforward, but may be complicated by the effects of other diseases or therapies. Emergent treatment is necessary to prevent further brain damage. This article reviews protocols for standard treatments of SE patients and includes recommendations for the management of refractory SE.