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Sharshar T, Porcher R, Asfar P, Grimaldi L, Jabot J, Argaud L, Lebert C, Bollaert PE, Harlay ML, Chillet P, Maury E, Santoli F, Blanc P, Sonneville R, Vu DC, Rohaut B, Mazeraud A, Alvarez JC, Navarro V, Clair B, Outin H, Azabou E, Beloncle F, Ben-Hadj O, Blanc P, Bollaert PE, Bolgert F, Bouadma L, Chillet P, Clair B, Corne P, Clere-Jehl R, Cour M, Crespel A, Déiler V, Dellamonica J, Demeret S, Harley ML, Henry-Lagarrigue M, Jabot J, Heming N, Hernu R, Kouatchet A, Lebert C, Lerolle N, Maury E, Letrou S, Mazeraud A, Mercat A, Mortaza S, Mourvillier B, Outin H, Paugham-Burtz C, Pierrot M, Provent M, Rohaut B, De La Salle S, Santoli F, Schenk M, Siami S, Souday V, Sharshar T, Sonneville R, Timsit JF, Thuong M, Weiss N. Valproic acid as adjuvant treatment for convulsive status epilepticus: a randomised clinical trial. Crit Care 2023; 27:8. [PMID: 36624526 PMCID: PMC9830759 DOI: 10.1186/s13054-022-04292-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Generalised convulsive status epilepticus (GCSE) is a medical emergency. Guidelines recommend a stepwise strategy of benzodiazepines followed by a second-line anti-seizure medicine (ASM). However, GCSE is uncontrolled in 20-40% patients and is associated with protracted hospitalisation, disability, and mortality. The objective was to determine whether valproic acid (VPA) as complementary treatment to the stepwise strategy improves the outcomes of patients with de novo established GCSE. METHODS This was a multicentre, double-blind, randomised controlled trial in 244 adults admitted to intensive care units for GCSE in 16 French hospitals between 2013 and 2018. Patients received standard care of benzodiazepine and a second-line ASM (except VPA). Intervention patients received a 30 mg/kg VPA loading dose, then a 1 mg/kg/h 12 h infusion, whilst the placebo group received an identical intravenous administration of 0.9% saline as a bolus and continuous infusion. Primary outcome was proportion of patients discharged from hospital by day 15. The secondary outcomes were seizure control, adverse events, and cognition at day 90. RESULTS A total of 126 (52%) and 118 (48%) patients were included in the VPA and placebo groups. 224 (93%) and 227 (93%) received a first-line and a second-line ASM before VPA or placebo infusion. There was no between-group difference for patients hospital-discharged at day 15 [VPA, 77 (61%) versus placebo, 72 (61%), adjusted relative risk 1.04; 95% confidence interval (0.89-1.19); p = 0.58]. There were no between-group differences for secondary outcomes. CONCLUSIONS VPA added to the recommended strategy for adult GCSE is well tolerated but did not increase the proportion of patients hospital-discharged by day 15. TRIAL REGISTRATION NO NCT01791868 (ClinicalTrials.gov registry), registered: 15 February 2012.
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Affiliation(s)
- Tarek Sharshar
- grid.508487.60000 0004 7885 7602Neuro-Intensive Care Medicine, Anaesthesiology and ICU Department, GHU-Psychiatry and Neurosciences, Pole Neuro, Sainte-Anne Hospital, Institute of Psychiatry and Neurosciences of Paris, INSERM U1266, Université Paris Cité, Paris, France
| | - Raphaël Porcher
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004 Paris, France ,grid.411394.a0000 0001 2191 1995Centre d’Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004 Paris, France
| | - Pierre Asfar
- grid.411147.60000 0004 0472 0283Department of Medical Intensive Care, University Hospital, Angers, France
| | - Lamiae Grimaldi
- grid.50550.350000 0001 2175 4109Clinical Research Unit, Assistance Publique - Hôpitaux de Paris University Paris-Saclay. Faculty of medicine, University of Versailles Saint-Quentin en Yvelines. Inserm U1018 Team Anti-infective evasion and pharmacoepidemiology, Boulogne-Billancourt, France
| | - Julien Jabot
- Medical-Surgical Intensive Care Unit, CHU Felix-Guyon, Saint-Denis, La Réunion, France
| | - Laurent Argaud
- grid.412180.e0000 0001 2198 4166Service de Médecine Intensive-Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Christine Lebert
- grid.477015.00000 0004 1772 6836Médecine Intensive Réanimation, Centre Hospitalier Départemental de Vendée, La Roche-sur-Yon, France
| | - Pierre-Edouard Bollaert
- grid.29172.3f0000 0001 2194 6418CHRU-Nancy, Service de Médecine Intensive Réanimation, Université de Lorraine, 54000 Nancy, France
| | - Marie Line Harlay
- grid.412201.40000 0004 0593 6932Médecine Intensive Réanimation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Patrick Chillet
- Service de Médecine Intensive - Réanimation, Centre hospitalier Léon Bourgeois, Châlons en Champagne, France
| | - Eric Maury
- grid.462844.80000 0001 2308 1657Service de Médecine Intensive et Réanimation Hôpital Saint-Antoine, Paris-Sorbonne Université, Paris, France
| | - Francois Santoli
- grid.414308.a0000 0004 0594 0368Médecine Intensive—Réanimation, Centre Hospitalier Robert Ballanger, Aulnay sous Bois, France
| | - Pascal Blanc
- grid.440383.80000 0004 1765 1969Réanimation Médico Chirurgicale, Centre Hospitalier René Dubos, Pontoise, France
| | - Romain Sonneville
- Université de Paris Cité, INSERM UMR1137, Paris, France ,grid.411119.d0000 0000 8588 831XAPHP Nord, Médecine Intensive – Réanimation, Hôpital Bichat—Claude Bernard, Paris, France
| | - Dinh Chuyen Vu
- General Intensive Care Unit, Sud-Essonne Hospital, Etampes, France
| | - Benjamin Rohaut
- grid.462844.80000 0001 2308 1657Department of Neurology, Neuro-ICU & Brain institute - ICM, Pitié-Salpêtrière Hospital APHP, Sorbonne Université, Paris, France
| | - Aurelien Mazeraud
- grid.508487.60000 0004 7885 7602Anaesthesiology and ICU Department, GHU-Psychiatry and Neurosciences, Pole Neuro, Sainte-Anne Hospital, Perception and Memory Unit, Neurosciences Department, Institut Pasteur, Université Paris Cité, Paris, France
| | - Jean-Claude Alvarez
- grid.12832.3a0000 0001 2323 0229Department of Pharmacology and Toxicology, Inserm U-1173, Raymond Poincare Hospital, AP-HP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, 104 Boulevard Raymond Poincare, 92380 Garches, France
| | - Vincent Navarro
- grid.425274.20000 0004 0620 5939AP-HP, Epilepsy Unit, Pitié-Salpêtrière Hospital, Sorbonne Université, and Paris Brain Institute, Paris, France
| | - Bernard Clair
- grid.12832.3a0000 0001 2323 0229General Intensive Care Unit, APHP, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Hervé Outin
- grid.418056.e0000 0004 1765 2558Intensive Care Unit Centre Hospitalier Intercommunal, Poissy/Saint-Germain-en-Laye, France
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