Epilepsy - Treatment

Treatment of Status Epilepticus

The treatment goals of status epilepticus are the following:

Stop the seizures.
Prevent recurrence.
Determine and prevent any factors that might have triggered it.
Manage any complications.

Initial Management. The earlier a patient is treated, the better the results. In one study, seizures stopped in 80% of patients who were treated within 30 minutes. Only 40% of patients responded when they were treated after two hours. Initial management of status epilepticus consists of the following:

Administer any seizure medications.
Support systems to maintain or attain normal breathing, blood pressure, electrolyte balances, body temperature, and heart functions.
Oxygen for patients who may need it.
Attention by medical personnel trained to determine any treatable cause of status epilepticus, such as drug withdrawal, low blood sugar, infection, substance abuse (particularly cocaine), or eclampsia (elevated blood pressure induced by pregnancy).

Medications for Status Epilepticus. One or more of the following medications may be used initially:

Benzodiazepine. An intravenously (IV) administered or injected benzodiazepine such as lorazepam (Ativan), diazepam (Valium), clonazepam, or midazolam (Versed) is usually used. Lorazepam or clonazepam is now preferred since they have a longer duration of action. Of note, midazolam is the only benzodiazepine available as a muscular injection. It may prove to be effective for children, as safe as other benzodiazepines, and safer than barbiturates. Intravenous diazepam is currently the first choice for children with status epilepticus. Rectal administration of benzodiazepines, either diazepam or lorazepam, may also be beneficial. Some evidence suggests that rectal administration of lorazepam is safer and more effective than diazepam in children, but more research is needed.
Phenytoin or Fosphenytoin. Many doctors use phenytoin or fosphenytoin if seizures are not controlled by a benzodiazepine. These drugs must be prescribed with caution for patients who have liver and blood abnormalities or certain heart arrhythmias. Fosphenytoin works faster, and is safer than phenytoin.
Phenobarbital. Although effective, barbiturates, such as phenobarbital (Barbita, Luminal), can reduce consciousness, blood pressure, and respiratory rate. They are generally used only when other drugs have failed.

Other medications or higher doses of the above-mentioned drugs may be used for status epilepticus patient who fail to respond to initial treatments. They include:

Higher-dose barbiturates.
Higher-dose intravenous benzodiazepines. In one study midazolam, the injected benzodiazepine, was as effective and possibly safer than propofol, an intravenous sedative also used for uncontrolled status epilepticus.
Propofol (Diprivan), an intravenously administered sedative. A 2003 analysis of 22 studies suggested that this drug poses an increased risk of mortality. Experts recommended that this drug not be used routinely until better trials have been performed.

All of the medications mentioned carry a risk for hypotension, an abrupt and possibly dangerous drop in blood pressure, which may require treatment.