Individual research recommendation details

Recommendation ID

CG137/4

Question

Treatment of convulsive status epilepticus (that is, not just refractory): What is the most effective and safest AED to treat:

• established (usually lasting longer than 30 minutes) convulsive status epilepticus

• refractory convulsive status epilepticus?

Any explanatory notes
(if applicable)

Convulsive status epilepticus (CSE) should be treated as an emergency. The most important aspect of treatment is to try to stop the seizure. Prompt, successful treatment of CSE avoids the need for admission to an intensive care unit (ICU). The most commonly used medication is phenytoin. This should be used with care and close monitoring because of the risk of hypotension and cardiac arrhythmia. Sodium valproate and levetiracetam are potentially as effective and safer alternatives but there are very limited comparative data.

CSE that is refractory to first-line treatment (RCSE) is rare and often complicated by irreversible neurological and intellectual sequelae, including death. Reasons for these complications include the underlying cause of RCSE, its duration and management. The majority, if not all patients with RCSE are managed in an ICU. There are no agreed drugs or treatment protocols for treating RCSE. The three most commonly used anticonvulsants are thiopental sodium, midazolam and propofol (propofol is rarely used in children). Data on treatment in children, young people and adults are limited and anecdotal. A recently completed 2-year audit of everyone younger than 16 years with RCSE treated in an ICU in England, Wales and Scotland will provide unique epidemiological data on paediatric RCSE, its causes and current management. These data could be used to design a randomised controlled trial (RCT) of specific drug treatments and protocols.

The research should include:

• a multicentre randomised comparative trial of intravenous levetiracetam, sodium valproate and phenytoin in initial treatment of status epilepticus

• a multicentre RCT of treatment of refractory status epilepticus in ICUs, including midazolam and thiopental sodium (and propofol in adults)

• primary outcome of cessation of CSE

• secondary outcomes including recurrence within a designated period (probably 12 hours), mortality and morbidity

• cost data including treatment costs and days in intensive care.

Source guidance details

Comes from guidance

Epilepsies: diagnosis and management

Number

CG137

Date issued

January 2012

Other details