Second-Line Home Therapy Outcomes in Patients With Status Epilepticus - Neurology Advisor

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Allocation of a second-line home medication for patients with refractory convulsive status epilepticus did not have an effect on clinical seizure cessation, according to study results published in Neurology.

Up to half of patients with status epilepticus are benzodiazepine non-responders. As this is the standard first-line therapy, there remains an urgent need for determining which second-line therapies effectively reduce seizures. The objective of the current study was to determine whether a second-line anticonvulsant medication that is part of a patient's home regimen can influence outcomes for patients with benzodiazepine- refractory convulsive status epilepticus.

Researchers conducted a tertiary analysis of the Established Status Epilepticus Treatment Trial which was a double-blind comparative study. Patients (N=232) with status epilepticus who presented at 57 emergency departments in the United States with ongoing convulsive seizures were randomized to receive 60 mg/kg levetiracetam, 20 mg/kg fosphenytoin, or 40 mg/kg valproate. Use of the randomized medication at home was associated with the primary outcome of clinical seizure cessation and improved consciousness at 60 minutes.

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A total of 89 participants used their medication at home and 143 used nonhome medications. The home and nonhome medication cohorts were aged mean 33 (standard deviation [SD], 26) and 30 (SD, 24) years, 56% and 60% were men or boys, and 47% and 46% were Black, respectively.

Patients reported taking levetiracetam only (74%), levetiracetam and valproate (7%), valproate only (7%), levetiracetam and phenytoin (6%), phenytoin only (5%), and phenytoin and valproate (1%).

Seizure cessation within 60 minutes was reported by 44% who took their allocated home medication and 53% who took a nonhome medication (odds ratio [OR], 0.69; 95% CI, 0.40-1.17; P =.17). Adjudicated seizure cessation was achieved by 42% of the home medication and 57% of the nonhome medication cohorts (OR, 0.53; 95% CI, 0.31-0.90; P =.02).

No significant differences were observed for adverse effects, except more in the home group had acute seizure recurrence 60 minutes to 12 hours after drug infusion (20% vs 10%; P =.05).

This study was limited by the fact that this secondary analysis was not prespecified in the original trial design.

These data indicated that there were no clear differences in these second-line therapies for refractory convulsive status epilepticus.

"However, the significant benefit seen on the secondary adjudicated outcome and the direction of the point estimates on the primary outcome suggests that it may be preferable to treat those who present in status epilepticus with a nonhome anticonvulsant," the researchers wrote. "Selecting a nonhome anticonvulsant medication could inform a novel and practical approach to a key therapeutic decision, often under the clinician's immediate control at the bedside, with potential to improve outcomes for patients with status epilepticus."

Reference

Wabl R, Terman SW, Kwok M, et al. Efficacy of Home Anticonvulsant Administration for Second-Line Status Epilepticus Treatment. Neurology. Published online June 29, 2021. doi:10.1212/WNL.0000000000012414

Topics:

Epilepsy Seizure Disorders

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