New study suggests levetiracetam for epileptic seizures in children when benzodiazepines fail
Tuesday, May 14, 2019
Emergency department (ED) doctors now have a better way to treat status epilepticus in pediatric patients that fails first-line benzodiazepine treatment, according to the results of a new study.
Prolonged epileptic seizures are a common, and potentially fatal, pediatric neurological emergency, with an estimated incidence of 18 to 23 per 100,000 children annually and a mortality rate of 2 to 7%.
Up to 5% of affected children die, and a third suffer long-term complications associated with brain damage. As a rule of thumb, the longer the status epilepticus seizure, the greater the chance of long-term complications.
ED clinicians typically treat status epilepticus with benzodiazepines, followed as necessary with phenytoin, but this approach often leads to intubation and ventilation. Now, the results of a study from researchers in New Zealand and Australia suggest there is a better way to treat severe epileptic seizures in children, and the results of the study will likely change how ED doctors around the world manage status epilepticus in pediatric patients.
Comparing Levetiracetam with Phenytoin as the Second Line of Status Epilepticus Treatment
Benzodiazepines are the first line of treatment of severe seizures, but the medication only stops seizures in 40 to 60% of patients. Phenytoin (Dilantin) is currently the second line of treatment, but researchers have never assessed the practice in a major and robust randomized controlled trial. Furthermore, phenytoin is associated with a number of serious complications.
Researchers compared phenytoin with levetiracetam as the second line of treatment for seizures. Children who continue seizing after receiving phenytoin typically need intubation, sedation and placement on a ventilator in intensive care.
Levetiracetam is a newer anticonvulsant routinely used daily to prevent seizures; its side effects are much less severe. It has never undergone proper testing against phenytoin for the treatment of severe prolonged seizures, though, which underscores the importance of this study.
The research covered 13 emergency departments at hospitals in Aotearoa New Zealand and Australia, and it involved 233 pediatric patients aged between three months and 16 years.
The team of scientists found that phenytoin and levetiracetam were equally as good when given individually: both had a 50 to 60% success rate at stopping a prolonged seizure. They also found that treatment with one drug and then the other boosted the success rate to approximately 75%. Administering the two medications consecutively may potentially reduce the number of ventilated children by as much as half.
"This study has now given us robust evidence to manage children with prolonged seizures without reverting to intubation and intensive care," says the leader of the study, Dr. Stuart Dalziel, who is professor of emergency medicine and paediatrics in the Departments of Surgery and Paediatrics at the University of Auckland.
"By controlling seizures in the emergency department we will increase the chance of these children recovering more quickly and returning back to their normal lives," he says. "This research has already changed practice and led to new guidelines in New Zealand and Australia."
"This study is going to profoundly improve treatment for children who are critically ill with epilepsy around the world," says the lead author of the study, Professor Franz Babl, who is also professor of paediatric emergency medicine at the University of Melbourne.
The Health Research Council of New Zealand funded the research. The researchers published their results in the medical journal The Lancet.
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