Seizure control best with sequential second line treatment


By Mardi Chapman

3 May 2019

Sequential treatment with phenytoin and levetiracetam in the second-line treatment of paediatric convulsive status eplilpeticus can reduce the number of children requiring more aggressive management.

A study of more than 200 children presenting to 13 emergency departments in Australia and New Zealand compared the two drugs in patients who were still symptomatic despite two doses of benzodiazepines.

Seizures were controlled in about 60% of children randomised to phenytoin and 50% of children randomised to levetiracetam.

When the children with persistent seizures were crossed over to receive the alternative drug, seizure control increased to about 75% at two hours.

The study, published in The Lancet, found no significant differences in median time to seizure control, rate or duration of ICU admission or length of hospital stay between the two patient groups.

There was one death in the phenytoin group from haemorrhagic encephalitis, which was not thought to be due to the study drug. No other serious adverse events were recorded.

“Although both drugs were associated with considerable failure rates when given by themselves, treatment with one drug and then the other reduced the failure rate by more than 50%, at the expense of only an additional 10 min (compared with giving phenytoin alone),” the study investigators said.

“Clinicians should therefore consider sequential use of phenytoin and levetiracetam, or levetiracetam and phenytoin, for management of paediatric convulsive status epilepticus before moving on to RSI and intubation.”

Professor Stuart Dalziel, from the Departments of Surgery and Paediatrics at the University of Auckland and paediatric emergency medicine specialist at Auckland’s Starship Children’s Hospital, told the limbic there were no barriers to sequential use of the two medications in Australia or New Zealand.

“While levetiracetam is more expensive, this is a very small cost in the overall treatment of the disease, particularly if the use of levetiracetam avoids intensive care unit admission,” he said.

He added that the research has highlighted two obvious gaps for further investigation.

“The first, can medications be given earlier by paramedics in order to terminate the seizures early?”

“Secondly, there still remains a very resistant group of patients in whom none of the current first and second line strategies appear to work. Can this group of patients be identified earlier and managed more aggressively to control their seizure activity?”

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