Consider Levetiracetam for Benzo-Resistant Status Epilepticus

New evidence will renew debate about which med to use for status epilepticus patients who DON'T respond to a benzodiazepine.

Continue to first optimize the benzo dose...such as giving up to 8 mg of lorazepam.

There are several recommended options to try next...but many hospitals use IV fosphenytoin due to long-standing experience.

Now evidence suggests fosphenytoin, levetiracetam, and valproic acid are equally effective at stopping convulsive status epilepticus...including in the elderly and kids age 2 and older.

Standardize practice and use the agent you can access the fastest. The longer status epilepticus continues, the more likely it is to be unresponsive to meds...and cause neurological damage.

Consider using levetiracetam. Storing its commercially available premade bags or vials for IV push on the unit can save time...instead of having to prep loading doses of other meds.

Plus levetiracetam has fewer interactions or adverse effects.

If you know a patient has missed doses of their maintenance antiepileptic, it's okay to use that agent. But feel comfortable giving a dose of levetiracetam acutely if you can start it faster.

Use high doses for status epilepticus. For example, give levetiracetam 60 mg/kg...up to 4,500 mg. Feel comfortable infusing this dose over as little as 10 minutes...based on recent evidence.

But administration can be challenging, since many adults will need 3 premade 1,500 mg levetiracetam bags...or 9 vials. Use EHR alerts to help avoid errors, such as inadvertently giving just 1 bag.

If an antiepileptic doesn't work, don't generally try a different one...they're not often effective third-line. Instead, typically move to a propofol or midazolam infusion to stop seizures.

See our chart, Pharmacotherapy of Status Epilepticus, for more on ketamine and other options for refractory patients.

Key References

  • N Engl J Med 2019;381(22):2103-13
  • Epilepsy Curr 2016;16(1):48-61
  • Neurocrit Care 2012;17(1):3-23
Hospital Pharmacist's Letter. February 2020, No. 360219

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