By Eleanor McDermid, Senior medwireNews Reporter
A study comparing outcomes among patients treated with first-line lorazepam, midazolam or clonazepam for status epilepticus finds that the three drugs are broadly equivalent.
“We were pretty happy to find that, because we use clonazepam every day in Switzerland”, Vincent Alvarez (Hôpital du Valais, Sion, Switzerland) told delegates at the European Academy of Neurology congress in Berlin, Switzerland.
He noted that clonazepam is also easy to use, because it does not need to be stored cold.
The study, which compared patients in three US centres, where lorazepam is the preferred first-line treatment, to those in a Swiss centre, where clonazepam is the recommended first-line agent due to previous unavailability of lorazepam.
Alvarez said that although benzodiazepines are the recommended first-line treatment for status epilepticus, there is only strong evidence for lorazepam and midazolam, whereas only two, fairly old, published studies offer evidence for clonazepam.
In total, 72 patients in the current study received clonazepam as a first-line agent, 82 received lorazepam and 23 were given midazolam.
The researchers found a large difference in the proportion of patients who were refractory to each drug, with 50.85% and 42.86% requiring a different anti-epileptic drug (AED) after use of clonazepam and midazolam, respectively, compared with 89.47% after use of lorazepam.
However, they also found that while 72% of patients given clonazepam and about half of those given midazolam received a sufficient loading dose according to current guidelines, this was only the case for 12% of patients given lorazepam.
Nonetheless, after accounting for this factor, patients remained a significant 6.4-fold more likely to be refractory to lorazepam than clonazepam, while there was no significant different between refractoriness to clonazepam and midazolam.
Other factors, including time to treatment, STatus Epilepticus Severity Score and aetiology did not differ between refractory and non-refractory patients.
There was a similar pattern for the number of AEDs needed, with patients 4.35-fold more likely to need a larger number of AEDs if they received lorazepam than if they received clonazepam, but no more likely if they received midazolam. But only severity score and aetiology predicted mortality.
Alvarez highlighted the frequent underdosing of lorazepam found in the study, which he said added to other observational studies showing that guidelines for status epilepticus are “poorly followed in daily-life practice.”
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