Lorazepam and Diazepam are both great for pediatric status epileptics

Continuing onward with the top ten articles presented at the recent AAP NCE in San Diego is a randomized control trial comparing lorazepam versus diazepam for pediatric status epilepticus.

Lorazepam vs Diazepam for Pediatric Status Epilepticus

James M. Chamberlain, MD; Pamela Okada, MD, Maija Holsti, MD; Prashant Mahajan, MD, MBA, Kathleen M. Brown, MD, Cheryl Vance, MD, Victor Gonzalez, MD, Richard Lichenstein, MD, Rachel Stanley, MD, MPH, David C. Brousseau, MD, MPH, Joseph Grubenhoff, MD, Roger Zemek, MD, David W. Johnson, MD, Traci E. Clemons, PhD, Jill Baren, MD, MPH, for the Pediatric Emergency Care Applied Research Network (PECARN). JAMA, 2014
Links PubMed JAMA

The bottom line

Lorazepam and diazepam are equally efficacious and safe choices for the treatment of status epilepticus in pediatric patients.

What they did

The authors conducted a double blind RCT over 4 years for patient between 3 months and 18 years with status epilepticus. The study included 273 patients; 140 randomized to 0.2mg/kg of IV diazepam and 133 randomized to 0.1mg/kg of IV lorazepam. The dose of each drug was repeated at 5 minutes, followed by fosphenytoin if there was no cessation of seizures. The primary outcome was stoppage of seizures at 10 minutes without recurrence by 30 minutes.

  • Seizures stopped by 10 minutes in 101/140 (72.1%) of the diazepam group and 97/133 (72.9%) of the lorazepam group – a risk difference of 0.8% (95% CI, −11.4% to 9.8%)
    • No difference in efficacy regardless of etiology (febrile seizures vs not etc,.)
  • The median time to termination of status epilepticus with diazepam was 2.5 minutes and 2.0 minutes in lorazepam – The difference was not significant (P = .80)
  • 26 in each group required assisted ventilation – risk difference, 1.6 (95% CI, −9.9% to 6.8%)
  • Lorazepam patients were more likely to be sedated (66.9% vs 50%,) – absolute risk difference, 16.9% (95% CI, 6.1% to 27.7%)
  • Approximately 10% of patients in both groups had recurrent seizures in 60 minutes, and just under 40% recurred in 4 hours!
  • The only statistically significant difference between treatment groups in any of the secondary outcomes was in the incidence of sedation, which occurred in 81 of 162 diazepam patients (50%) and 99 of 148 lorazepam patients (66.9%) (absolute risk difference, 16.9%; 95% CI, 6.1%-27.7%)
    • The corollary of the above was that there was a significant difference favoring diazepam arm in time to return to baseline mental status (hazard ratio, 1.96; 95% CI, 1.35-2.84; P = .0004); eFigure 3 in Supplement)

What you can do

  • Know that both IV lorazepam and diazepam will stop seizures in status epilepticus by 10 minutes in over 70% of patients
  • Conversely, once seizures get going it is sometimes difficult to stop them, and a second dose is often warranted.
  • Include prehospital dose(s) in your management plans – this can include Diastat at home and EMS administered therapies
  • If you are writing an algorithm or protocol – especially for prehospital purposes – remember to keep things simple. Know what drugs are available and also that you should probably make a single recommendation to keep things straightforward.
By | 2016-12-14T12:56:49+00:00 January 5th, 2015|Article Reviews, Neurology|

About the Author:

Brad Sobolewski, MD, MEd is an Associate Professor of Pediatric Emergency Medicine and an Assistant Director for the Pediatric Residency Training Program at Cincinnati Children's Hospital Medical Center. He is on Twitter @PEMTweets and authors the Pediatric Emergency Medicine site PEMBlog. All views are strictly my own and not official medical advice.