Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children

Appleton, Richard; MacLeod, S. M.; Martland, Timothy

doi:10.1002/14651858.cd001905.pub2

Cited by 78 publications

(67 citation statements)

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“…Updated Cochrane review provides some evidence to support the use of intravenous lorazepam in the management of acute tonic clonic convulsions in childhood. It is as effective as and safer than intravenous diazepam in treating acute tonic-clonic convulsions and SE in children [20]. It also provides evidence to support the use of buccal midazolam as the first line treatment of an acute tonic-clonic convulsion and convulsive SE in childhood where intravenous access is not available [20].…”

Section: Resultsmentioning

confidence: 94%

“…It is as effective as and safer than intravenous diazepam in treating acute tonic-clonic convulsions and SE in children [20]. It also provides evidence to support the use of buccal midazolam as the first line treatment of an acute tonic-clonic convulsion and convulsive SE in childhood where intravenous access is not available [20]. This is of particular importance in countries with a high incidence of CNS infectious diseases, where children often present late and in shock (making it difficult to obtain rapid intravenous access) and where intravenous cannula and equipment are in limited supply.…”

Section: Resultsmentioning

confidence: 99%

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Clinical Profile of SE in Children in a Tertiary Care Hospital in Bihar

Kumar¹,

Kumari

Narain

2014

JCDR

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Background: Status epilepticus (SE) is a common, life threatening neurologic disorder that is essentially an acute, prolonged epileptic crisis. SE can represent an exacerbation of a pre-existing seizure disorder, the initial manifestation of a seizure disorder, or an insult other than a seizure disorder.Objectives: To study the aetiology, clinical profile, and outcome of SE in pediatric age group.Setting and study design: Prospective study at a tertiary care medical college hospital in Bihar, India. Materials and methods:Study was carried out for a period of one year (from April 2008 to March 2009). Seventy patients of SE in the age group of six month to 12 years were included in the study. Clinical history, general and systemic examination and relevant investigations along with pretested questionnaire were used to categorise different variables. Independent t-test was used for continuous variables and chi-square test for categorical variables.Results: Mean age for the study population was found to be 5.94 years (SD=3.152). Preponderance of male (60%) over female (40%) was observed. Aetiology included Idiopathic (27.14%), remote symptomatic (20%), acute symptomatic (47.14%), febrile (2.86%) and progressive encephalopathy (2.86%) groups. Generalised tonic clonic convulsion (GTC) convulsion was observed in 91.4% of SE patients while 8.6% had partial SE. Eighteen patients (25.7%) had prior history of convulsion whereas 52 patients (74.3%) presented with SE as first episode of convulsion. In our study, mortality rate was found to be 31.4% and acute symptomatic causes were responsible for most of the deaths.Conclusion: SE is a severe life threatening emergency with substantial morbidity and mortality. Patients with younger age and male sex are slightly more vulnerable to develop SE. Longer duration of SE and acute symptomatic aetiologies are independent predictors for poor outcome.

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Section: Resultsmentioning

confidence: 94%

Section: Resultsmentioning

confidence: 99%

Clinical Profile of SE in Children in a Tertiary Care Hospital in Bihar

Kumar¹,

Kumari

Narain

2014

JCDR

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“…72,73 There may be drugs, other than diazepam, which have an improved benefit-risk ratio when used to treat seizures in children. 74 Further research is therefore warranted to optimise strategies for treating seizures, for both in-hospital and out-of-hospital care.…”

Section: Discussionmentioning

confidence: 99%

ADRIC: Adverse Drug Reactions In Children – a programme of research using mixed methods

Smyth

Peak

Turner

et al. 2014

Programme Grants for Applied Research

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AimsTo comprehensively investigate the incidence, nature and risk factors of adverse drug reactions (ADRs) in a hospital-based population of children, with rigorous assessment of causality, severity and avoidability, and to assess the consequent impact on children and families. We aimed to improve the assessment of ADRs by development of new tools to assess causality and avoidability, and to minimise the impact on families by developing better strategies for communication.Review methodsTwo prospective observational studies, each over 1 year, were conducted to assess ADRs in children associated with admission to hospital, and those occurring in children who were in hospital for longer than 48 hours. We conducted a comprehensive systematic review of ADRs in children. We used the findings from these studies to develop and validate tools to assess causality and avoidability of ADRs, and conducted interviews with parents and children who had experienced ADRs, using these findings to develop a leaflet for parents to inform a communication strategy about ADRs.ResultsThe estimated incidence of ADRs detected in children on admission to hospital was 2.9% [95% confidence interval (CI) 2.5% to 3.3%]. Of the reactions, 22.1% (95% CI 17% to 28%) were either definitely or possibly avoidable. Prescriptions originating in the community accounted for 44 out of 249 (17.7%) of ADRs, the remainder originating from hospital. A total of 120 out of 249 (48.2%) reactions resulted from treatment for malignancies. Off-label and/or unlicensed (OLUL) medicines were more likely to be implicated in an ADR than authorised medicines [relative risk (RR) 1.67, 95% CI 1.38 to 2.02;p < 0.001]. When medicines used for the treatment of oncology patients were excluded, OLUL medicines were not more likely to be implicated in an ADR than authorised medicines (RR 1.03, 95% CI 0.72 to 1.48;p = 0.830). For children who had been in hospital for > 48 hours, the overall incidence of definite and probable ADRs based on all admissions was 15.9% (95% CI 15.0 to 16.8). Opiate analgesic drugs and drugs used in general anaesthesia (GA) accounted for > 50% of all drugs implicated in ADRs. The odds ratio of an OLUL drug being implicated in an ADR compared with an authorised drug was 2.25 (95% CI 1.95 to 2.59;p < 0.001). Risk factors identified were exposure to a GA, age, oncology treatment and number of medicines. The systematic review estimated that the incidence rates for ADRs causing hospital admission ranged from 0.4% to 10.3% of all children [pooled estimate of 2.9% (95% CI 2.6% to 3.1%)] and from 0.6% to 16.8% of all children exposed to a drug during hospital stay. New tools to assess causality and avoidability of ADRs have been developed and validated. Many parents described being dissatisfied with clinician communication about ADRs, whereas parents of children with cancer emphasised confidence in clinician management of ADRs and the way clinicians communicated about medicines. The accounts of children and young people largely reflected parents’ accounts. Clinicians described using all of the features of communication that parents wanted to see, but made active decisions about when and what to communicate to families about suspected ADRs, which meant that communication may not always match families’ needs and expectations. We developed a leaflet to assist clinicians in communicating ADRs to parents.ConclusionThe Adverse Drug Reactions In Children (ADRIC) programme has provided the most comprehensive assessment, to date, of the size and nature of ADRs in children presenting to, and cared for in, hospital, and the outputs that have resulted will improve the management and understanding of ADRs in children and adults within the NHS. Recommendations for future research: assess the values that parents and children place on the use of different medicines and the risks that they will find acceptable within these contexts; focusing on high-risk drugs identified in ADRIC, determine the optimum drug dose for children through the development of a gold standard practice for the extrapolation of adult drug doses, alongside targeted pharmacokinetic/pharmacodynamic studies; assess the research and clinical applications of the Liverpool Causality Assessment Tool and the Liverpool Avoidability Assessment Tool; evaluate, in more detail, morbidities associated with anaesthesia and surgery in children, including follow-up in the community and in the home setting and an assessment of the most appropriate treatment regimens to prevent pain, vomiting and other postoperative complications; further evaluate strategies for communication with families, children and young people about ADRs; and quantify ADRs in other settings, for example critical care and neonatology.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

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“…Benzodiazepines (BDZs) remain first-line agents for the acute management of convulsive seizures and status epilepticus [1,2] while their use in the long-term prophylactic treatment of epilepsy has been historically limited by two major problems: side-effects, especially sedation, and the high potential for tolerance [3]. According to the NICE guidelines, children, young people and adults with epilepsy should receive emergency care in case of prolonged (lasting more than 5 minutes) or repeated (three or more in an hour) convulsive seizures [4].…”

Section: Introductionmentioning

confidence: 99%

“…Diazepam (DZP), lorazepam (LZP) and midazolam (MDZ) are the most widely used drugs in both adults and children. They have different pharmacokinetic profiles [5,6] and are available in different pharmacological formulations [1,7] (Table 1). For many years, rectal diazepam has been a very popular rescue medication and still represents the only out of hospital treatment approved in the US, but this rout of administration is problematic and most of the time socially unacceptable, especially in adults [8].…”

Section: Introductionmentioning

confidence: 99%

New Non-Intravenous Routes for Benzodiazepines in Epilepsy: A Clinician Perspective

Mula

2016

CNS Drugs

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Benzodiazepines (BDZs) represent first line treatment for the acute management of epileptic seizures and status epilepticus. The emergency use of BDZs requires timely administration and considering that most seizures occur outside of the hospital, there is a significant need for easy to use delivery methods that can be given quickly and safely by nonclinical caregivers. In addition, the ideal route of administration should be reliable in terms of absorption. In the US, rectal diazepam is the only licensed formulation, while in the EU rectal diazepam and buccal midazolam are currently licensed. However, both the rectal and buccal administration are not ideal as the absorption can be sometimes unpredictable. Several alternative routes are being explored and are currently under investigation. This is a narrative review of available data about delivery methods for BDZs alternative to the intravenous and oral routes for the acute treatment of seizures. Unconventional delivery options such as the direct delivery in the central nervous system or inhalers are reported. Available data shows that intranasal diazepam or midazolam and the intramuscular auto-injector for midazolam are as effective as rectal or intravenous diazepam. Head to head comparisons with buccal midazolam are urgently needed. In addition, the majority of trials focused on children and adolescents and further trials in adults are warranted.

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Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children

Abstract: Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children.

Cited by 78 publications

References 9 publications

Clinical Profile of SE in Children in a Tertiary Care Hospital in Bihar

Clinical Profile of SE in Children in a Tertiary Care Hospital in Bihar

ADRIC: Adverse Drug Reactions In Children – a programme of research using mixed methods

New Non-Intravenous Routes for Benzodiazepines in Epilepsy: A Clinician Perspective

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