The Fat is in the Fire: Ketogenic Diet for Refractory Status Epilepticus

Abstract

In Clinical Science Commentary Status epilepticus has a high degree of long-term functional poor outcomes, with mortality rates as high as 50% (1). Standard anticonvulsant treatments include benzodiazepines, phenytoin, and phenobarbital; newer agents include levetiracetam and valproate (2). Unfortunately, status epilepticus can remain refractory to these interventions, at times requiring anesthetics such as pentobarbital, midazolam, propofol, and ketamine to achieve burst suppression (2). Yet even these treatments can eventually fail, with patients experiencing persistent seizures when they are weaned off general anesthesia. Sadly, few other options are then available. The ketogenic diet is a high-fat, low-carbohydrate nonpharmacologic treatment for epilepsy (3). In continuous use since 1921, over the past two decades, there has been a dramatic resurgence in research and clinical interest in this therapy, typically for children with intractable epilepsy. There is a misperception that the ketogenic diet is universally comprised of bacon, eggs, and heavy whipping cream. The reality is that several all-liquid ketogenic formulas exist and can be provided by a trained dietitian, typically for infants and children with gastrostomy tubes (3).

Dietary Therapies for Epilepsy

“…[24] For patients in status epilepticus, the KD is a very feasible option and requires primarily switching the patient's nasogastric tube formula from standard to ketogenic, with successful results typically described within 7-10 days [ Table 3]. [25] Other new conditions reported recently include childhood absence epilepsy and Sturge-Weber syndrome. [26,27]…”

Status Epilepticus : An Intractable Case with a Successful Outcome

“…Despite Pentobarbital infusion being associated with fewer breakthrough seizures and treatment failures, many studies suggest that continuous infusions of Propofol or Midazolam should be considered as agents of choice in RSE because of the better side-effect compared to Pentobarbital 18,21,24 . When coma-inducing agents are employed, coma should be maintained for at least 24-48 hours 25 .…”

Sodium-glucose cotransporter 2 inhibition and health benefits: The Robin Hood effect

“…It is possible that SGLT2 inhibition may be studied in neurological diseases such as epilepsy, Alzheimer disease, and Parkinson's disease, where ketogenic diet has been shown to enhance mitochondrial function and improve clinical outcomes. [ 35 ] They may also help in certain cancers where delivery of ketones is facilitated while that of glucose is attenuated, forcing a shift in substrate use, and thus preventing growth of tumor cells. A similar mechanism may work in cardiac ischemia, where mitochondrial energetics are made more efficient with use of alternative fuel.…”