Valproic Acid as Adjuvant Treatment for Convulsive Status Epilepticus: a Randomised Clinical Trial

Abstract

Background Generalised convulsive status epilepticus (GCSE) is a medical emergency. Guidelines recommend a stepwise strategy of benzodiazepines followed by a second-line anti-seizure medicine (ASM). However, GCSE is uncontrolled in 20–40% patients and is associated with protracted hospitalisation, disability, and mortality. The objective was to determine whether valproic acid (VPA) as complementary treatment to the stepwise strategy improves the outcomes of patients with de novo established GCSE. Methods This was a multicentre, double-blind, randomised controlled trial in 244 adults admitted to intensive care units for GCSE in 16 French hospitals between 2013 and 2018. Patients received standard care of benzodiazepine and a second-line ASM (except VPA). Intervention patients received a 30mg/kg VPA loading dose, then a 1mg/kg/h 12h infusion, whilst the placebo group received an identical intravenous administration of 0.9% saline as a bolus and continuous infusion. Primary outcome was proportion of patients discharged from hospital by day 15. The secondary outcomes were seizure control, adverse events, and cognition at day 90. Results 126 (52%) and 118 (48%) patients were included in the VPA and placebo groups. 224 (93%) and 227 (93%) received a first-line and a second-line ASM before VPA or placebo infusion. There was no between-group difference for patients hospital-discharged at day 15 [VPA, 77 (61%) versus placebo, 72 (61%), adjusted relative risk 1.04; 95% confidence interval (0.89–1.19); p = 0.58]. There were no between-group differences for secondary outcomes. Conclusions VPA added to the recommended strategy for adult GCSE is well tolerated but did not increase the proportion of patients hospital-discharged by day 15. Trial registration no. NCT01791868 (ClinicalTrials.gov registry), registered: 15 February 2012

Status epilepticus: what's new for the intensivist

“…There was no improvement in proportion of patients discharged from hospital and no decrease in incidence of RSE or SRSE in the valproate group. Nevertheless, recurrence of seizures during ICU stay tended to be lower in the valproate group [59 ▪▪ ]. Thus, the prophylactic administration of a third-line ASM is not indicate in GCSE controlled with the first and second lines ASMs (Fig.…”

Editorial: The neurologist's guide to the ICU galaxy

“…Thus, coma remains one of the most frequent reasons for admission to intensive care. Status epilepticus [1,2] and autoimmune encephalitis [3] are undoubtedly the neuro-critical care pathologies which have attracted the most interest in recent years.…”