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Phenytoin, valproate, levetiracetam and lacosamide in status epilepticus. Which is first choice and when should it be used?
Brigo, F; Kalss, G; Trinka, E
Z EPILEPTOL. 2018; 31(4): 250-255.
Originalarbeiten (Zeitschrift)


Kalss Gudrun
Trinka Eugen


Benzodiazepine refractory or established status epilepticus (ESE) is defined as ongoing seizure activity despite the use of benzodiazepines. In patients with tonic clonic status epilepticus (TCSE) this crucial time point (t1) is defined as 5min. Phenytoin is indicated for ESE and is often administered simultaneously with benzodiazepines, without waiting to see whether a recurrent seizure occurs after breaking through the SE. This approach is clinically justified in that asecondary seizure prophylaxis must be established beyond the antiepileptic effect of the benzodiazepine. Severe undesired side effects are arterial hypotension and compartment syndrome or necrosis in cases of extravasation. Therefore, acentral venous line and an intensive care unit (ICU) setting are recommended. Hepatotoxicity and renal toxicity are important long-term effects, which makes levetiracetam interesting in patients with appropriate comorbidities. The most frequent undesired side effect is somnolence. Levetiracetam and valproate do not have severe cardiorespiratory side effects. Therefore, they are favorable in the emergency room setting. Levetiracetam is especially favorable in patients with liver or renal diseases, and valproate in older patients. The most important risk collective is patients with mitochondrial diseases in whom valproate is contraindicated. The main side effect is dizziness. Lacosamide seem to have a favorable effect especially in patients without other sodium channel blockers; however, an atrioventricular block is an important side effect in the emergency setting. Evidence for the clinical use of second line therapies in ESE is limited; however, avery important study on the use of levetiracetam, fosphenytoin and valproate in ESE (established status epilepticus treatment trial, ESETT) is now ongoing. Its results are likely to greatly influence the clinical practice in the future.

Find related publications in this database (Keywords)

Established status epilepticus
Benzodiazepine resistant status epilepticus
Second line therapy