UMEM Educational Pearls

Category: Pediatrics

Title: Status epilepticus medication management in children

Keywords: Keppra, Dilantin, status epilepticus (PubMed Search)

Posted: 7/20/2019 by Jenny Guyther, MD (Updated: 7/18/2024)
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Question

-Benzodiazepines alone are effective in terminating status epilepticus in 40 to 60% of pediatric patients

-The guidelines for second line agents are based on observational studies and expert opinion

-Adverse effects of phenytoin include hepatotoxicity, pancytopenia, Stevens-Johnson syndrome, extravasation injuries, hypotension and arrhythmias

- Levetiracetam has a reduced risk of serious adverse events, greater compatibility with IV fluids and can be given in 5 minutes versus 20 minutes for phenytoin.

 

Bottom line: In a recent randomized control trial they found that levetiracetam was not superior to phenytoin as a second line agent for management of convulsive status epilepticus in children.  There was no difference between efficacy or safety outcomes between the two groups.

Answer

Phenytoin is the second line treatment for pediatric convulsive status epilepticus after failure of first-line benzodiazepines but is only effective in approximately 60% of cases.  This study was an open label, multicenter, randomized control trial conducted in Australia and New Zealand with children aged 3 months to 16 years with status epilepticus who had failed first-line benzodiazepine treatment.  Patients were randomly assigned to to receive 20 mg/kg of phenytoin or 40 mg/kg of levetiracetam with the primary outcome being seizure resolution at 5 minutes

There were 233 children included in the study and seizure activity stopped in 60% of the patients in the phenytoin group and 50% of the patients in the levetiracetam which was not a statistically significant difference.

References

Dalziel at al.  Levetiracetam versus phenytoin for second line treatment of convulsive status epilepticus in children; an open label, multicenter, randomized control trial.  The Lancet.  Published online April 17, 2019.