Still Seizing? New ACEP Policy on Second-Line Anticonvulsants

October 8, 2024

Written by Vivian Lei

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ACEP released a clinical policy that addresses the choice of a second-line agent for adults with refractory seizures after adequate dosing of benzodiazepines.

Still seizing? Take your pick of second-line agents
A systematic review of the literature was conducted to address the following question:

In emergency department patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of benzodiazepine, which agent or agents should be administered next to terminate seizures?

The literature reviewed in this policy statement came primarily from the Established Status Epilepticus Treatment Trial (ESETT) which compared the efficacy of levetiracetam, fosphenytoin, and valproate in patients with refractory generalized convulsive status epilepticus (GCSE). The review found that approximately half of all patients achieved seizure cessation within 60 minutes of treatment with any of the three medications, with no significant differences in efficacy or safety among them. Adverse effects, including hypotension and respiratory distress, were observed but were not significantly different across the treatment groups.

How will this change my practice?
Prompt initiation of a second-line agent for refractory seizures is vital to reduce morbidity and mortality in patients with GCSE. This study supports the use of levetiracetam, fosphenytoin, and valproate as second-line agents with similar efficacy. Which one you pick may ultimately come down to clinical judgment based on individual patient factors, local availability, and institutional protocols.

Source
Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Seizures: Approved by the ACEP Board of Directors, April 17, 2024. Ann Emerg Med. 2024 Jul;84(1):e1-e12. doi: 10.1016/j.annemergmed.2024.02.018. PMID: 38906639.