Yes! We've reached our target of 0.1mg/kg of lorazepam, but the patient continues to have generalized convulsions. We need to move forward to a second-line agent. We know from the ESETT study that our second-line agents of IV levetiracetam 60mg/kg (max 4500mg), IV fosphenytoin 20mg PE/kg (max 1500mg PE), and IV valproic acid 40mg/kg (max 3000mg) are roughly equally efficacious in aborting generalized convulsive status epilepticus. (Some caveats include how this includes all-comers and the definition of cessation of seizure activity including that of "nystagmoid eye movements." The former is important to note as the general study population there isn't enriched for patients with epilepsy. If our patient has known epilepsy and is already known to be on a maximal dose of one of these three ASMs, then it seems obvious that loading them with that same ASM would not be very helpful. Use the information you have available to you.)
We do like levetiracetam because it is benign from a drug-drug interaction standpoint and is easily available. (This latter part is key, as institutions are able to stock this on each unit without needing to have pharmacy formulate an IV piggyback solution.) Fosphenytoin is an enzyme inducer, and has a [low] risk of causing hypotension. Valproic acid is an enzyme inhibitor and should probably be avoided if there's hepatic dysfunction. Impaired renal clearance will influence the maintenance dosing for renally-cleared drugs like levetiracetam, but it will not affect the loading dose, which itself is a function of the volume of distribution and the desired serum level.
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