Table 1.
Parenteral Drugs for Refractory Status Epilepticus.
| Medication | Loading dose (IV, unless specified) | Maintenance dose (IV, unless specified) | Approximate terminal serum t 1/2 (hours) | Serum level (μg/mL)a | Important considerations |
|---|---|---|---|---|---|
| ACTH | >2 years = 40-80 U; IM or SC <2 year = 150 U/m2 |
>2 years = 40 U IM/d <2 years = 75 U/m2 IM BID for 2 weeks |
0.25 (IV) | – | |
| Brivaracetam | Unknown | 11-19 kg = 2.5 mg/kg BID; 20-49 kg = 2 mg/kg BID; 50+ kg = 100 mg BID (age 4+ years); 100 mg BID (adult)b | 9 | – | |
| Ketamine | 1-2.5 mg/kg | 3-10 mg/kg/hc | 2.5 | Combine with BDZ. Avoid in neonates and third trimester of pregnancy | |
| Lacosamide | 5-10 mg/kg over 15-30 minutesd (FDA-approved “loading dose” is 200 mg in adults) | 13 mg/kg/d divided BID (children); 200 mg BID (adult)b | 15 | 4-12 | Atrial arrhythmia; first, second, and third degree heart block. Rarely: ventricular arrhythmia, death |
| Levetiracetam | 60 mg/kg over 15 minutes (max 4500 mg) | 21 mg/kg BID (<6 months), 25 mg/kg BID (0.5-4 years), 30 mg/kg BID (4-16 years), 1500 mg BID (adult)b | 7 | 20-50 | |
| IVIg | 0.4-2 g/kg/d for 3 to 5 days | NA | – | ||
| Magnesium sulfate | 50 mg/kg (max 4 g) | 20-40 mg/kg/h | 30-60 | ||
| Methylprednisolone succinate | 10-30 mg/kg/d for 3 to 5 days | Sometimes after 3-5 days: oral prednisone 1 mg/kg/d | – | ||
| Midazolam | 0.2-0.5 mg/kg | 0.1-2.0 mg/kg/hc or 2.0-40 μg/kg/min | Initially = 1-4.5 (child), 2-7 (adult); prolonged = up to 24 | Variable | Clearance is fastest in infants and slows markedly with prolonged administration |
| Pentobarbital | 5-15 mg/kg at max rate of 50 mg/min | 0.5-5 mg/kg/hc | 15-22 | ||
| Propofol | 1-2 mg/kg bolus every 3-5 minutes up to max of 10 mg/kg | 1-15 mg/kg/h initially, then max 5 mg/kg/hc | Initially = 0.67, prolonged = 4-7, >10 days = 24-72 | Children: avoid or use only briefly due to risk of PRIS | |
| Pyridoxine | 100 mg every 5 minutes. ×5 doses | 15-30 mg/kg/d PO or IV | |||
| Valproic acid | 40 mg/kg over 10-60 minutes (max up to 20 mg/kg/min) | 5-15 mg/kg every 6 hours, starting 30 minutes after end of loading dose. Maximum of 60 mg/kg/d totalb | 9-16 | 50-150 |
Abbreviations: ACTH, adrenocorticotropic hormone; BDZ, benzodiazepine; BID, twice daily; FDA, Food and Drug Administration; IM, intramuscular; IV, intravenous; IVIg, intravenous immunoglobulin; PO, orally; PRIS, propofol infusion syndrome (see text).
aCommon steady state serum concentrations observed in ambulatory epilepsy patients.29
bMaximum FDA-approved maintenance dose for ambulatory patients with epilepsy.29
cMay be titrated to produce burst suppression pattern (5- to 15-second interburst interval) on continuous electroencephalogram monitoring.
d Theoretical loading dose, but ventricular and atrial arrhythmias are a concern.