Table 1.
Commonly used agents for the management of status epilepticus
| Drug | Loading dose | Maintenance dose | Therapeutic range | Adverse events | Considerations |
|---|---|---|---|---|---|
| Lorazepam (Ativan) | 0.1 mg/kg i.v. (up to 4 mg per dose) | None | N/A | Hypotension, respiratory depression | i.v. contains propylene glycol |
| Diazepam (Valium) | 0.15 mg/kg i.v. (up to 10 mg per dose) | None | N/A | Hypotension, respiratory depression | i.v. contains propylene glycol, can be administered rectally |
| Phenytoin (Dilantin) | 20 mg/kg i.v. | 5–7mg/kg/day in two to three divided doses | Total: 15–25μg/ml Free: 1.5–2.5 μg/ml | Hypotension, bradycardia, purple glove syndrome | i.v. contains propylene glycol, strong CYP inducer, tablets and suspension can adsorb to enteral feeding tubes |
| Fosphenytoin (Cerebryx) | 20 mg PE/kg i.v. | 4–6mg/kg/day in two to three divided doses | Prodrug that converts to phenytoin in 15 min, strong CYP inducer, can be administered IM | ||
| Valproate sodium (Depacon) | 20–40 mg i.v. | 500–1000 mg q6-8 h | 50–150 μg/ml | Hyperammonemic encephalopathy, pancreatitis, hepatotoxicity, thrombocytopenia | Carbapenems will significantly lower VPA levels and should not be used concomitantly, CYP inhibitor |
| Phenobarbital | 20 mg/kg i.v. | 1–3 mg/kg/day in two to three divided doses | 15–40 μg/ml (higher levels have been reported) | Hypotension, respiratory depression | i.v. contains propylene glycol, strong CYP inducer |
| Lacosamide (Vimpat) | 200–400 mg i.v. | 200–300 mg i.v. q12h | N/A | PR prolongation | Minimal drug-drug interactions, dose adjustment in renal impairment |
| Levetiracetam (Keppra) | 1000–3000 mg i.v. | 2,000–6000 mg/day in two to four divided doses | N/A | Psychosis | Minimal drug-drug interactions, dose adjustment in renal impairment |
| Topiramate (Topamax) | 200–400 mg NG/PO | 300–1600 mg/day NG/PO in two divided doses | N/A | Hyperchloremic metabolic acidosis | No i.v. formulation, dose adjustment in renal impairment, can potentiate hyperammonemia if administered with valproic acid |
| Midazolam (Versed) | 0.2 mg/kg i.v. | 0.05–2 mg/kg/h | Titrated to EEG | Hypotension, respiratory depression | Active metabolite renally cleared, tachyphylaxis with prolonged used |
| Propofol (Diprivan) | 1–2 mg/kg i.v. | 30–200 μg/kg/min | Titrated to EEG | Hypertriglyceridemia, propofol-related infusion syndrome (PRIS) with high doses and prolonged duration, respiratory depression | Lipid emulsion, adjust caloric intake |
| Pentobarbital (Nembutal) | 5 mg/kg i.v. | 0.5–10 mg/kg/h | 10–20 μg/ml; titrated to EEG | Paralytic ileus, immunosuppression, cardiovascular depression, respiratory depression, hypokalemia | Contains propylene glycol, strong CYP inducer, may result in autoinduction |
| Thiopental (Pentothal) | 2–7 mg/kg i.v. | 0.5–5 mg/kg/h | Titrated to EEG | Paralytic ileus, immunosuppression, hypokalemia, cardiovascular depression, respiratory depression | Metabolized to pentobarbital, strong CYP inducer, may result in autoinduction |
| Ketamine (Ketalar) | 1 mg/kg i.v. | 1–10 mg/kg/h | Titrated to EEG | Hypertension, tachyarrhythmias,hypersalivation, respiratory depression | CYP2C9 substrate: phenytoin and phenobarbital will lower ketamine concentrations |