Abstracts

Rationale: The management of status epilepticus (SE) continues to be a challenge. Benzodiazepines (BZD) are used as first line and antiepileptic drugs (AED) are used as second line agents. No single AED hs been shown to be superior. The Established Status Epilepticus Treatment Trial (ESETT) using intravenous AEDs after failing initial treatment with BZD is ongoing and will provide more data regarding efficacy of the first AED. Our goal is to study the efficacy of single and combination anti epileptic drugs (AEDs) for treatment of SE at our center. Methods: A chart review was done on a prospective database of SE patients admitted to the Neurocritical Care unit (NICU). Anoxic Myoclonic SE were excluded. Demographics, epilepsy history, AED compliance, initial BZD administration, each AED administered, date and time of the last seizure was obtained. The number of AEDs to abort SE was assessed. An AED was successful if it was the last drug added prior to aborting SE. The efficacy of various AEDs, in the order administered, in aborting SE was compared. In patients requiring multiple AEDs, the efficacies of different combinations were assessed and compared. Results: A 100 patients with SE was admitted over 27 months. Median age was 58 years (IQR 45-65), majority were African American (84%) with a slight male predominance (53%). Most had a prior history of epilepsy (70%) and 45% were poorly compliant with AEDs. BZD were administered as the first line in 93% of the patients. All patients received the first AED (as second line agent). The SE termination rate after the 1st AED was 21% (Table 1). Phenytoin, levetiracetam and lacosamide were the most commonly used first AED (Table 2). As the first AED, no significant difference among various AEDs was found (see Table 2) In our cohort, 79% of patients received a second AED. Adding the second AED improved SE termination rates to 65%. Phenytoin as second AED was superior to the other AEDs (72%vs.48 %;p=0.05). Phenytoin was also superior to lacosamide as the second AED (72%vs.42%;p=0.04). A third AED, administered in 39% of patients, improved SE termination rates to 84%. As a third AED, no single drug was superior. A combination of two AEDs was used in 79% of patients. The most commonly used combinations were phenytoin-levetiracetam (35.4%) and lacosamide-levetiracetam (30.4%). The combination of phenytoin-levetiracetam had a better success rate than lacosamide-levetiracetam in terminating SE (78.6%vs.37.5%;p < 0.001). Conclusions: While BZD continue to be the first-line agents in treatment of SE, AEDs continue to be important second-line agents. While none of the AEDs were found to be better than others as single agents, phenytoin used as the second AED was most efficacious in the termination of SE. We also found that phenytoin-levetiracetam combination is superior. The study was limited to the patients admitted to the NICU introducing bias towards more RSE. Funding: Not funded.