Authors :
Presenting Author: Jesus Eric Pina-Garza, MD – The Children’s Hospital at TriStar Centennial, Tennessee, USA
Michael Chez, MD – Sutter Neuroscience Institute, Sacramento, CA, USA; James Cloyd, PhD – College of Pharmacy, University of Minnesota, Minneapolis, MN, USA; Lawrence Hirsch, MD, PhD – Yale Comprehensive Epilepsy Center, New Haven, CT, USA; Reetta Kälviäinen, MD, PhD – University of Eastern Finland and Epilepsy Center Kuopio University Hospital, Member of EpiCARE ERN, Kuopio, Finland; Pavel Klein, MD – Mid-Atlantic Epilepsy and Sleep Center, Bethesda, MD, USA; Lieven Lagae, MD, PhD – University Hospitals Leuven, Member of EpiCARE ERN, Belgium; Raman Sankar, MD – David Geffen School of Medicine UCLA, University of California, Los Angeles, CA, USA; Nicola Specchio, MD, PhD – Bambino Gesù Children’s Hospital, Member of EpiCARE ERN, Italy; Adam Strzelczyk, MD, PhD – Epilepsy Center Frankfurt Rhine-Main, Goethe-University Frankfurt, Frankfurt am Main, Germany; Manuel Toledo, MD – Vall d’Hebron Hospital, Member of EpiCARE ERN, Spain; Eugen Trinka, MD, PhD – Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Member of EpiCARE ERN, Salzburg, Austria
Rationale:
The concept of rapid and early seizure termination (REST) has been proposed as a treatment goal for certain seizure emergencies, with the objective of early initiation of treatment in acute seizure emergencies (Asnis-Alibozek A, et al. Epilepsy Behav Rep 2020;15:100409). While there is international guidance on the definitions and treatment of status epilepticus (SE), there is a lack of clarity regarding prolonged seizures (PS) and seizure clusters (SC). Our group has previously reported consensus recommendations on the terminology defining different types of PS and SC, REST as a management paradigm, and new terminology to describe treatments that can achieve REST (acute seizure termination [AST] and acute seizure prevention [ASP] medication) (Pina-Garza JE, et al. 35
th IEC. Abstract 119). Here we report consensus recommendations relating to the patient/seizure types that warrant REST and advice regarding ideal time of intervention.
Methods:
An expert working group, comprising twelve pediatric and adult epileptologists, neurologists and pharmacologists from Europe and North America used a modified Delphi consensus methodology to develop and anonymously vote on statements regarding REST for the management of seizure emergencies. Consensus was defined as ≥ 75% voting "Agree"/"Strongly agree."
Results:
All expert working group members strongly agreed or agreed that all patients who have experienced PS should be offered an AST medication for REST and all patients who have experienced SC should be offered an ASP medication. Consensus was also reached on which patients with specific seizure types warrant REST and should be offered AST/ASP medication
(Table 1). Consensus statements and level of agreement on advice to patients and caregivers regarding when to use AST/ASP medication to achieve REST are shown in
Table 2. All expert working group members agreed that when prescribing AST/ASP medication for REST, a seizure action plan should be agreed upon in consultation with the patient and caregiver. Eleven out of twelve working group members strongly agreed or agreed that patients with a history of PS of any type who have a recognizable pattern of onset should be advised to administer AST medication as early as possible. All expert working group members strongly agreed or agreed that in patients who have SC as their main seizure pattern, AST and/or ASP medication should be considered at onset of the first seizure.
Conclusions:
This expert working group had a high level of agreement on the recommendations for situations where REST is warranted to stop an ongoing seizure and prevent subsequent seizures, and on advice to patients and caregivers regarding when to use these medications. These recommendations will complement existing guidance for SE and provide new guidance for PSs and SCs, with the possibility of treating earlier to rapidly terminate a seizure and potentially avoid progression to SE.
Funding:
UCB Pharma-sponsored