SAN DIEGO —Benzodiaze­pines are effective and the most common initial treatment in an emergency department for patients with acute repetitive seizures. However, patients were just as likely to have seizure recurrence with benzodiazepine treatment as with longer-acting antiepileptic drugs (AEDs), according to Tricia Y. Ting, MD, and colleagues. Patients who received a benzodiazepine were more than five times as likely to be hospitalized and on average spent more than four hours longer in the emergency department than did patients who had received only a longer-acting AED, the researchers reported.

“Benzodiazepine therapy, alone or in combination with longer-acting AEDs, is effective for aborting seizures in acute repetitive seizures, although the adverse effects of benzodiazpines may contribute to the need for hospitalization,” stated Dr. Ting at the 60th Annual Meeting of the American Epilepsy Society. “Alternative therapies for acute repetitive seizures, preferably anticonvulsants that are both rapid in onset and long-acting, should therefore be investigated.” Dr. Ting is an Assistant Professor of Neurology at the University of Maryland Medical Center in Baltimore.

The investigators reviewed the rec­ords of 29,592 patients who presented to the University of Maryland Medical Center’s emergency department in a seven-month period, 250 of whom had seizures. Fifty-one of these patients (20%) had multiple seizures, two of whom had status epilepticus and were subsequently excluded. A total of 37 patients (15%) met the researchers’ criterion for acute seizures—that is, they had multiple seizures within the 24-hour period prior to their arrival at the emergency department.

Generalized tonic-clonic seizures were the most frequent, occurring in 25 (68%) of the 37 patients with acute repetitive seizures. The most common precipitating factors for seizures were subtherapeutic AED levels or missed AED doses and infection. Alcohol withdrawal seizures were excluded, however, from the analysis. Seven patients presented with new-onset seizures.

The investigators found that patients had an average of three seizures within 24 hours prior to admission to the emergency department. Patients who were hospitalized had an average of 3.6 seizures, while those who were discharged from the emergency department had an average of 2.7 seizures. The average duration of an acute repetitive seizure cluster was 5.1 hours, and the average time to treat after the first seizure in an acute repetitive seizure cluster was 5.8 hours. For patients who were subsequently hospitalized, the average time to treat was 6.3 hours, while the average time to treat for those discharged from the emergency department was 3.9 hours.

Twenty-nine patients with an acute repetitive seizure were treated with anticonvulsant medication en route to or in the emergency department. Lorazepam or diazepam was the most common initial treatment in 19 patients (66%), with a concomitant longer-acting AED like phenytoin or valproic acid also administered to five patients (17%). Eleven patients (38%) received phenytoin as initial therapy for acute repetitive seizures; seven received phenytoin alone without concomitant benzodiazepine therapy.

After initial treatment for acute repetitive seizures, seven patients (24%) had seizure recurrence. About 26% of patients who received a benzodiazepine as initial therapy had seizure recurrence, while 20% of those who received only a longer-acting AED had seizure recurrence. No patient had seizures following additional treatment with a benzodiazepine, phenytoin, or valproic acid. Fourteen patients (38%) were hospitalized after initial treatment in the emergency department. About 65% of those who had received any benzodiazepine were admitted to the hospital, compared with 12.5% of patients who had taken a longer-acting AED.

Patients with acute repetitive seizures spent an average of 7.79 hours in the emergency department. Those who took a benzodiazepine had an average of 11.4 hours in the emergency department, and those who had taken only a longer-acting AED had an average of 7.2 hours in the emergency department. This difference may partially reflect a selection bias, as patients with more severe repetitive seizures likely required more emergent care and aggressive benzodiazepine dosing resulting in more adverse effects prolonging hospitalization.

“Patients with acute repetitive seizures commonly present to the emergency department, comprising approximately 15% of admissions for seizures at a tertiary care center emergency department,” said Dr. Ting. “Although acute repetitive seizures may be the initial presentation in a patient with new-onset seizures, it is more likely precipitated in patients with known epilepsy by poor medication compliance and/or acute illness.“Patients were more likely to be hospitalized if they had a greater number of seizures prior to presentation and if they had a longer acute repetitive seizure cluster duration prior to treatment,” Dr. Ting continued. “Therefore, patients with epilepsy should be educated about the need for medication compliance and early treatment in case of acute repetitive seizures.”

NR