A Refresher: Treating Status Epilepticus in the ICU
I was working in the intensive care unit (ICU) the other night when I was called to the emergency department to see a patient who was reported to be in status epilepticus (SE). The patient had received several doses of lorazepam (Ativan®) and was loaded with intravenous levetiracetam (Keppra®). I hadn’t ever used levetiracetam for patients with SE before, so I went ahead and loaded the patient with fosphenytoin (Cerebyx®). I’d hardly call myself an expert in neurocritical care, so I figured it was time to go back and read about the management of SE in the ICU.
There’s no shortage of review articles out there, but I started with guidelines published by the Neurocritical Care Society in 2012. Levetiracetam is on the list of agents recommended for emergent, urgent, and refractory treatment of SE. All levetiracetam recommendations are class IIb/level C (more data are needed, but treatment is not unreasonable based on consensus opinion, case reports, or standard of care).
A quick look at the available references confirms that most are small case reports or observational case series. A recent review says that the practice of using levetiracetam shows promise—citing efficacy, safety, and tolerability across studies and one pilot study that compared levetiracetam to lorazepam. They also noted that the Neurocritical Care Society guidelines list no serious adverse effects and minimal drug interactions. Perhaps levetiracetam is the ideal drug to use in the elderly and in the ICU.
To be clear, I’ll still be using lorazepam as my first line based on the results from the Veterans Affairs Status Epilepticus Cooperative Study Group. It’s absolutely the best designed study on SE that we have. For urgent control, levetiracetam sure looks like a reasonable option when compared with fosphenytoin, which often causes hypotension.
Cost: A Reasonable Consideration
Of course, cost must be considered, and while I was unable to find a cost-efficacy analysis specific to SE treatment, studies looking at levetiracetam vs phenytoin for prophylaxis after traumatic brain injury clearly favored phenytoin.[4,5]
It’s not clear that these data can be readily generalized to SE treatment. In summary, for patients who are elderly, hemodynamically unstable, or on multiple medications, I’ll be using levetiracetam at the doses recommended in the recent guidelines.