TREATMENT OF
Prolonged Acute Convulsive Seizures

Information On Prolonged Seizures

Prolonged acute convulsive seizures (PACS) are the most common neurological emergencies in children (incidence: 18 to 23 per 100,000 per year), which require appropriate treatment strategies to prevent potential morbidity and mortality. 1-3
Early treatment of prolonged acute convulsive seizures is important as it reduces the risk of progression to status epilepticus (SE). SE is defined as a seizure lasting  >5 minutes, or as two or more seizures without an intervening period of consciousness.4
Convulsive SE is associated with an increased risk of mortality. SE, in general, is associated with increased mortality, cognitive impairment, permanent neurological defects, and subsequent epilepsy.5,6
Delaying treatment for prolonged acute convulsive seizures reduces the chance of a successful response to medication.5

Optimal Treatment Of Prolonged Acute Convulsive Seizure

NICE clinical guideline CG137 recommends administering immediate emergency care and treatment to children, young people and adults* who have prolonged (lasting 5 minutes or more) or repeated (three or more in an hour) convulsive seizures.7
A seizure lasting >5 minutes is unlikely to stop spontaneously. Established status epilepticus (SE) is defined as a seizure lasting longer than 5 minutes. SE and established SE can result in life-threatening complications such as brain damage, and thus early intervention is required to reduce this risk.4
Benzodiazepines have the ability to stop seizures rapidly for the majority of children and are the drug of choice for treatment of prolonged or repeated generalised, convulsive seizures in the community.4
*BUCCOLAM is licensed for children and adolescents (aged 3 months to <18 years) only.9
Treatment delay, which can result from delays in reaching hospital and/or delays in paramedics/ambulance staff being able to access the child to administer medication6, is associated with pharmacoresistance and a reduced chance of a successful response to medication.5 Every minute of treatment delay from the start of convulsive SE to arrival at a hospital results in a 5% cumulative increase in the risk of an episode of SE lasting >60 minutes. Treatment delay is associated with poorer outcomes due to the increased risk of complications such as brain damage and learning difficulties.8

Treatment Options

Benzodiazepines are the drug of choice for treatment of prolonged or repeated generalised, convulsive seizures in the community in children.7
Historically, rectal diazepam has been the most common treatment option for prolonged seizures. It is effective at stopping seizures but viewed by many as socially unacceptable due to the administration method.8 In an education setting, the requirement for patients to be partially undressed can be viewed as problematic for the patient, school staff, and other students, especially in partially conscious students when there is no ready means of privacy to preserve the patient’s dignity.10
Oromucosal diazepam is a widely used alternative to rectal diazepam, and in a trial in young people (n=42), was found to be at least as effective as rectal diazepam in treating seizures.** The use of a non-rectal route may overcome potentially unpredictable absorption in the event of constipation or bowel movement disorders.5
NICE clinical guideline CG137 states that buccal midazolam should be administered as a first-line treatment in children, young people and adults* with prolonged or repeated seizures, unless rectal diazepam is preferred, or intravenous access is already established; in the latter case intravenous lorazepam should be administered. Both buccal midazolam and rectal diazepam should only be prescribed to children, young people and adults who have had a previous episode of prolonged or serial convulsive seizures.7
*BUCCOLAM is licensed for children and adolescents (aged 3 months to <18 years) only.9
**p-value = 0.16

References:

  1. Abend NS, Marsh E. Convulsive and nonconvulsive status epilepticus in children. Current Treatment Options in Neurology. 2009 Jul 1;11(4):262-72

  2. Ashrafi MR, Khosroshahi N, Karimi P, Malamiri RA, Bavarian B, Zarch AV, Mirzaei M, Kompani F. Efficacy and usability of buccal midazolam in controlling acute prolonged convulsive seizures in children. European Journal of Paediatric Neurology. 2010 Sep 1;14(5) :434-8

  3. Lagae L. Clinical practice. European Journal of Pediatrics. 2011 Apr 1;170(4):413-8

  4. British Medical Journal. Status epilepticus. Available from: https://bestpractice.bmj.com/topics/en-gb/464 (accessed 03 Apr 2020)

  5. Scott RC, Besag FM, Neville BG. Buccal midazolam and rectal diazepam for treatment of prolonged seizures in childhood and adolescence: a randomised trial. The Lancet. 1999 Feb 20;353(9153):623-6.

  6. Novorol CL, Chin RF, Scott RC. Outcome of convulsive status epilepticus: a review. Archives of Disease in Childhood. 2007 Nov 1;92(11):948-51

  7. National Institute for Health and Care Excellence (NICE). Epilepsies: Diagnosis and Management. Available from: https://www.nice.org.uk/guidance/cg137/chapter/1-Guidance#prolonged-or-repeated-seizures-and-convulsive-status-epilepticus-2 (accessed 03 Apr 2020)

  8. Pellock JM. Overview: definitions and classifications of seizure emergencies. Journal of Child Neurology. 2007 May;22(5_suppl):9S-13S

  9. BUCCOLAM SmPC. Available from: https://www.medicines.org.uk/emc/product/7460 (accessed 03 Apr 2020)

  10. Hartman AL, Devore CD. Rescue medicine for epilepsy in education settings. Pediatrics. 2016 Jan 1;137(1):e20153876″

This information is provided as a resource to HCP’s who prescribe or administer Buccolam.

Reporting of adverse events (Healthcare Professionals in the UK)

Adverse events should be reported. Reporting forms and information can be found at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. Adverse events should also be reported to Neuraxpharm. at: pv-uk@neuraxpharm.com