Puneet Jain1, Suvasini Sharma2, Tarun Dua3, Corrado Barbui4, Rashmi Ranjan Das5, Satinder Aneja6. 1. Division of Pediatric Neurology, Department of Neonatal, Pediatric and Adolescent Medicine, BL Kapur (BLK) Super Speciality Hospital, Pusa Road, New Delhi 110005, India. Electronic address: puneet_mpa@yahoo.com. 2. Division of Pediatric Neurology, Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi 110001, India. Electronic address: sharma.suvasini@gmail.com. 3. Programme for Neurological Diseases and Neuroscience Evidence, Research and Action on Mental and Brain Disorders (MER), Department of Mental Health and Substance Abuse, World Health Organization. Electronic address: duat@who.int. 4. WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Section of Psychiatry, University of Verona, Italy. Electronic address: corrado.barbui@univr.it. 5. Department of Pediatrics, All India Institute of Medical Sciences, Bhuvaneshwar, Odisha, India. Electronic address: rrdas05@gmail.com. 6. Division of Pediatric Neurology, Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi 110001, India. Electronic address: drsaneja@gmail.com.
Abstract
OBJECTIVES: To explore the existing evidence for anti-convulsant drugs and their routes of administration in treating acute seizures in children and adults when intravenous access is not available. METHODS: All major databases including Medline via Ovid, PubMed, Cochrane CENTRAL, Embase, and Google Scholar were searched till May 2015. Randomized and quasi-randomized controlled trials comparing two anti-convulsant drugs (at least one comparator being administered through non-intravenous route) for treatment of acute seizures were included. OUTCOME MEASURES: Primary outcome measure was proportion of children with clinical seizure cessation within 10min of drug administration. Secondary outcome measures were time taken to clinical seizure cessation from the time of admission and from the time of drug administration, and incidence of significant adverse effects. RESULTS: Out of the 19,165 citations, 26 studies were finally included. Regarding the primary outcome measure, the quality of evidence was 'moderate' for following 3 comparisons: buccal midazolam being superior to per-rectal diazepam (RR 1.14; 95% CI, 1.06-1.24), intra-nasal lorazepam being same as intravenous lorazepam (RR 1.04; 95% CI, 0.89-1.22) and intramuscular paraldehyde (RR 1.22; 95% CI, 0.99-1.52). The quality of evidence was 'very-low' for 1 comparison: per-rectal lorazepam being superior to per-rectal diazepam (RR 3.17; 95% CI, 1.63-6.14). The quality of evidence was 'low' for following 2 comparisons: sub-lingual lorazepam being inferior to rectal diazepam (RR 0.71; 95% CI, 0.62-0.81), and intranasal midazolam being superior to per-rectal diazepam (RR 1.14; 95% CI, 1.05-1.25). The rest of the comparisons did not show any difference, but the quality of evidence was 'low' to 'very low'. The time to seizure cessation after drug administration was lower in the intravenous group. However, time to seizure cessation after presentation (includes time for drug administration) was lower in the non-intravenous group. Significant adverse effects were infrequently reported and when present, were similar in both the groups. CONCLUSIONS: When intravenous access is not available, non-intravenous routes of administration of benzodiazepines should be considered for the control of acute seizures in children/adults. The preference may be guided by availability, expertise and social preference. [PROSPERO No: CRD42015019012].
OBJECTIVES: To explore the existing evidence for anti-convulsant drugs and their routes of administration in treating acute seizures in children and adults when intravenous access is not available. METHODS: All major databases including Medline via Ovid, PubMed, Cochrane CENTRAL, Embase, and Google Scholar were searched till May 2015. Randomized and quasi-randomized controlled trials comparing two anti-convulsant drugs (at least one comparator being administered through non-intravenous route) for treatment of acute seizures were included. OUTCOME MEASURES: Primary outcome measure was proportion of children with clinical seizure cessation within 10min of drug administration. Secondary outcome measures were time taken to clinical seizure cessation from the time of admission and from the time of drug administration, and incidence of significant adverse effects. RESULTS: Out of the 19,165 citations, 26 studies were finally included. Regarding the primary outcome measure, the quality of evidence was 'moderate' for following 3 comparisons: buccal midazolam being superior to per-rectal diazepam (RR 1.14; 95% CI, 1.06-1.24), intra-nasal lorazepam being same as intravenous lorazepam (RR 1.04; 95% CI, 0.89-1.22) and intramuscular paraldehyde (RR 1.22; 95% CI, 0.99-1.52). The quality of evidence was 'very-low' for 1 comparison: per-rectal lorazepam being superior to per-rectal diazepam (RR 3.17; 95% CI, 1.63-6.14). The quality of evidence was 'low' for following 2 comparisons: sub-lingual lorazepam being inferior to rectal diazepam (RR 0.71; 95% CI, 0.62-0.81), and intranasal midazolam being superior to per-rectal diazepam (RR 1.14; 95% CI, 1.05-1.25). The rest of the comparisons did not show any difference, but the quality of evidence was 'low' to 'very low'. The time to seizure cessation after drug administration was lower in the intravenous group. However, time to seizure cessation after presentation (includes time for drug administration) was lower in the non-intravenous group. Significant adverse effects were infrequently reported and when present, were similar in both the groups. CONCLUSIONS: When intravenous access is not available, non-intravenous routes of administration of benzodiazepines should be considered for the control of acute seizures in children/adults. The preference may be guided by availability, expertise and social preference. [PROSPERO No: CRD42015019012].
Authors: Andrew Stolbach; Vikhyat Bebarta; Michael Beuhler; Shaun Carstairs; Lewis Nelson; Michael Wahl; Paul M Wax; Charles McKay Journal: J Med Toxicol Date: 2018-04-17
Authors: Lara Kay; Nina Merkel; Anemone von Blomberg; Laurent M Willems; Sebastian Bauer; Philipp S Reif; Susanne Schubert-Bast; Felix Rosenow; Adam Strzelczyk Journal: Ann Clin Transl Neurol Date: 2019-11-04 Impact factor: 4.511