Use of oral anti-seizure medication via nasogastric tube to treat IV-diazepam resistant status epilepticus in a setting with limited resources: An observational study

Abstract

Introduction: Despite the availability of new antiseizure medications (ASM), status epilepticus (SE) is still associated with a high mortality rate. One third of cases present with benzodiazepine resistance. The availability of intravenous ASMs in Indonesia is limited, meaning that the use of oral ASMs to treat SE is unavoidable. This study aimed to determine whether oral formulations of levetiracetam, topiramate, and valproic acid could successfully terminate diazepam-resistant SE.

Methods: This prospective cohort study was conducted at Dr. Cipto Mangunkusumo National Hospital between June 2021 and March 2023. Patients with SE aged over 18 years, who achieved clinically apparent seizure cessation with second-line oral ASMs following diazepam, were enrolled. Plasma levels of ASMs were assessed 24 h after the last seizure. Demography, clinical characteristics, and the percentage of successful seizure termination was recorded, as well as duration of seizure termination.

Results: Of the 53 participants, 33, 15, and 5 subjects were administered levetiracetam, topiramate, and valproic acid respectively. Of these, 26 (79 %), 15 (100 %), and 4 (80 %) achieved seizure termination. The median dose required to terminate clinically apparent seizures for oral formulations of levetiracetam, topiramate, and valproic acid were 23 mg/kg, 6 mg/kg, and 20 mg/kg. Seizure termination duration was significantly longer in the topiramate group. Median plasma levels (µg/ml) for levetiracetam, topiramate, and valproic acid among subjects who achieved seizure termination with one second-line ASM were 18.3, 9.5, and 43.2. The 30-day mortality rate among subjects administered levetiracetam, topiramate, and valproic acid, was 15 %, 53 %, and 40 %, respectively.

Conclusion: Oral ASMs can be a viable option for the treatment of diazepam-resistant SE in settings with limited resources, where intravenous formulations are not attainable.

Keywords: Levetiracetam; Limited resources; Seizure termination; Status epilepticus; Topiramate; Valproic acid.