• Up to 1/3 of status epilepticus do not respond to benzodiazepines.
• Fosphenytoin, valproate, and levetiracetam are 3 antiepileptic medications commonly used to treat benzodiazepine-resistant status epilepticus, though it is unclear which is more effective.
• Results from the long awaited Established Status Epilepticus Treatment Trial (ESETT) has just been released.
• Fosphenytoin, valproate, and levetiracetam each achieved seizure cessation within 1 hour in approximately 50% of patients.
  • 80% of responders had seizure cessation within 20 minutes.
• Seizure recurrence was observed in 10% of each treatment group.
• It is important to note the dosages of antiepileptic medications used were:
  • Fosphenytoin 20 mg PE/kg, max 1500 mg 
  • Valproate 40 mg/kg, max 3000 mg
  • Levetiracetam 60 mg/kg, max 4500 mg

Bottom Line: Fosphenytoin, valproate, and levetiracetaim have similar efficacy in treatment of benzodiazepine-resistant status epilepticus.

References

Kapur J, Elm J, Chamberlain JM, et al. Randomized trial of three anticonvulsant medications for status epilepticus. N Engl J Med. 2019;381:2013-13.

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