Preferred rectal benzo in convulsive status epilepticus

Q: Which of the following medicines is preferred as per rectal administration in convulsive status epilepticus? - select one

A) Lorazepam 

B) Midazolam 

C) Diazepam 

D) Chlordiazepoxide

E) Flurazepam

Answer: C

The objective of treatment in convulsive status epilepticus is to administer the first line of drug, i.e., benzodiazepines, as soon as possible (ASAP!)

IF an Intravenous line cannot be established quickly, other routes should be considered. As a rule of thumb,

• Lorazepam (choice A) is preferred for the intravenous (IV) route
• Midazolam (choice B) is preferred for intramuscular (IM), intranasal, or buccal route, and
• Diazepam (choice C) is preferred for rectal administration

It is prudent to order other intravenous nonbenzodiazepine antiseizures such as levetiracetam, fosphenytoin, valproate, lacosamide, or phenobarbital simultaneously as per the clinical judgement of the physician.

Chlordiazepoxide (choice D) is preferred to prevent the recurrence of seizures.

Flurazepam (choice E), one of the earliest 'benzos' and less used now, is good as an anti-anxiety or as a sleep medicine.

#Neurology

References:

1. Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr 2016; 16:48.

2. Prasad M, Krishnan PR, Sequeira R, Al-Roomi K. Anticonvulsant therapy for status epilepticus. Cochrane Database Syst Rev 2014; :CD003723.

3. Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med 2012; 366:591.

4. Alldredge BK, Gelb AM, Isaacs SM, et al. A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. N Engl J Med 2001; 345:631.

5. Kellinghaus C, Rossetti AO, Trinka E, et al. Factors predicting cessation of status epilepticus in clinical practice: Data from a prospective observational registry (SENSE). Ann Neurol 2019; 85:421.