Identification and treatment of acute repetitive seizures in children and adults

Opinion statement

Acute repetitive seizures are a predictable component of a patient’s seizure disorder, historically distinct from the patient’s other epileptic seizures in type, frequency, severity, or duration, and with an onset easily recognized by caregiver and physician. Onset has a consistent predictable component (such as aura or prodrome, which may be a convulsive or nonconvulsive symptom, or characteristic single or multiple seizures) that is predictably and temporally linked to subsequent seizures. Typically there is recovery between seizures. Episodes may or may not progress to a prolonged seizure or to status epilepticus but may be predictable for each patient based on history. Acute repetitive seizures may include any type of epileptic seizure and may occur at any age. Other terms for acute repetitive seizures include cluster, serial, recurrent, or crescendo seizures. Treatment should only be administered by caregivers who in the opinion of the prescriber are capable of monitoring the clinical response and recognize when the response is such that immediate professional evaluation or care is necessary. Caregivers must be comfortable so that they feel capable of recognizing when and how to treat. The prescriber and caregiver should have a written plan on when to treat and what to observe and do after treatment. The most immediate treatment for out of hospital care and the only US Food and Drug Administration-approved product for acute repetitive seizures is rectal diazepam gel administered at a dose of 0.2 to 0.5 mg/kg, depending on age and weight (Class I evidence). Treatment may produce central nervous system depression. Oral, buccal, and sublingual benzodiazepines (lorazepam, diazepam) are also used for treatment but only if the risk of aspiration is not a concern and recognizing that absorption time will be increased (Class III evidence). Nasal benzodiazepine products, available in some countries, are not yet available in the United States.