Abstract
Acute repetitive seizures, more commonly known as cluster, crescendo or sequential seizures, are defined as episodes of increased seizure activity occurring in patients with refractory epilepsy who are already receiving stable regimens of anticonvulsants. They lie in the seizure spectrum between isolated seizures and status epilepticus. If acute repetitive seizures are left untreated, they may progress to status epilepticus.
Acute repetitive seizures and prolonged seizures are rated as a neurological emergency and treatment must be prompt. The primary goals of therapy are cessation of the seizure and prevention of recurrence. The use of traditional intravenous agents such as phenytoin, phenobarbital (phenobarbitone), lorazepam and diazepam is well established in the first-line treatment of acute seizures. However, adverse effects and the time to onset of effect often dictate the choice between older anticonvulsants. Newer agents (such as fosphenytoin) and alternative routes of administration (such as rectal administration of diazepam solution) have been developed in an effort to reduce adverse effects, decrease the time to onset of effect, reduce acute care facility costs and investigate the possibility of home treatment.
Diazepam rectal gel, a newer formulation of diazepam intended for rectal administration, effectively terminates acute seizures and prevents recurrence within the first 12 hours after administration. Diazepam rectal gel is available for use by a trained caregiver in a home setting and, therefore, emergency room treatment and hospitalisation may not be required and could be avoided. This may result in reductions in financial and emotional costs associated with acute repetitive seizures, but broader clinical experience is needed to assess this. Diazepam rectal gel is not associated with respiratory depression and most adverse effects appear to be mild to moderate in severity.
At present, diazepam rectal gel is a valuable addition to the current anticonvulsant armamentarium for first-line therapy of acute repetitive seizures. Wider clinical experience will better determine the place of this formulation in the treatment of this debilitating disorder.
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References
Henriksen O. An overview of benzodiazepines in seizure management. Epilepsia 1998; 39 Suppl. 1: S2–6
Heaney DC, Sander J. Ensuring appropriate care in epilepsy: an overview of epidemiological and cost of illness considerations. Dis Manage Health Outcomes 1998 Dec; 4: 303–13
The epidemiology of the epilepsies: future directions. Ilae Commission Report. Epilepsia 1997 May; 38: 614–8
Garnett WR. Epilepsy. In: DiPiro JT, Talbert RL, Hayes PE, et al., editors. Pharmacotherapy: a pathophysiologic approach. 2nd ed. Norwalk: Appleton & Lange, 1993: 879–903
Meldrum BS. Anatomy, physiology, and pathology of epilepsy. Lancet 1990 Jul 28; 336: 231–4
Lowenstein DH, Alldredge BK. Status epilepticus. N Engl J Med 1998 Apr 2; 338: 970–6
Lowenstein DH, Bleck T, Macdonald RL. It’s time to revise the definition of status epilepticus. Epilepsia 1999 Jan; 40(1): 120–2
Working Group on Status Epilepticus. Treatment of convulsive status epilepticus: recommendations of the Epilepsy Foundation of America’s Working Group on Status Epilepticus. JAMA 1993 Aug 18; 270(7): 854–9
Shafer PO. New therapies in the management of acute or cluster seizures and seizure emergencies. J Neurosci Nurs 1999 Aug; 31: 224–30
Mitchell WG. Status epilepticus and acute repetitive seizures in children, adolescents, and young adults: etiology, outcome, and treatment. Epilepsia 1996; 37 Suppl. 1: S74–80
Morton LD, Rizkallah E, Pellock JM. New drug therapy for acute seizure management. Semin Pediatr Neurol 1997 Mar; 4(1): 51–63
Cereghino JJ, Mitchell WG, Murphy J, et al. Treating repetitive seizures with a rectal diazepam formulation: a randomized study. North American Diastat Study Group. Neurology 1998 Nov; 51: 1274–82
Pellock JM. Management of acute seizure episodes. Epilepsia 1998; 39 Suppl. 1: S28–35
Haut SR, Shinnar S, Moshé SL, et al. The association between seizure clustering and convulsive status epilepticus in patients with intractable complex partial seizures. Epilepsia 1999 Dec; 40: 1832–4
Sander JWAS, Shorvon SD. Epidemiology of the epilepsies. J Neurol Neurosurg Psychiatry 1996 Nov; 61: 433–43
O’Hara K, Driscoll-Bannister S. Self-care management of acute seizure episodes in nonmedical settings by using Diastat (diazepam rectal gel). North American Diastat Group [abstract]. Epilepsia 1997; 38 Suppl. 8: 228
Kriel RL, Cloyd JC, Hadsall RS, et al. Home use of rectal diazepam for cluster and prolonged seizures: efficacy, adverse reactions, quality of life, and cost analysis. Pediatr Neurol 1991 Jan–Feb; 7: 13–7
Morton LD, Pellock JM. Treatment options for acute seizure care: use of new formulations. CNS Drugs 1998 Dec; 10(6): 405–16
Uthmann BM, Wilder BJ. Emergency management of seizures: an overview. Epilepsia 1989; 30 Suppl. 2: S33–7
Dooley JM. Rectal use of benzodiazepines. Epilepsia 1998; 39 Suppl. 1: S24–27
Dreifuss FE, Rosman NP, Cloyd JC, et al. A comparison of rectal diazepam gel and placebo for acute repetitive seizures [see comments]. N Engl J Med 1998 Jun 25; 338: 1869–75
McEvoy GK, editor. AHFS drug information. Bethesda (MD): American Society of Health-System Pharmacists, Inc., 2000
Parke-Davis. Cerebyx®. Physicians’ Desk Reference 54th Edition; 2000; 2235–8
Athena Neurosciences Inc. Diastat® (diazepam rectal gel) rectal delivery system prescribing information. San Francisco, (CA): Athena Neurosciences Inc., 1997
Browne TR. Fosphenytoin (Cerebyx). Clin Neuropharmacol 1997; 20(1): 1–12
Browne TR. The pharmacokinetics of agents used to treat status epilepticus. Neurology 1990 May; 40 Suppl. 2: 28–32
Crawford TO, Mitchell WG, Fishman LS, et al. Very-high dose phenobarbital for refractory status epilepticus in children. Neurology 1988; 38: 1035–40
Rey E, Tréluyer J-M, Pons G. Pharmacokinetic optimisation of benzodiazepine therapy for acute seizures: focus on delivery routes. Clin Pharmacokinet 1999 Jun; 36: 409–24
Cloyd JC, Lalonde RL, Beniak TE, et al. A single-blind, crossover comparison of the pharmacokinetics and cognitive effects of a new diazepam rectal gel with intravenous diazepam. Epilepsia 1998 May; 39: 520–6
Lombroso CT. Intermittent home treatment of status and clusters of seizures. Epilepsia 1989; 30 Suppl. 2: S11–4
Knudsen FU. Plasma-diazepam in infants after rectal administration in solution and by suppository. Acta Paediatr Scand 1977; 66(5): 563–7
Abbott KJ. Febrile seizures: which to treat and how. Curr Ther 1995 Aug; 36: 65–70
Rosman NP, Colton T, Labazzo J, et al. A controlled trial of diazepam administered during febrile illnesses to prevent recurrence of febrile seizures. N Engl J Med 1993 Jul 8; 329: 79–84
Shafer PO. Epilepsy and seizures: advances in seizure assessment, treatment, and self-management. Nurs Clin North Am 1999 Sep; 34: 743–59
Dieckmann RA. Rectal diazepam therapy for prehospital pediatric status epilepticus. West J Med 1991 Sep; 155: 287–8
Pellock JM, Dreifuss F, Cloyd JC, et al. Rectal diazepam for the treatment of acute repetitive seizures: an open-label, multicenter study [abstract]. Neurology 1994 Apr; 44 Suppl. 2: A297
Dieckmann RA. Rectal diazepam for prehospital pediatric Status epilepticus. Ann Emerg Med 1994 Feb; 23: 216–24
Scott RC, Besag FMC, Neville BGR. Buccal midazolam and rectal diazepam for treatment of prolonged seizures in childhood and adolescence: a randomised trial. Lancet 1999 Feb 20; 353: 623–6
Watson HR. A diazepam rectal solution for home or institutional treatment of status epilepticus in children and adults. Aust J Hosp Pharm 1988; 18(5): 333–9
Kriel RL, Cloyd JC, Pellock JM, et al. Rectal diazepam gel for treatment of acute repetitive seizures. North American Diastat Study Group. Pediatr Neurol 1999 Apr; 20: 282–8
Pellock JM, Mitchell WG, Cloyd JC. Diastat (diazepam rectal gel) in the treatment of acute repetitive seizures in adults [abstract]. Epilepsia 1998; 39 Suppl. 6: 126–7
Mitchell WG, Conry JA, Crumrine PK, et al. An open-label study of repeated use of diazepam rectal gel (Diastat) for episodes of acute breakthrough seizures and clusters: safety, efficacy, and tolerance. North American Diastat Group. Epilepsia 1999 Nov; 40: 1610–7
Riela AR, Rosenfeld WE, Ramsay RE, et al. Safety and tolerability of a single dose administration of Diastat® (diazepam rectal gel) to patients with epilepsy on antiepileptic drugs (AEDs) [abstract]. Neurology 1999 Apr 12; 52 Suppl. 2: 391
Shellenberger K, Groves L, Franklin J, et al. Diastat (Diazepam rectal gel) therapy of acute epileptic seizures does not compromise respiratory function [abstract]. AnnNeurol 1998 Sep; 44: 569
Brown L, Bergen DC, Kotagal P, et al. Safety of Diastat® when given at larger-than-recommended doses for treatment of acute repetitive seizures [abstract]. Neurology 1999; 52 Suppl. 2: A522–523
Groves L, Shellenberger MK, Germanson TP, et al. Diastat® (diazepam rectal gel): one dose or two? [abstract]. Epilepsia 1999; 40(7): 93–4
Berg M, Jones-Saete C. Long-term intermittent use of Diastat (diazepam rectal gel) in a self-care management program [abstract]. North American Diastat Study Group. Epilepsia 1997; 38 Suppl. 8: 228–9
Vining EPG. Gaining a perspective on childhood seizures. N Engl J Med 1998 Jun 25; 338: 1916–8
Ritter FJ, Frost MD, Karney VL, et al. Cost savings and effectiveness of rectal diazepam for treatment of prolonged or acute repetitive seizures in children 5 years and younger [abstract]. Neurology 2000 Apr; 54 Suppl. 3: A295
Hunt SL, Sternbergh E, Barron TF. Acute seizure management in school with diazepam rectal gel: education of school personnel [abstract]. Epilepsia 1999; 40 Suppl. 7: 71
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Various sections of the manuscript reviewed by: R. Kriel, Department of Neurology, Hennepin County Medical Center, Minneapolis, Minnesota, USA; I. Leppik, MINCEP Epilepsy Care, Minneapolis, Minnesota, USA; W. Mitchell, Neurology Department, Children’s Hospital, Los Angeles, California, USA; J. Pellock, Division of Child Neurology, Medical College of Virginia, Richmond, Virginia, USA; B.Uthman, Departments of Neurology and Neuroscience, University of Florida College of Medicine and Brain Institute, Gainsville, Florida, USA.
Data Selection
Sources: Medical literature published in any language since 1966 on Diazepam Rectal Gel, identified using Medline supplemented by AdisBase (a proprietary database of Adis International, Auckland, New Zealand). Additional references were identified from the reference lists of published articles. Bibliographical information, including contributory unpublished data, was also requested from the company developing the drug.
Search strategy: AdisBase search terms were ‘seizures’ or ‘epilepsy’ and (‘guideline’ or ‘guideline-utilisation’ or ‘practice-guideline’ or ‘disease-management-programmes’ or ‘treatment-algorithms’ or ‘reviews-on-treatment’ or ‘drug-evaluations’ or ‘epidemiology’ or ‘cost-of-illness’ or ‘pathogenesis’), or ‘repetitive seizures’ or ‘breakthrough seizures’ or ‘recurrent seizures’ or ‘acute repetitive seizures’ or ‘acute epileptic seizsure’ or ‘uncontrolled seizures’ or ‘Diazepam Rectal Gel’ and (‘review’ or ‘clinical-study’). Medline search terms were ‘epilepsy’ or ‘seizures’ and (‘guidelines’ or ‘decision-making’ or ‘health-policy’ or ‘managed-care-programmes’ or ‘epidemiology’ or ‘outcome-assessment-health-care’ or ‘clinical-protocols’ or ‘guideline in pt’ or ‘practice-guideline in pt’), or ‘Diazepam Rectal Gel’ and ‘review in pt’. Searches were last updated 13 Nov 2000.
Selection: Studies in patients with epilepsy who received diazepam rectal gel. Inclusion of studies was based mainly on the methods section of the trials. When available, large, well controlled trials with appropriate statistical methodology were preferred. Relevant pharmacodynamic, pharmacokinetic, pharmacoeconomic and epidemiological data are also included.
Index terms: epilepsy, diazepam, rectal, children, acute repetitive seizures, status epilepticus, pharmacoeconomics, disease management, review on treatment.
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Matheson, A.J., Lowe, M.N., Palmer, K.J. et al. Management of Acute Repetitive Seizures. Dis-Manage-Health-Outcomes 8, 355–368 (2000). https://doi.org/10.2165/00115677-200008060-00005
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DOI: https://doi.org/10.2165/00115677-200008060-00005