Webinar: Epilepsy Emergencies and Current Rescue Medications

Tuesday, August 13, 2019
1:00 pm - 2:00 pm CDT

Seizures can be both unpredictable and unrelenting. When a seizure becomes an emergency, rescue medications provide immediate relief and help prevent the need for emergency care. While existing therapies do stop these epilepsy emergencies in many patients, some are still searching for an option that works for them.

In this webinar, Dr. Kamil Detyniecki of the University of Miami provides an overview of the different types of seizure emergencies, while also discussing the currently available rescue medications.

View our follow-up webinar on the latest advances in rescue medications.

Download Full Transcript

Dr. Kamil DetynieckiAre these medications combined with other treatments or solo treatments?

These medications are not supposed to replace the daily antiepileptic medications that you take. These are only to be used in situations of emergencies. When you are prescribed a rescue therapy, you continue taking your daily medications. Rescue meds are extra protection in case of a situation that requires treatment.

Are there differences in effectiveness between the different delivery methods of rescue medications such as buccal or nasal or…

The important thing is that these medications get to the system as fast as possible. There are not good studies comparing one to another, because it’s very hard to make a study like that unbiased and blinded (a blinded study is one in which the participants don’t know if they are taking a placebo or not). But there have been some studies comparing rectal diazepam with nasal midazolam, and they seem to be compatible.

During your presentation, you mentioned the side effects of some of the rescue medications. Does delivery method affect these side effects?

Yes, absolutely. So as I mentioned, the nasal administration has the potential for irritation in the nose. That’s one type of side effect. In addition, medications have different half lives, which means they may stay in your system for different lengths of time. For example, diazepam stays in your system longer. After taking it, the effect of sedation may last for a longer time than midazolam. In some patients this may be beneficial, because there maybe longer lasting protection. So one may be better for one patient then versus others.

Is current research suggesting that rescue medications, such as Nayzilam, will be effective?

Yeah, absolutely. For the nasal midazolam, there was a large, multicenter study comparing this medication with placebo. This study showed that the nasal midazolam was much more effective than using the dummy medication. That’s what we use and that’s what the FDA used to approve this medication.

When is a patient considered to be in status epilepticus? Does the length of time vary between children and adults?

Definitions have this problem that they’re never perfect and this is what we have right now. And I think that, again, in terms of when to treat, it’s different. One definition may say that status epilepticus is five minutes, but this doesn’t mean that we need to wait five minutes in order to start treatment.

That is what has been shown based on animal and human data; if a seizure goes for five minutes or longer, there’s a less likelihood that it will stop on its own. For some patients, if a seizure is one, two minutes long, it may be too long for them. Every patient is different, but not aware of any that we’re changing that definition.

What would you say to say school teachers or school personnel who refuse to administer a rectal medications?

There’s been a lot of debate about having the school administer those medications. I think that the problem with the rectal administration maybe resolved now that we have nasal. Again, rectal is troublesome in patients’ privacy. But now that we have the option of nasal, hopefully that won’t be a problem.

Can diastat be given twice at one time if the seizures persist after the first dose ? Or do you have to wait a certain period of time between doses?

Typically the dose is calculated by weight. There is a possibility of giving another dose, but I would normally wait at least 10 minutes or more to know if the first dose had an effect. We have to always assess whether the patient may be overly sedated, having any difficulty breathing, etc. But those discussions about the dose need to be specifically addressed with with the neurologist. I can’t give you an answer for everyone.

But to answer shortly. Yes. In some patients, we can.

Is there an average length for how long it takes a rescue medication to take effect?

Yes. And really it depends on the type of rescue medications. Oral medications can take much longer. That’s why we’re so excited to have different routes of administration. If you swallow a pill, it may take 20 minutes or more to start working. A convulsion going on for a long time, it’s unacceptable.

Nasal may work as fast as 10 minutes, and there are new medications that are being searched in and are being researched that may work even faster as fast as IV. So there’s different times depending on the type on the medication and the route of administration. But the fastest we have right now are the rectal and the nasal.

What are the differences between Versed and Nayzilam?

The active compound is the same. Versed is the brand name of midazolam, which is the same compound which in this brand name Nayzilam. The main difference is that when you use the off label midazolam, like I showed this picture of this young kid getting the Versed with a syringe or a spray. That is because we’re using a product that is being developed for IV, it’s very diluted. You need to use much more volume or much more amount of liquid that it actually doesn’t all get absorbed in the drips behind the nose, so it’s not ideal.

This product that was FDA approved, Nayzilam, is a much smaller concentration, so it’s just one dose, and so that is an improvement compared to the off label, but the actual medication that is being used is the same.

If you can use the nasal spray to stop a seizure and it’s not effective, can you switch rescue medications and give Diastat?

These are great questions and that’s why it’s important to have a rescue plan. Every rescue plan needs to have an option. What if the rescue medication doesn’t work? When can you use another dose, should you call 911… Again, this is not an answer for everyone, and it really depends on the age of the patient and the dose that is to be given.

Using different types of rescue medication at the same time is possible, but it’s unusual. There are rescue medications that you can repeat after five or 10 minutes. It’s not that commonly used but it’s possible. But this is something that should be discussed and patients should ask that of their neurologist.

Again important to have a rescue plan where we discuss these situations… what to do with one medication doesn’t work. Can I use a second dose? When should I call 911? And so on.

If a patient already has a benzo, such as Onfi, as part of their daily AED regime, are the rescue meds effected?

The good answer is: it’s possible. There’s a phenomenon of tolerance to benzodiazepines, and so if a patient is on Onfi or clobazam, it’s possible that they may require a higher dose of rescue medication.

And this is something that is going to need more research for the newer medications. For the new medication, Nayzilam, the patients in the study were not allowed to be on benzodiazepines. And so we need more information about it. It’s definitely not a contraindication, but it may be that the patients may notice that they may require a higher dose.

Are there resources available for school personnel or other professionals on how to use rescue medications? 

I think that the Epilepsy Foundation is a great resource. They have examples of rescue medication plans.

Are there sublingual rescue medications that would work more quickly than a pill?

People are using lorazepam or clonazepam buccally or sublingually. I think the exact absorption has not been studied as well, but there’s a potential that it works faster than swallowing the pill. Although many of these pills are not meant to be used sublingually, so they may not dissolve as fast.

There are companies trying to develop different products, for example, a film that goes into the cheek to get absorbed faster. It’s an active area of research looking for different routes of administration.

For a child who has had a history of refractory epilepticus, when would it be ideal to administer the rescue medications or call 911? This person in particular is not comfortable waiting five minutes.

So, the answer is right there. If you’re not comfortable waiting five minutes, you shouldn’t do that. There is not an answer for everyone. And that’s why I continue to mention that which rescue medication you use, when to administer it, etc. should be a decision between the patient, caregiver, and the doctor depending on the user’s seizures, what kind of seizures they have.

For example, you may be willing to wait longer if you’re having a focal motor seizure, which is a seizure where you have, for example, motor activity without loss of awareness. These seizures can go on for several minutes without causing any significant harm to the patient, but a tonic-clonic seizure going on for four or five minutes, it can be potentially a concern.

The CURE Leaders in Epilepsy Webinar Series has covered many topics related to epilepsy and innovations in research. Check out our full list of available webinars here.

The information contained herein is provided for general information only and does not offer medical advice or recommendations. Individuals should not rely on this information as a substitute for consultations with qualified health care professionals who are familiar with individual medical conditions and needs. CURE strongly recommends that care and treatment decisions related to epilepsy and any other medical condition be made in consultation with a patient’s physician or other qualified health care professionals who are familiar with the individual’s specific health situation.

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