Optimizing Benzodiazepine Use for Breakthrough Seizures in Epilepsy

Author(s):

A panelist discusses how selecting the optimal benzodiazepine rescue medication depends on factors such as route of administration, setting, and patient preference, with intranasal formulations increasingly favored for their rapid onset, ease of use, and greater acceptance in outpatient and home environments.

Summary for Physicians:

EP: 1.Overview of Status Epilepticus and Prolonged Seizures in Epilepsy

EP: 2.Standard of Care and Role of Rescue Medications in Epilepsy

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EP: 3.Optimizing Benzodiazepine Use for Breakthrough Seizures in Epilepsy

Benzodiazepines Used as Rescue Medications:
The most commonly used benzodiazepines for seizure rescue therapy include the following:

Diazepam – available as a rectal gel (Diastat) and intranasal spray (Valtoco)
Midazolam – available as an intranasal spray (Nayzilam), buccal formulation (in some countries), and intramuscular injection
Lorazepam – typically administered intravenously, primarily in emergency or hospital settings

Differences Between Agents:
These medications differ in terms of route of administration, speed of onset, and practical use:

Diazepam has a rapid onset and is effective in stopping seizures quickly. The rectal gel has been used for years, especially in pediatric patients, although the intranasal formulation offers a more socially acceptable and convenient alternative.
Midazolam has a very rapid onset and is available in user-friendly forms such as intranasal spray. It is often preferred for its ease of administration and quick effect in community or home settings.
Lorazepam is generally reserved for in-hospital use due to its intravenous route. It is considered highly effective for status epilepticus but not practical for at-home rescue.

Determining the Best Option:
Choosing the most appropriate rescue treatment and delivery method involves individualized assessment, including the following:

Patient age, weight, and seizure characteristics
The likely setting of administration (home, school, hospital)
Caregiver ability and comfort with specific routes
Past response to treatment and potential adverse effects
Route preference (eg, intranasal is preferred over rectal by many patients and caregivers)
Access and insurance coverage

Intranasal benzodiazepines have become the preferred option in many outpatient settings due to their effectiveness, ease of use, and higher acceptance among patients and families.