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The Safety and Effectiveness of Intravenous Lacosamide for Refractory Status Epilepticus in the Critically Ill
Newey CR, Le NM, Ahrens C, et al. Neurocrit Care. 2017; 26: 273-9.
Study Question: Is lacosamide safe and effective at terminating status epilepticus (SE)?
Study Description: This was a retrospective, single-center study of patients diagnosed with SE and treated with at least one dose of IV lacosamide. Patients who were lacosamide-naïve were included in the effectiveness analysis. Patients were monitored on continuous electroencephalography prior to administration of lacosamide and at least 48 hours after administration. The safety analysis included an electrocardiogram (EKG), hypotension (defined as a drop in systolic blood pressure >20 mmHg), liver enzymes and renal function.
Results: The safety analysis included 84 patients, 78 of which had an EKG prior to receiving lacosamide. There was no significant difference in pre- and post-lacosamide PR interval overall or between systolic or diastolic blood pressure at 1, 4 and 24 hours after lacosamide administration. There was also no significant difference in liver function tests at day 1 post-lacosamide. Creatinine was not significantly different from pre- and 1 and 7 days post-lacosamide.
Fifty-one patients met inclusion for the effectiveness arm of the study. The mean loading and maintenance doses of lacosamide were 188.3 mg (SD ±150.1) and 362.7 mg/d (SD ±134.1), respectively. The average length of SE prior to receiving lacosamide was 23.5 hours (SD ±3.6). After receiving lacosamide, the length of SE was 31.1 hours (SD ±4.6). Excluding benzodiazepines, the majority of patients received phenytoin or levetiracetam as first or second line therapy with lacosamide being second to fourth line. At 4 hours, 15.7% of lacosamide patients responded, which increased to 82.4% by 48 hours. In these patients, lacosamide was the terminating drug in 58.8%.
Conclusion(s): Lacosamide appears to be safe and effective when used for SE in the critically ill population. Due to the unique mechanism of action, good bioavailability, quick onset, linear kinetics and minimal adverse effects and drug interactions, it is an ideal antiepileptic medication for use in critically ill patients compared to older antiepileptics.
Perspective: This larger study confirms what has been described in smaller cohorts and likely reflects current practice in many institutions, as lacosamide has become more widely utilized due to its ideal properties listed above. Lacosamide is a safe and effective agent to use as a second to fourth line agent in SE patients who are refractory to first line medications (after benzodiazepines). Presently, phenytoin, valproate or levetiracetam should remain first line agents as this study did not address the use of lacosamide as initial therapy.