An overview of benzodiazepines for adult status epilepticus and the role of the emergency medicine pharmacist

: Status epilepticus (SE) is a neurological emergency with the primary goal of therapy being rapid cessation of seizure activity through pharmacological measures. This article provides an overview of optimal benzodiazepine use in the emergent care of SE and highlights the role of emergency medicine pharmacists. Both Neurocritical Care and American Epilepsy Society guidelines list benzodiazepines as the first-line options for emergent treatment of SE. Individual agents have alternative routes of administration and pharmacokinetic advantages that allow for timely, patient-specific treatment. Lorazepam is the most commonly used benzodiazepine for SE and has long been preferred due to its prolonged duration of action in the central nervous system; however, midazolam may be preferable in the pre-hospital setting or where intravenous access is not readily available. Adverse effects commonly considered with benzodiazepines include respiratory depression and hypotension, which are identified as barriers to guideline-recommended doses; however, risks of underdosing benzodiazepines have been described and may contribute to progression to refractory SE. The route and timing of administration must be considered as well, as studies have consistently shown that earlier administration of treatment is associated with a favourable clinical outcome. Pharmacists have a role in optimizing medication management by supporting timely selection of an appropriate benzodiazepine and adhering to guideline-recommended doses to avoid the progression to refractory SE, as well as contributing to local quality improvement initiatives.