Comparative Effectiveness of Levetiracetam, Fosphenytoin, Lacosamide, and Valproate in Benzodiazepine-refractory Status Epilepticus: A Retrospective Study Based on ESETT Criteria
Ajaz Sheikh1, Fahham Asghar1, Uzair Hamid1, Sumayya Naz1, Mehmood Rashid1, Hira Burhan1
1The University of Toledo
Objective:
Based on the ESETT criteria, to compare 60-minute effectiveness after benzodiazepine failure for levetiracetam (LEV), fosphenytoin/phenytoin (PHT), and valproate (VPA)—defined as seizure cessation with improving responsiveness without additional ASM—and include lacosamide (LAC) as an added comparator given its wide real-world use.
Background:
ESETT found no difference in 60-minute effectiveness among LEV, PHT, and VPA. Since then, LAC has been used increasingly as a second-line agent, however it was not part of ESETT, creating a need to evaluate it alongside the original drugs.
Design/Methods:
Using an SlicerDicer on EPIC EMR, we identified adult ED encounters for status epilepticus treated with benzodiazepines and then a second-line ASM (LEV, VPA, PHT, or LAC). For this abstract, we report exposure counts and crude intubation proportions as an unadjusted “failure” signal. A planned IRB-approved chart review will count each encounter once with a single second-line drug, define clear time windows, exclude patients intubated before the second-line drug, assess the ESETT 60-minute endpoint, and adjust for confounders.
Results:
Over the last 10 yeas, benzodiazepine-treated encounters at our center were n=1,001. Second-line exposures: LEV n=1,104; VPA n=266; PHT n=229; LAC n=100. Crude “failure” (intubation during the index encounter): LEV 13.3% (147/1,104), VPA 22.9% (61/266), PHT 22.3% (51/229), LAC 27.0% (27/100). Rates were similar for LAC, VPA, and PHT, and lower for LEV. A subgroup receiving pre-hospital benzodiazepines was noted within the LEV cohort. The larger LEV count reflects its broad use in our center. Extraction of ESETT-aligned primary and secondary outcomes is in progress pending IRB approval.
Conclusions:
Preliminary, unadjusted intubation rates were comparable for VPA, PHT, and LAC, with a lower crude rate for LEV. These early signals need confirmation in an IRB-approved study that applies clear exposure rules, standardized timing, and risk adjustment, and that formally evaluates the ESETT 60-minute effectiveness endpoint.
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