Abstract Details

Title Comparative Effectiveness of Levetiracetam, Fosphenytoin, Lacosamide, and Valproate in Benzodiazepine-refractory Status Epilepticus: A Retrospective Study Based on ESETT Criteria

Topic Epilepsy/Clinical Neurophysiology (EEG)

Presentation(s) P6 - Poster Session 6 (5:00 PM-6:00 PM)

Poster/Presentation
Number 11-010

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.

Authors/Disclosures
Hira Burhan, MD PRESENTER	Dr. Burhan has nothing to disclose.
Ajaz Sheikh, MD (ProMedica Neurosciences Center)	Dr. Sheikh has nothing to disclose.
Fahham Asghar, MD (The University of Toledo)	Mr. Asghar has nothing to disclose.
Uzair Hamid, MD, MBBS (UIcomp OSF St. Francis Med Center)	Dr. Hamid has nothing to disclose.
Sumayya Naz, MD (ProMedica Neuroscience Center)	Dr. Naz has nothing to disclose.
Mehmood Rashid, MD (Neuroscience Center)	Dr. Rashid has nothing to disclose.

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