Commonly Used Benzodiazepines for Status Epilepticus

Benzodiazepine is the standard of care for emergency treatment of SE.

The most commonly used Benzodiazepines are:

Lorazepam, Midazolam, and Diazepam.

A. Lorazepam

• Mechanism of Action: binds to Benzodiazepine receptors on the post-synapse to enhance the inhibitory effects of GABA
• Route of Administration: Intraveous
• Dose: 0.1 mg/kg with a maximum single dose of 4mg
• Pharmacokinetics: onset of action – 1 to 3 minutes
  • Longer duration of action compared to IM Midazolam

• Adverse Effects: hypoventilation, hypotension, and cardiac rhythm disturbance
• Pearls: Best agent for SE patients with IV access

B. Midazolam

• Mechanism of Action: related to accumulation of GABA to inhibit seizure and affinity to benzodiazepine receptors
• Route of Administration: Intramuscular and Intranasal
• Dose: 0.2 mg/kg, with maximum single dose of 10mg IM ; 5 – 10 mg (0.2 mg/kg) IN
• Pharmacokinetics: half-life of 1.5 to 2.5 hours
• Adverse Effects: pain on injection site, hypoventilation, hypotension, and cardiac rhythm disturbance
• Pearls: drug of choice for patients for SE patients with no IV access; IM Midazolam shows similar response rate to IV Lorazepam in that pharmacologic effect of both for the cessation of seizure happens at the same time only that because of the route of administration of IM Midazolam, drug can be administered faster

C. Diazepam

• Mechanism of Action: facilitates inhibitory activity of GABA at various sites
• Route of Administration: Intravenous, Intrarectal, Intramuscular
• Dose: 10 mg IV, may repeat q5-10 minutes with a maximum cumulative dose of 30mg ; 5 – 20 mg IR
• Pharmacokinetics: half-life of 1.5 to 2.5 hours
• Adverse Effects: withdrawal symptoms, hypotension, and cardiovascular collapse
• Pearls: rapidly re-distributes into adipose with short-lived efficacy