How does lorazepam compare with other anticonvulsant therapies for people in status epilepticus?

Abstract

Intravenous (IV) lorazepam may be superior to IV diazepam, IV phenytoin, and intramuscular (IM) midazolam in terms of achieving seizure freedom, but comparative adverse event profiles and other outcomes remain uncertain.Reviewers compared IV lorazepam with a range of other anticonvulsant therapies for people in status epilepticus. In terms of seizure control, IV lorazepam seems to increase the number of people achieving seizure freedom compared with IV diazepam (633 vs 426 per 1000 people; moderate‐certainty evidence; all values on average) or IV phenytoin (649 vs 436 per 1000 people; based on 1 RCT with 198 participants), but seems to result in fewer people achieving seizure freedom than IM midazolam (634 vs 734 per 1000 people; based on 1 RCT with 893 participants). The comparative effect on seizure control for other IV alternatives to lorazepam (diazepam plus phenytoin, phenobarbitone, midazolam, levetiracetam) remains uncertain, as these were assessed in too few people.One RCT with 893 participants that compared IM midazolam with IV lorazepam reported on the need for ventilatory support, hospitalization, and intensive care unit (ICU) admission. The rate of ventilatory support was similar across groups, but fewer people required hospitalization or ICU admission with midazolam than with lorazepam (hospitalization: 576 vs 656 per 1000 people; ICU admission: 286 vs 362 per 1000 people). These outcomes either were not assessed or were assessed in too few participants for other comparisons. Mortality and adverse effects were also assessed in too few participants to allow reliable assessments.One trial compared intranasal lorazepam with IM paraldehyde and reported only on cessation of seizures and mortality. Due to the small number of participants (160 children and adolescents), the impact on both outcomes remains uncertain.