Skip to main navigation
Skip notifications
Access to POEMs and Essential Evidence Plus will no longer be included in CMA membership as of Dec. 1, 2023.
Search
Two RCTs: levetiracetam is not superior to phenytoin to treat status epilepticus but is easier to use and may be safer
Clinical Question
Is levetiracetam superior to phenytoin as a second-line agent in treating children with status epilepticus?
Bottom line
These 2 open-label trials show that levetiracetam (Keppra) and phenytoin (Dilantin) are comparable in halting seizures in children with status epilepticus who need second-line treatment. Levetiracetam, however, can be administered more quickly and, according to the very limited data from these trials, it also appears to be safer. 1b-
Reference
Study design: Randomized controlled trial (nonblinded)
Funding: Government
Setting: Emergency department
Synopsis
Benzodiazepines are first-line treatment for children with status epilepticus, but they only work 40% to 60% of the time. Phenytoin, the currently recommended second-line agent, requires slow administration and can cause hypotension and cardiac arrhythmias. The authors of the 2 studies (one study in the United Kingdom, the other in Australia and New Zealand) used comparable methods: open-label trials of children who presented to emergency departments in status epilepticus needing second-line treatment. The children received either levetiracetam (40 mg/kg over 5 minutes; n [for the 2 studies] = 271) or phenytoin (20 mg/kg over 20 minutes; n = 248). In the EcLiPSE trial, the main outcome was the time to cessation of all seizure activity (similar mean time with levetiracetam and phenytoin: 35 and 45 minutes, respectively), while in ConSEPT the main outcome was whether seizure activity stopped 5 minutes after completing the infusion (again, similar: 60% vs 50%, respectively). In EcLiPSE, one third of patients in each group required an additional anticonvulsant and approximately 20% required rapid sequence induction to halt the seizures. In ConSEPT, however, approximately one quarter of the children in each group required rapid sequence induction. In each study, one child died; each had received phenytoin. In the EcLiPSE trial, one child treated with phenytoin developed life-threatening hypotension, increased focal seizures, and decreased consciousness. ConSEPT reported no other serious events, but it will take a larger study to confidently say that one drug is safer than the other.
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI