I hope you had a wonderful and safe 1st and 4th of July (my American and Canadian friends)! Enjoy this week's TidBit Tuesday...
What drug, route and dose do you use for at home acute seizure management?
For most of us, benzodiazepine drugs (diazepam, midazolam, lorazepam) are our first choice drugs for acute seizure cessation.
Not all benzodiazepine drugs are equal!
What routes can you give the drugs? What routes shouldn’t you give the drugs?
Benzodiazepine drugs were introduced in the 1960s for human status epilepticus. A 2015 human meta-analysis identified that benzodiazepines are the “best” first line IV drugs. To date, there have not been any veterinary studies identifying which drug is ‘best’ for acute seizure management. We’ve just always used benzodiazepines so we continue to do so. Furthermore, limited data regarding efficacy is available for veterinary patients. So, what do we know?? The table below outlines the approved routes for each of the common benzodiazepine drugs. This should be printable.
DiazepamSafe for dogs ☒Safe for cats ☒ Okay if given:IV ☒IM ☐ Not recommended!Rectal ☒ Preferred drug!Intranasal ☒MidazolamSafe for dogs ☒Safe for cats ☒ Okay if given:IV ☒IM ☒Rectal ☐ (nope).Intranasal ☒ Preferred drug!LorazepamSafe for dogs ☒Safe for cats ☒ Okay if given:IV ☒IM ☐ No dataRectal ☐ Nope, not absorbedIntranasal ☒
In 2017 a randomized veterinary clinical trial determined that intranasal midazolam was superior to rectal diazepam for controlling seizures in some dogs. As such, intranasal midazolam (0.2 mg/kg intranasal) is currently my treatment recommendation for at home anti-convulsant care. Guess what? It works great in hospital too when you cannot access a vein fast enough.
My current recommendations for at home care are:
1) Intranasal midazolam at 0.2 mg/kg IN up to 3x in 24 hours. Use a nasal atomizer - it's a game changer.
2) Rectal diazepam at 1 mg/kg PR up to 3x in 24 hours. Make sure to prescribe the BOTTLE, this drug is light sensitive so dosing it in a syringe makes it useful for up to 30 minutes and then it may loose potency.
Other choices, such as rectal or IV levetiracetam, have been evaluated for acute seizure management too. We have more data about benzodiazepine drugs, and I'm more accustomed to using them (over the past 20 years!) therefore they are still my preference. I'll keep you posted if data surfaces suggesting we should change to using levetiracetam, or another drug, instead of the benzodiazepine class.
Stay safe and keep those consults coming! For July my days of operation should remain Monday-Saturday. The schedule will change at the end of August once we sort out what kind of schooling we will be doing for the kiddos - I will keep you posted or you can always check the website or Facebook. Thanks for reading!