lorazepam intranasal (NRL-2) / Neurelis - LARVOL DELTA

Benzodiazepines for the Treatment of Seizure Clusters. (PubMed, CNS Drugs) - "Three rescue therapies are currently FDA-approved for this indication, with diazepam rectal gel being the first in 1997, for patients aged ≥  2 years...Treatments that have been used off-label for seizure clusters in the USA include midazolam for injection as an intranasal spray (indicated for sedation/anxiolysis/amnesia and anesthesia) and tablet forms of clonazepam (indicated for treatment for seizure disorders) and lorazepam (indicated for anxiety)...Finally, the potential benefits of seizure action plans and candidates for their use are addressed. This paper is intended to provide details about the unique characteristics of rescue therapies for seizure clusters to help clarify appropriate treatment for individual patients."

Journal • Review • Anesthesia • CNS Disorders • Epilepsy • Mood Disorders • Psychiatry

Statewide Emergency Medical Services Protocols for Status Epilepticus Management. (PubMed, Ann Neurol) - "All adult protocols recommend intravenous benzodiazepines (midazolam, n=33; lorazepam, n=23; diazepam, n=24), 30 recommend intramuscular (midazolam, n=30; lorazepam, n=8; diazepam, n=3), and 27 recommend intranasal (midazolam, n=27; lorazepam, n=3), while pediatric protocols also frequently recommend rectal diazepam (n=14). Recommended dosages vary widely, and first- and second-line agents are designated in only 18 and 2 states, respectively. Given this degree of variability, standardized national EMS guidelines are needed."

Clinical • Journal • CNS Disorders • Epilepsy • Pediatrics

[VIRTUAL] Changes in the patient call volume and call characteristics to an epileptologist during the COVID-19 pandemic (AES 2020) - "Leading up to the pandemic the epileptologist prescribed oral lorazepam or intranasal midazolam to be used as seizure rescue medication to patients with poorly controlled epilepsy. During the “active” phase of the COVID-19 pandemic, a significant decline in call volume to the epileptologist occurred. Even patients who suffered break-through seizures and seizure clustering did not call the epileptologist. Patients who needed in-person evaluation and management for seizure clustering, multiple break-through seizures, suspected seizures declined to come to see the epileptologist at his in-hospital faculty practice office."

Clinical • CNS Disorders • Epilepsy • Infectious Disease • Novel Coronavirus Disease • Respiratory Diseases

Comparison of intranasal midazolam versus intravenous lorazepam for seizure termination and prevention of seizure clusters in the adult epilepsy monitoring unit. (PubMed, Epilepsy Behav) - "In our retrospective study, INM was comparable with IVL for seizure termination and prevention of seizure clusters in the adult EMU. Intranasal midazolam circumvents the need for IV access to be maintained throughout hospitalization and is an attractive alternative to IVL as a rescue therapy in this setting. Ideally, future large, prospective, randomized, and double blind studies are needed to confirm these findings."

Clinical • Journal • Retrospective data • CNS Disorders • Epilepsy

Non-intravenous rescue medications for pediatric status epilepticus. A cost-effectiveness analysis (AES 2017) - "To quantify the cost-effectiveness of rescue medications for pediatric status epilepticus: rectal diazepam, nasal midazolam, buccal midazolam, intramuscular midazolam, and nasal lorazepam. For pediatric status epilepticus, buccal midazolam and nasal midazolam are the most cost-effective non-intravenous rescue medications in the USA. Rectal diazepam is not a cost-effective alternative and this conclusion remains extremely robust to wide variations of the input parameters."

Clinical • HEOR • CNS Disorders • Epilepsy

Intranasal Lorazepam for Treatment of Severe Agitation in a Pediatric Behavioral Health Patient in the Emergency Department. (PubMed, Ann Emerg Med) - "Intranasal absorption is more rapid than intramuscular, with sedatives such as lorazepam reaching peak serum concentrations up to 6 times faster when administered intranasally. We present the first report of using intranasal lorazepam as a needle-free method of providing rapid and effective sedation to treat severe agitation in a pediatric behavioral health patient presenting to the ED."

Clinical • Journal

Standardized Pathway Implementation for the Treatment of Pediatric Status Epilepticus (AES 2019) - "Intranasal midazolam and intravenous lorazepam were specified as first line benzodiazepines (BZD), second line medication options were expanded (see Figure 1), and midazolam was recommended as the initial third line continuous infusion...Considering all second line medications given (with and without SE), more valproic acid (p=0.0001) and less levetiracetam (p=0.008) were provided post-pathway, but this was not associated with reduced frequency of fosphenytoin and phenobarbital dosing (p=0.957)...While different second line medications were prescribed post-pathway, the overall incidence of requiring one and two doses of second-line medication was unchanged. Further analyses will evaluate whether these changes were associated with changes in patient outcome."

Clinical

Decreasing Seizure Treatment Time Through Quality Improvement Reduces Critical Care Utilization. (PubMed, Pediatr Neurol) - "Children with status epilepticus were treated with benzodiazepines more rapidly and effectively following implementation of QI methodology. These interventions reduced utilization of critical care and mitigated hospital charges."

Journal