Keppra vs. Dilantin in Management of Status
The Article: Chakravarthi, S., et al. “Levetiracetam versus phenytoin in management of status epilepticus.” Journal of clinical neuroscience: official journal of the Neurosurgical Society of Australasia 22.6 (2015): 959-963.
The Idea: To compare levetiracetam (LEV) and phenytoin (PHT) as second line treatments for status epilepticus (SE).
The Study: This was an open-label randomized study conducted on 44 patients in a tertiary care center in Northern India. Consecutive patients presenting in status epilepticus (continuous, generalized convulsive seizure lasting > 5 minutes or two or more seizures during which the patient does not regain normal sensorium) were randomized to either LEV or PHT based on the order in which they presented. Odd patients got PHT, even got LEV. All patients got a 0.1mg/kg bolus of IV lorazepam and were enrolled in the study if that failed to control their seizures. Patients in the PHT got a 20 mg/kg dose, patients in the LEV group got a 20 mg/kg loading dose. These were followed by maintenance doses of the respective drugs. Inclusion Criteria were patients who fulfilled the definition of SE and failed to improve with IV lorazepam. Exclusion criteria were patients already taking one of the study drugs and those with drug withdrawal seizures. The primary outcome was successful clinical termination of seizure activity within 30 minutes after initiation of drug infusion. Secondary outcomes included recurrence of seizures within 24 hours, neurological outcome, need for ventilator assistance and mortality during hospital stay.
The Results: No statistically significant difference between PHT and LEV in achieving control of seizures within 30 minutes (68.2% vs 59.1%), recurrence of seizure within 24 hours, neurological outcome, need for ventilator assistance or mortality.
The Takeaway: The author’s conclusion that levetiracetam is not inferior to phenytoin as a second line agent in the management of status epilepticus is based on weak evidence. This study has several limitations. First, this is a very small study (44 total patients) and there is no power calculation in the text. Second, the researchers were not blinded to the treatments each patient was receiving. Third, the patients in the study are not representative of the patient population in the United States. Therefore, there needs to be a better study before any conclusions can be drawn comparing the relative effectiveness of levetiracetam with other anti-epileptics.