Rescue Medication for Seizures

For most people with epilepsy, seizures can be kept at bay with medication. But if seizures do recur, the goal is to keep them as brief and infrequent as possible. This requires diligent assessment and adjustment of the daily drug regimen, as well as a “rescue” medication that can be given on the spot for any seizures that are prolonged or recur in clusters.

So far, the Food and Drug Administration has approved three drug formulations to stop a cluster of repetitive seizures. The first to become available, in 2005, was a form of diazepam (dye AY zu pam) that must be given rectally, almost like a liquid suppository. It was approved for anyone over age 2, but for older children, teens and adults, the rectal route raised some practical issues and privacy concerns.

[See: Was That a Seizure?]

For the next 14 years after rectal diazepam was approved, the only non-rectal alternatives for rescue medication were so-called off-label options — drugs that were approved by the FDA for long-term treatment of seizures, but not for rescue during clusters. In response to this limitation, doctors sometimes prescribed rapidly dissolving oral tablets or concentrated oral solutions, or provided devices that create a nasal spray from a drug in liquid form.

This changed in 2019, when the FDA approved a nasal spray form of rescue medication called midazolam (mi DAZ oh lam). The drug had long been approved to treat seizures, but not in a form that could be readily given by non-medical care partners. Nasal spray midazolam was a welcome new addition for pre-hospital care, but it was only approved for people who are age 12 or older and weigh over 40 kilograms (about 90 pounds). This left younger school-aged children with only rectal or off-label options.

In January 2020, the age gap was closed when nasal spray diazepam was approved by the FDA for treatment of clusters of repetitive seizures in people age 6 and older. With diazepam remaining available for seizure rescue in rectal form, the recent additions of nasal spray diazepam and midazolam now ensure that we have age-appropriate rescue options for people of every age over 2 years.

[See: Relieving the Stigma of Epilepsy.]

Rectal diazepam, nasal spray diazepam and nasal spray midazolam are all fast-working, effective and easy to use. They each come in pre-measured, ready-to-use devices that do not require assembly. However, it’s important for patients and their non-medical care partners to clearly understand when and how to use these medications, and to carry or store them in accessible locations so that they’re always readily available. Periodic “practice runs” with the involved care partners are always a good idea.

The nasal sprays are specifically FDA-approved for treatment of clusters or repetitive seizures, but they’re also used off-label to end seizures with whole body convulsion and loss of consciousness that do not stop on their own within 3 to 5 minutes. The purpose of rescue medication is to prevent prolonged seizure episodes, called status epilepticus, which is a neurological emergency with potentially serious consequences.

Not everyone with epilepsy requires having a rescue medication available for emergency use. People with well-controlled seizures and no prior episodes of clusters or long seizures may not need to have a rescue medication constantly available. But for individuals with a higher risk for long seizures or clusters, keeping a rescue medication close by is worth the effort. This includes people with frequent seizures despite medical treatment, a prior history of long seizures or clusters, or a tendency to miss doses of their prescribed daily medication. Research shows that repeated seizure clusters can have a negative impact on long-term seizure control and well-being, so stopping clusters early is an important goal.

[Read: First Approved Nasal Spray to Treat Seizure Clusters.]

Decisions about the use of seizure rescue medication must be tailored for each person. So far, surveys indicate that rescue medication is under-prescribed, especially for adults. Now that new formulations have become commercially available, it’s hoped that rescue medications will be more widely provided so that care partners can effectively assist when needed at home, school, work, or anywhere else.

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