Drugs used for Status epilepticus not listed below:

• Diazepam (see 4.1.2 Anxiolytics)

Benzodiazepines

MHRA Drug Safety Update (March 2020): Benzodiazepines and opioids: reminder of risk of potentially fatal respiratory depression.

• benzodiazepines (and benzodiazepine-like drugs) and opioid medicines (opioids) can both cause respiratory depression; when used together, additive effects on the central nervous system increase the risks of sedation, respiratory depression, coma, and death

Buccolam

(Midazolam)

• Oromucosal solution 5mg/ml pre-filled oral syringe 2.5mg/0.5ml, 5mg/1ml, 7.5mg/1.5ml, 10mg/2ml (£22.88 = 10mg pre-filled oral syringe)

Indications

• Prolonged or repeated seizures in the community

Dose

• >6 months to <1 year: 2.5mg
• 1 year to <5 years: 5mg
• 5 years to <10 years: 7.5mg
• 10 years to <18 years: 10mg
• 18 years and older: 10mg (unlicensed)

Notes

1. Prescribe by brand (the brand of midazolam should be specified on the individual patient care plan). Buccolam brand is recommended for new initiations
2. Prescribers are reminded that the different brands of buccal midazolam contain different concentrations of the drug
3. For patients currently established on Epistatus brand (10mg/ml, non-formulary), continued prescribing is accepted
4. The brand should not be changed without the full involvement of specialist and patient/carer
5. For infants between 3-6 months of age treatment should be in a hospital setting where monitoring is possible and resuscitation equipment is available
6. Whilst Buccolam is not licensed for patients aged 18 years and older, NICE CG137 recommends buccal midazolam as first-line treatment for prolonged or repeated seizures in adults in the community. Rectal diazepam (licensed) may be used if preferred, or if midazolam is not available
7. Patients should have an individual care plan which should clearly define when administration is necessary; family/carers should be trained in administration

Midazolam

• Solution for injection ampoule 1mg/ml (2ml, 5ml)
• Solution for injection ampoule 5mg/ml (2ml)
• Solution for infusion vial 1mg/ml (50ml)

Notes

1. There have been reports of overdose when high strength midazolam has been used for conscious sedation. Use should be restricted to general anaesthesia, intensive care, palliative care or other situations where the risk has been assessed.
2. Flumazenil must be kept in all departments that use IV or SC midazolam (NPSA/2008/RRR011).
3. Midazolam is a Schedule 3 CD and must be ordered in the CD order book.

Lorazepam

• Tablets 1mg (£1.43 = 1mg daily)
• Injection 4mg/1ml
• Intravenous injection (into large vein) 2mg/ml (for use in University Hospitals Plymouth NHS Trust)

Indications

• Short-term use in anxiety or insomnia
• Status epilepticus

Dose

• Oral, anxiety, 1–4mg daily in divided doses; elderly (or debilitated) half adult dose
  • Insomnia associated with anxiety, 1–2mg at bedtime
• I/M (when oral and intravenous routes not possible) or slow I/V injection (into a large vein), acute panic attacks, 25–30 micrograms/kg (usual range 1.5–2.5mg), repeated every 6 hours if necessary
• Status epilepticus: by slow I/V (into large vein), 4mg repeated once after 10 minutes if necessary; child under 12 years 100 micrograms/kg (maximum 4mg) repeated once after 10 minutes if necessary

Notes

1. Lorazepam has a short duration of action and is used for the management of the acutely disturbed patients in accordance with the appropriate Trust's rapid tranquillisation guidelines.

Thiopental

• Injection powder for reconstitution, 500mg vial

Paraldehyde

• Rectally administered 5ml ampoule. Paediatrics only.
• Enema 50% in olive oil 30ml (unlicensed) (for use in University Hospitals Plymouth NHS Trust)