Seizure clusters, defined as closely grouped seizures representing an increase in seizure frequency compared with baseline, are commonly reported by patients with drug-resistant epilepsy. Seizure clusters are disruptive to patients and their families. Terminating them may require medical intervention, and they may evolve into status epilepticus if not treated in a timely manner. Early treatment by a family member or caregiver is most likely to terminate a cluster and avoid transport to an emergency department.
Oral benzodiazepines are frequently prescribed for mild clusters, but severe clusters require treatment through a nonoral route. Rectal diazepam is the only treatment approved for administration by a nonmedical caregiver. Researchers have investigated intranasal diazepam and midazolam, intramuscular diazepam, and buccal midazolam for the treatment of seizure clusters. Regulatory approval for clinical use may be forthcoming for some of these approaches. The study by Sperling and colleagues demonstrates that intranasal diazepam is well absorbed and that serum levels reach therapeutic concentrations, regardless of whether diazepam is administered during or after a generalized tonic-clonic seizure.
Although rectal diazepam may be an excellent option for the treatment of seizure clusters in some individuals, rectal administration may be embarrassing to some patients and difficult for some caregivers. Alternative treatment options will be welcome.
—Bassel Abou-Khalil, MD
Professor of Neurology
and Director of the Epilepsy Center