Transnasal Revolution? The Promise of Midazolam Spray to Prevent Seizure Clusters

Excerpt

In epilepsy patients with repetitive, prolonged seizures or status epilepticus, rapid and effective antiseizure treatment is recommended according to current guidelines (clinical guideline (CG137) for epilepsy). This recommendation is based on evidence that (1) with every epileptic seizure there is an increasing likelihood of recurrent seizures [1]; (2) seizure duration correlates with the risk of seizure transformation into status epilepticus [2]; and (3) status epilepticus is associated with serious cerebral and systemic sequelae [3]. The results from several randomized trials [4‐7] emphasize benzodiazepines, such as lorazepam, diazepam, midazolam, and clonazepam as first-line antiseizure drugs. Despite the undeniable need for immediate antiseizure treatment, the rapid administration of benzodiazepines faces many challenges: Intravenous routes can be difficult to establish in the acute setting, subcutaneous intramuscular injections bear the disadvantage of slow drug absorption and pharmacodynamic variability, rectal drug administration is accompanied by social awkwardness and a sense of shame, and the buccal pathway is often hampered by jaw clenching, hypersalivation, or uncontrolled swallowing [8]. These limitations are likely to result in inconsistent use of benzodiazepines, especially in the acute prehospital setting [9, 10], and call for a more secure, reliable, and faster pathway for the administration of emergency first-line antiseizure treatment in the acute setting. …