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November 24, 2015; 85 (21) Editorial

Better meta-analytic methods, but best initial treatment for status epilepticus remains obscure

Robert Silbergleit, Josemir W. Sander
First published October 28, 2015, DOI: https://doi.org/10.1212/WNL.0000000000002159
Robert Silbergleit
From the Department of Emergency Medicine and the Neurological Emergencies Treatment Trials Clinical Coordinating Center (R.S.), University of Michigan, Ann Arbor; NIHR University College London Hospitals Biomedical Research Centre (J.W.S.), UCL Institute of Neurology, London, UK; and Stichting Epilepsie Instellingen Nederland (SEIN) (J.W.S.), Heemstede, the Netherlands.
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Josemir W. Sander
From the Department of Emergency Medicine and the Neurological Emergencies Treatment Trials Clinical Coordinating Center (R.S.), University of Michigan, Ann Arbor; NIHR University College London Hospitals Biomedical Research Centre (J.W.S.), UCL Institute of Neurology, London, UK; and Stichting Epilepsie Instellingen Nederland (SEIN) (J.W.S.), Heemstede, the Netherlands.
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Better meta-analytic methods, but best initial treatment for status epilepticus remains obscure
Robert Silbergleit, Josemir W. Sander
Neurology Nov 2015, 85 (21) 1830-1831; DOI: 10.1212/WNL.0000000000002159

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The most effective benzodiazepine and route of delivery to use as initial treatment for people in status epilepticus is not clear, despite many small and a few medium and large clinical trials. There are many potential choices of both drug and route. Everybody has their favorite and a reason for their choice. Americans like lorazepam, for which there is a wealth of data, but they consistently underdose it. The British favor midazolam and continental Europeans often choose clonazepam for its favorable pharmacology, but hunger for randomized clinical data to support their preconceived conclusions. Families of people with epilepsy prefer giving agents across the buccal mucosa rather than rectally. Some paramedics like the certainty of an IM injection and others the needleless-ness of an intranasal atomizer. Administrators want to avoid higher-cost preparations and favor agents with long shelf lives without refrigeration. Clinical investigations are typically designed with only one of these aspects in mind. As with the blind men and the elephant (figure), a coherent view of the big picture remains elusive. How, then, are we to best understand the data surrounding this clinical question?

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  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the editorial.

  • See page 1859

  • © 2015 American Academy of Neurology
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