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

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?