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Three Part Question

In [children in status epilepticus] is [lorazepam better than diazepam] at [safely terminating the seizure]?

Clinical Scenario

A 2 year old is brought to the emergency department with a first presentation of fitting secondary to febrile illness. She has been fitting for >30 minutes. You obtain intravenous access and wonder if lorazepam or diazepam would be best at terminating the fit safely.

Search Strategy

Medline 1966-9/99 using OVID interface.
Ovid MEDLINE 1966 to March Week 3 2006
OVID Embase 1980 to 2006 Week 12
The Cochrane Library 2006, Issue 1
Medline:({status epilepticus.mp. OR exp epilepsy/ OR epilep$.mp. OR exp seizures/ OR convulsions.mp. OR fit$.mp.} AND {exp lorazepam OR lorazepam.mp.} AND {exp diazepam/ OR diazepam.mp.} AND BestBETs Paediatric filter. LIMIT to Humans and English Language
Embase: ({status epilepticus.mp. OR exp epilepsy/ OR epilep$.mp. OR seizure$.mp OR exp convulsion/ OR fit$.mp.} AND {exp lorazepam OR lorazepam.mp.} AND {exp diazepam/ OR diazepam.mp.} AND [exp emergency ward/] LIMIT to Humans and English Language and (infant or child or preschool child <1 to 6 years> or school child <7 to 12 years> or adolescent <13 to 17 years>)
Cochrane:(status epilepticus *drug therapy [MeSH] AND child [MeSH]) 11 articles – 1 relevant

Search Outcome

65 references found on all three databases, of which 2 were relevant to the question. These are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Appleton RE et al, 1995, UK	102 children attending the Emergency department with acute convulsions and status epilepticus Odd and even dates. 53 Diazepam (0.3-0.4 mg/kg) vs 33 Lorezepam (0.05-0.1 mg/kg) 16 excluded from study due to inappropriate dose given	Controlled trial	Seizure control with a single dose	76% vs 51%	Not blinded
Queshiri A et al, 2002, UK	46 children attending the Emergency Department with prolonged seizure. 17 Diazepam (0.3 mg/kg) vs 31 Lorezepam (0.1 mg/kg)	Controlled trial	Seizure control within 5 min of cannula insertion	65% vs 65%	Not blinded, Not randomised

Comment(s)

A Cochrane review has been published on this topic, but includes the first paper only. This BET does not address the issue of the relative safety of the two treatments.

Editor Comment

* = awaiting data

Clinical Bottom Line

Lorazepam and diazepam are equally effective at seizure control in children.

References

1. Appleton RE, Sweeney A, Choonara I, Robson J, Molyneux E. Lorazepam versus diazepam in the acute treatment of epileptic seizures and status epilepticus. Developmental Medicine and Child Neurology 1995;37:682-8.
2. Qureshi A, Wassmer E, Davies P et al. Comparative audit of intravenous lorazepam and diazepam in the emergency treatment of convulsive status epilepticus in children. Seizure 2002;11:141-4.