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Phenytoin or Fosphenytoin as a second line treatment of Status Epilepticus in the Emergency Department.

Three Part Question

In [adult patients presenting in Status epilepticus to the Emergency Department] is [Fosphenytoin superior to Phenytoin] in [seizure control or side effects]

Clinical Scenario

A 52 yr old known epileptic is brought in fitting for short time period to the Emergency Department (ED). She has received an appropriate dose of PR Diazepam pre-hospital and the seizure continues despite further IV lorazepam. You wonder whether there is any evidence to suggest a benefit of IV Fosphenytoin over IV Phenytoin as second line treatment of status epilepticus.

Search Strategy

Medline 1966 to April 2004 and Embase 1980 to 2005 week 16 using the OVID interface.
[exp status epilepticus] AND [exp phenytoin OR] AND [exp fosphenytoin OR] Limit to human and English language. All papers cross-referenced.

Search Outcome

Altogether 88 papers were found of which only 1 directly addressed the three-part question.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Coplin WM et al
256 patients presenting in Status epilepticus to the Emergency DepartmentRandomized controlled trialAdverse eventsPhenytoin =6.5%, Fosphenytoin 6.4% OR 0.9, (95% Cl 0.4-2.6;p=1.0)Not mentioned which drug was more effective in controlling seizure activity. No specific mention of cardiac complications.
Length of Stay in EDMedian stay 6.7h for phenytoin and 5.7h for fosphenytoin (p=0.6)


Despite many literature reviews suggesting that fosphenytoin has fewer side effects and a seemingly intuitive advantage in speed of delivery as compare to phenytoin, there has only been one randomized control trial comparing them, which showed no difference on the incidence of adverse effects and length of stay in emergency department when fosphenytoin is used.

Clinical Bottom Line

There is no evidence as yet that fosphenytoin offers any significant clinical advantages over phenytoin in the emergency department.


  1. Coplin WM et al Randomized evaluation of adverse events and length-of-stay with routine emergency department use of phenytoin or fosphenytoin. Neurological Research. Vol. 24 (8) (pp 842-848), 2002.