Intranasal Midazolam Works for Seizure Emergencies in Kids

Megan Brooks

November 05, 2013

AUSTIN, Texas — For acute seizure emergencies in children, intranasal midazolam is as safe and effective as intravenously or rectally administered diazepam, according to a systematic review of published studies.

Syndi Seinfeld, MD, and John Pellock, MD, from Virginia Commonwealth University Medical Center in Richmond, did the analysis and presented their findings here at the Child Neurology Society (CNS) 2013 Annual Meeting.

They reviewed 7 randomized studies of intranasal midazolam for treatment of acute seizure emergencies in roughly 200 patients aged 18 or younger. Four trials compared intranasal midazolam with intravenous diazepam and 3 compared intranasal midazolam with rectal diazepam. Intranasal administration was achieved by spraying or dripping midazolam intravenous solution into the nose.

In all studies, intranasal midazolam (0.2 mg/kg) was as effective as intravenous or rectal diazepam (0.2 to 0.5 mg/kg) in treating seizure emergencies with a rapid (<5 minutes) onset of action, the researchers reported.

Intranasal midazolam and intravenous or rectal diazepam demonstrated similar safety profiles, with "few reports" of respiratory depression across all 3 treatment approaches, they noted.

No Surprises

"I was glad to see this abstract" reviewing the published studies on intranasal midazolam, Anup D. Patel, MD, attending physician at the Pediatric Epilepsy Center at Nationwide Children's Hospital in Columbus, Ohio, who wasn't involved in the study, told Medscape Medical News.

He said the findings come as "no surprise. We use off-label intranasal midazolam on a regular basis and have for several years," as do other institutions around the country, Dr. Patel said.

His center uses intranasal midazolam in both the inpatient and outpatient setting. "Patients and families are given specific instructions on when to use it, usually for prolonged seizures or clusters of seizures," Dr. Patel said.

"It's a lot cheaper than rectal diazepam and easier to administer. The downsides are that it's not an FDA [US Food and Drug Administration]-approved indication for its use," Dr. Patel noted.

But that may change. Upsher-Smith Laboratories is testing an intranasal formulation of midazolam for acute repetitive seizures in clinical trials, reported recently by Medscape Medical News.

Dr. Pellock, who worked on the current analysis, has been involved in advisory boards and served as consultant to Upsher-Smith Laboratories. Dr. Seinfeld and Dr. Patel have disclosed no relevant financial relationships.

Child Neurology Society (CNS) 2013 Annual Meeting. Abstract #80. Presented October 31, 2013.

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