Midazolam versus Diazepam for the treatment of status Epilepticus in children and young adults: A meta-analysis

Abstract

Background: Rapid treatment of status epilepticus (SE) is associated with better outcomes. Diazepamand midazolam are commonly used, but the optimal agent and administration route is unclear.Objectives: The objective was to determine by systematic review if nonintravenous (non-IV) midazolamis as effective as diazepam, by any route, in terminating SE seizures in children and adults. Time to seizurecessation and respiratory complications was examined.Methods: We performed a search of PubMed, Web of Knowledge, Embase, Cochrane Database of SystematicReviews, Database of Abstracts of Reviews of Effects, American College of Physicians JournalClub, Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied HealthLiterature, and International Pharmaceutical Abstracts for studies published January 1, 1950, throughJuly 4, 2009. English language quasi-experimental or randomized controlled trials comparing midazolamand diazepam as first-line treatment for SE, and meeting the Consolidated Standards of Reporting Trials(CONSORT)-based quality measures, were eligible. Two reviewers independently screened studies forinclusion and extracted outcomes data. Administration routes were stratified as non-IV (buccal, intranasal,intramuscular, rectal) or IV. Fixed-effects models generated pooled statistics.Results: Six studies with 774 subjects were included. For seizure cessation, midazolam, by any route, wassuperior to diazepam, by any route (relative risk [RR] = 1.52; 95% confidence interval [CI] = 1.27 to 1.82).Non-IV midazolam is as effective as IV diazepam (RR = 0.79; 95% CI = 0.19 to 3.36), and buccal midazolamis superior to rectal diazepam in achieving seizure control (RR = 1.54; 95% CI = 1.29 to 1.85). Midazolamwas administered faster than diazepam (mean difference = 2.46 minutes; 95% CI = 1.52 to 3.39 minutes)and had similar times between drug administration and seizure cessation. Respiratory complicationsrequiring intervention were similar, regardless of administration route (RR = 1.49; 95% CI = 0.25 to 8.72). Conclusions: Non-IV midazolam, compared to non-IV or IV diazepam, is safe and effective in treatingSE. Comparison to lorazepam, evaluation in adults, and prospective confirmation of safety and efficacyis needed. © 2010 by the Society for Academic Emergency Medicine.