Rescue medications for epilepsy can stop a seizure crisis in its tracks. Having these medications readily available provides a safety net for patients experiencing a prolonged seizure or seizure clusters outside a hospital setting.
At Penn Medicine, epilepsy specialists are spearheading the push to ensure every epilepsy patient has a rescue plan for seizures at home. A plan will often include monitoring and safety recommendations as well as the use of rescue medications. All neurologists can offer the recently approved intranasal options, which provide an easy-to-use rescue therapy in emergency situations. Through open clinical trials at Penn, patients can benefit from the latest developments in rescue medications, including a rapid-acting inhaled benzodiazepine.
Currently Available Epilepsy Rescue Medications for Outpatient Use
Most epilepsy rescue medications are benzodiazepines, a class of GABA-receptor agonists often used for daily seizure prevention, including forms of diazepam, lorazepam and midazolam. In the short term, benzodiazepines provide very effective acute seizure treatment.
“The key concern with the treatment of a seizure is how quickly you can get a molecule to the patient’s brain,” notes Michael Gelfand, MD, PhD, associate professor of clinical neurology. Dr. Gelfand specializes in epilepsy diagnosis and treatment at the Penn Epilepsy Center.
For decades, the only outpatient rescue option was rectal diazepam gel, approved by the Food and Drug Administration in 1997. Though effective, this method of delivery is often difficult for caretakers to administer, especially in a public setting and in adults.
Thanks to research partially conducted at Penn, the FDA recently approved two new intranasal options. Midazolam (Nayzilam®) was approved in 2019, and intranasal diazepam (Valtoco®) came on the market in 2020. Both are now widely available in the United States and work to halt a seizure with greater ease and less sedation.
The Search for the Most Efficient Rescue Therapy for Seizures
Researchers continue to investigate even faster methods of rescue medication delivery, including buccal and inhaled options, which avoid the additional steps of passing through the intestines and liver. The Penn team plays a significant role as a study site to help to identify patients who may benefit most.
An ongoing clinical trial at Penn is investigating staccato alprazolam, an inhaled benzodiazepine that potentially offers the most rapid rescue therapy. The small medication particles reach deep into the lungs, and are quickly absorbed into the bloodstream due to the lungs high perfusion rate, simple metabolic process and large surface area. According to Dr. Gelfand, strong data supports its ability to reach the brain and take effect in two minutes or less. “We think it may work in just 30 seconds,” he says.
Eligible patients have access to these innovative medications at Penn Epilepsy Center. To refer a patient to a clinical trial, visit our online referral site.
When to Prescribe Rescue Medication
Without exception, epilepsy patients who have an established pattern of seizures that last several minutes or longer should have a rescue medication on hand. Seizures may present as continuous events or as acute repetitive seizures.
For the remaining epilepsy patients, the guidelines for prescribing and using rescue medication for seizures are less clear-cut. “Ultimately, a medication with a small chance of preventing a trip to the emergency department and preventing status epilepticus is still an extremely helpful medication,” says Dr. Gelfand.
“A lot of us at Penn are finding that our patients do benefit from having rescue medications for an extra sense of security,” he reflects. “They provide patients with something to use on the off chance that their seizures become worse, even if we don’t know in advance that that’s going to happen.”
Encouraging a New Epilepsy Rescue Medication Protocol
The Penn team hopes to encourage more general neurologists to consider prescribing rescue medications to every patient with epilepsy. “You don’t have to be an epileptologist to prescribe rescue medications,” notes Dr. Gelfand. “But there’s still a lot of work for us to do in terms of education and establishing best use.”
The Penn team is also available to provide second opinions, consultations, and education about rescue medications for providers and patients. Dr. Gelfand also acknowledges neurologists’ concerns about broadly prescribing epilepsy rescue medications, including the possibility of benzodiazepine tolerance, dependence, or abuse.
“We’re prescribing these medications not to be taken every day, but really as an individualized plan for each patient,” he says. “I generally advise most of my patients that they should be using rescue medications only when needed. We’ll talk about when exactly that is for each person.”
The exact regimen depends on the severity and frequency of seizures, and the individual’s benefit from the medication. It may help some patients regularly, while acting as a back-up every six months for others. Dr. Gelfand starts with an estimate to determine whether the epilepsy rescue medication helps at all, and goes from there. He notes that patients typically should limit taking rescue medications to about once a week or less.
“When that’s the case, I really don’t have concerns,” he says. “I give patients a dose and amount that allows them to safely use it to prevent their seizures from getting worse and to keep them from having to go to the hospital.”
Additional Resources from the Penn Epilepsy Center