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Buccal midazolam versus rectal diazepam for seizures

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For the emergency treatment of seizures in hospital intravenous lorazepam may be used but in small children and outside hospital intravenous access is often difficult. Rectal diazepam has been used for many years and more recently midazolam has been used by nasal or buccal route. Now buccal midazolam has been compared with rectal diazepam in emergency departments in Liverpool, Derby, Nottingham, and Birmingham (OpenUrlCrossRefPubMedWeb of Science).

The study included children aged at least 6 months who had a continuing seizure and did not have established intravenous access. A total of 219 episodes in 177 patients were included in the analysis. Randomisation at each hospital was to weekly blocks of treatment with either buccal midazolam or rectal diazepam. For each drug the dose was 2.5 mg, 5 mg, 7.5 mg, and 10 mg at ages 6–12 months, 1–4 years, 5–9 years, and 10 years or older. Most of the children (62%) were between 1 and 4 years old (range at first treatment episode 7 months to 15 years). Treatment success (cessation of the seizure within 10 minutes without respiratory depression and with no seizure recurrence within 1 hour) was achieved in 61/109 episodes (56%) treated with buccal midazolam and 30/110 (27%) with rectal diazepam. (If the seizure was continuing at 10 min and there was intravenous access intravenous lorazepam was given.) After adjustment for hospital centre, age, diagnosis of epilepsy, presence of fever, use of antiepileptic drugs, prior treatment, and duration of seizure before treatment, buccal midazolam was significantly more effective than rectal diazepam (odds ratio 4.1). The median time to seizure cessation was 8 min (midazolam) vs 15 min (diazepam). Intravenous lorazepam was used in 36 episodes (33%) treated with midazolam and 63 episodes (57%) treated with diazepam. Respiratory depression was recorded in five episodes in the midazolam group and seven in the diazepam group.

Buccal midazolam is more effective than rectal diazepam for the emergency treatment of children with seizures.

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