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Treatment of nonconvulsive status epilepticus (NCSE) in adults

	Initial dose	Re-loading dose	Maintenance dose
Parenteral benzodiazepine choices (initial regimen)
Lorazepam	2 to 4 mg IV bolus up to up to 2 mg/min	2 to 4 mg IV	N/A
Diazepam	5 to 10 mg IV bolus up to 5 mg/min	5 to 10 mg IV	N/A
Midazolam	5 to 10 mg IV or IM	5 to 10 mg IV or IM	N/A
Nonsedating antiseizure choices (initial regimen)
Phenytoin	15 mg/kg IV (up to 50 mg/min)	10 to 15 mg/kg up to a maximum cumulative dose of 30 mg/kg*	5 to 7 mg/kg/day orally/IV, divided every 8 hours
Fosphenytoin	15 mg PE/kg IV (up to 150 mg PE/min)	10 mg PE/kg up to a maximum cumulative dose of 25 to 30 mg/kg*	5 to 7 mg PE/kg/day IV, divided every 8 hours
Valproate	30 mg/kg IV (up to 5 mg/kg/min)	20 mg/kg up to a maximum cumulative dose of 4000 mg	30 to 60 mg/kg/day, orally/IV divided every 6 to 12 hours^¶
Levetiracetam	40 mg/kg IV (up to 5 mg/kg/min, typically given over 15 min, maximum 4500 mg)	1000 to 2000 mg up to a maximum cumulative dose of 4500 mg	2 to 4 g/day orally/IV, divided every 6 to 12 hours^¶^Δ
Lacosamide	200 mg IV (over 15 min)	200 mg IV	200 to 600 mg/day orally/IV, divided every 12 hours^¶
Potential oral or nasogastric add-on nonanesthetic options
Topiramate	100 mg orally every 12 hours	N/A	300 to 800 mg/day orally, divided every 8 to 12 hours
Gabapentin	300 mg orally every 8 hours	N/A	1800 to 3600 mg/day orally, divided every 6 to 8 hours
Pregabalin	75 mg orally every 12 hours	N/A	150 to 600 mg/day orally, divided every 8 to 12 hours
Clobazam	10 to 20 mg orally every 12 hours	N/A	Up to 60 mg/day orally, divided every 12 hours
Perampanel	6 to 12 mg orally every 24 hours	N/A	Up to 12 mg orally every 24 hours
Oxcarbazepine	300 to 600 mg orally every 12 hours	N/A	Up to 2400 mg/day orally, divided every 12 hours
Carbamazepine	300 to 800 mg orally in two to four divided doses (product dependent)	N/A	Up to 1600 mg/day orally, divided every 12 hours (tablets) or every 6 hours (liquid)
Vigabatrin	500 to 750 mg orally every 12 hours	N/A	Up to 3000 mg/day orally, divided every 12 hours^◊
Continuous infusion anesthetic options in critically ill mechanically ventilated patients^§
Midazolam	0.2 mg/kg IV (up to 2 mg/min) every 5 min until seizures controlled or maximum dose of 2 mg/kg; followed by continuous infusion	N/A	0.05 to 2.9 mg/kg/hour continuous IV infusion
Propofol	1 to 2 mg/kg IV every 5 min until seizures controlled or maximum dose 10 mg/kg; followed by continuous infusion	N/A	1.8 to 12 mg/kg/hour continuous IV infusion (limit to 5 mg/kg/hour for treatment >48 hours)
Pentobarbital	5 mg/kg IV (up to 50 mg/min) every 5 min until seizures controlled up to a maximum of 25 mg/kg; followed by continuous infusion	N/A	0.5 to 10 mg/kg/hour continuous IV infusion
Ketamine	1.5 mg/kg IV every 5 min until seizures controlled or up to a maximum dose of 4.5 mg/kg; followed by continuous infusion	N/A	1.2 to 7.5 mg/kg/hour continuous IV infusion
Other potential treatments
Ketogenic diet
Methylprednisolone	1 g/day for 3 days	N/A	1 mg/kg/day then taper
IVIG	0.4 g/kg/day for 5 days	N/A	N/A
Plasma exchange
Hypothermia
Electroconvulsive therapy

For the initial treatment of NCSE in most adults, we suggest an IV benzodiazepine (eg, lorazepam) combined or sequenced with a nonsedating IV antiseizure medication (eg, fosphenytoin, valproate, levetiracetam, lacosamide) under closely monitored conditions with continuous EEG. Treatment choices and sequence must be individualized based upon clinical features. Refer to UpToDate topics on treatment of nonconvulsive status epilepticus for details.
Critically ill patients often exhibit altered drug pharmacokinetics due to organ dysfunction, reduced protein binding, and/or hypermetabolic state. Adjustment of dose guided by serum drug concentration may be necessary, particularly for levetiracetam, (fos)phenytoin, and valproate.^¶

D: day; EEG: electroencephalography; g: gram; h: hour; IM: intramuscular; IV: intravenous; IVIG: intravenous immunoglobulin; kg: kilogram; min: minutes; mg: milligram; N/A: not applicable; NCSE: nonconvulsive status epilepticus; PE: phenytoin equivalent.

* In patients receiving phenytoin chronically the maximum reloading dose is determined by assessment of serum concentration.

¶ Oral/enteral bioavailability may be limited in critically ill patients due to ileus, intestinal wall edema, and visceral hypoperfusion; IV formulations are preferred when available.

Δ Higher doses and more frequent dosing may be necessary in some critically ill patients.

◊ Vigabatrin has been associated with vision loss and availability in the United States is restricted. The US Food and Drug administration recommends baseline and serial monitoring of visual fields every three months in patients treated with vigabatrin.

§ Anesthetic agents are titrated to seizure termination by an experienced intensivist in a critical care unit.

Courtesy of authors with additional data from Brophy GM, Bell R, Claassen J, et al; Neurocritical Care Society Status Epilepticus Guideline Writing Committee. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17:3 and Lexicomp Online. Copyright © 1978-2023 Lexicomp, Inc. All Rights Reserved.

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