BNF for Children 2011-2012

BNFC 2011–2012 4.8.2 Drugs used in status epilepticus 231ache, paradoxical effects including aggression andanxiety, sexual dysfunction, urinary incontinence,urticaria, pruritus, reversible hair loss, skin pigmentationchanges; dysarthria, and visual disturbances onlong-term treatment; blood disorders reported; overdosage:see Emergency Treatment of Poisoning, p. 30Indication and doseAll forms of epilepsy. By mouthChild 1 month–1 year initially 250 micrograms atnight for 4 nights, increased over 2–4 weeks tousual maintenance dose of 0.5–1 mg at night (maybe given in 3 divided doses if necessary)Child 1–5 years initially 250 micrograms at nightfor 4 nights, increased over 2–4 weeks to usualmaintenance of 1–3 mg at night (may be given in 3divided doses if necessary)Child 5–12 years initially 500 micrograms at nightfor 4 nights, increased over 2–4 weeks to usualmaintenance dose of 3–6 mg at night (may begiven in 3 divided doses if necessary)Child 12–18 years initially 1 mg at night for 4nights, increased over 2–4 weeks to usual maintenancedose of 4–8 mg at night (may be given in3–4 divided doses if necessary)Note Clonazepam doses in BNFC may differ from those inproduct literatureAdministration for administration by mouth, injectionsolution may be given orallyClonazepam (Non-proprietary) KTablets, clonazepam 500 micrograms, net price 100-tab pack = £3.93; 2 mg, 100 tab-pack = £5.28. Label: 2,8, counselling, driving (see notes above)Rivotril c (Roche) KTablets, both scored, clonazepam 500 micrograms(beige), net price 100-tab pack = £3.69; 2 mg (white),100-tab pack = £4.93. Label: 2, 8, counselling, driving(see notes above)Injection, section 4.8.2Liquid, clonazepam 0.5 mg/5 mL; 2 mg/5 mL;2.5 mg/mLAvailable from ‘special-order’ manufacturers or specialistimporting companies, see p. 809Extemporaneous formulations available seeExtemporaneous Preparations, p. 6NITRAZEPAMCautions avoid abrupt withdrawal; respiratory disease;acute porphyria (section 9.8.2); muscle weaknessand myasthenia gravis; interactions: Appendix 1(anxiolytics and hypnotics)Contra-indications respiratory depression, acutepulmonary insufficiency, sleep apnoea syndrome;marked neuromuscular respiratory weakness includingmyasthenia gravisHepatic impairment see notes aboveRenal impairment see notes aboveSide-effects drowsiness, confusion, ataxia; see alsounder Diazepam (section 4.8.2); overdosage: seeEmergency Treatment of Poisoning, p. 30Licensed use not licensed for use in childrenIndication and doseInfantile spasms. By mouthChild 1 month–2 years initially 125 micrograms/kg twice daily, adjusted according to response over2–3 weeks to 250 micrograms/kg twice daily; max.500 micrograms/kg (not exceeding 5 mg) twicedaily; total daily dose may alternatively be given in3 divided dosesNitrazepam (Non-proprietary) KOral suspension, nitrazepam 2.5 mg/5 mL, net price150 mL = £5.09. Label: 1, 8Brands include Somnite c DOther drugsAcetazolamide (section 11.6), a carbonic anhydraseinhibitor, has a specific role in treating epilepsy associatedwith menstruation. It can also be used in conjunctionwith other antiepileptics for refractory tonicclonic,absence, or focal seizures. It is occasionallyhelpful in atypical absence, atonic, and tonic seizures.Piracetam is used as adjunctive treatment for corticalmyoclonus.4.8.2 Drugs used in statusepilepticusConvulsive status epilepticus Immediate measuresto manage status epilepticus include positioning thechild to avoid injury, supporting respiration includingthe provision of oxygen, maintaining blood pressure,and the correction of any hypoglycaemia. Pyridoxine(section 9.6.2) should be administered if the status epilepticusis caused by pyridoxine deficiency.Seizures lasting longer than 5 minutes should be treatedurgently with intravenous lorazepam and repeatedonce after 10 minutes if seizures recur or fail to respond.Intravenous diazepam is effective but it carries a highrisk of venous thrombophlebitis (reduced by using anemulsion formulation of diazepam injection). Clonazepamcan also be used as an alternative.Where facilities for resuscitation are not immediatelyavailable, midazolam can be given into the buccalcavity, or diazepam can be administered as a rectalsolution; the buccal route may be more acceptable inchildren.ImportantIf, after initial treatment with benzodiazepines, seizuresrecur or fail to respond 20 minutes after onset,phenytoin sodium, fosphenytoin, or phenobarbitalsodium should be used; the paediatric intensive careunit should be contacted.If these measures fail to control seizures 40 minutesafter onset, anaesthesia with thiopental (section15.1.1) or midazolam (section 15.1.4) should beinstituted with full intensive care support.Phenytoin sodium can be given by slow intravenousinjection, followed by the maintenance dosage if appropriate;monitor ECG and blood pressure, and reducerate of administration if bradycardia or hypotension4 Central nervous system