Prolonged Acute Convulsive Seizures Research Articles

Bioavailability and Safety of a New Highly Concentrated Midazolam Nasal Spray Compared to Buccal and Intravenous Midazolam Treatment in Chinese Healthy Volunteers.

IntroductionBuccal midazolam treatment is licensed in the European Union for prolonged acute convulsive seizures in children and adolescents, but the buccal pathway is often hampered by jaw clenching, hypersalivation, or uncontrolled swallowing. Midazolam formulations that are more secure, reliable, and faster for use are needed in the acute setting. Pharmacokinetics and comparative bioavailability of intranasally administered midazolam and two midazolam intravenous solutions administered buccally or intravenously in healthy adults were evaluated.MethodsIn this phase 1, open-label, randomized, single-dose, three-period, three-sequence crossover study, 12 healthy adults (19–41 years) were randomly assigned to receive 2.5 mg midazolam intranasally; 2.5 mg midazolam intravenously; 2.5 mg midazolam buccally. Blood samples were collected for 10 h post dose to determine pharmacokinetic profiles. Adverse events and vital signs were recorded.ResultsIntranasal administration of 2.5 mg midazolam demonstrated a more rapid median time to Cmax compared to buccal administration of midazolam (Tmax, 12.6 min vs. 45 min; Cmax, 38.33 ng/ml vs. 24.97 ng/ml). The antiepileptic effect of intranasal and buccal midazolam treatment lasted less than 4 h and generally did not differ from intravenously administered midazolam. No serious adverse events or deaths were reported, and no treatment-emergent adverse events led to study discontinuation.ConclusionIntranasal administration of midazolam may be a preferable alternative to the currently approve buccal midazolam treatment for prolonged acute convulsive seizures in children and adolescents.Trial RegistrationThis study is registered at the Chinese Clinical Trial [http://www.chictr.org.cn] (ChiCTR2000032595) on 3 May, 2020.

Health-related quality of life and the burden of prolonged seizures in noninstitutionalized children with epilepsy

ObjectiveThis study aimed to provide information on the burden of illness and health-related quality of life (HRQoL) in children with epilepsy who experience prolonged acute convulsive seizures (PACS) in the community setting, and to investigate factors that may predict poor HRQoL in this population. MethodsNoninstitutionalized children (aged 3–16 years) who had experienced at least one PACS within the past year and had currently prescribed PACS rescue medication were enrolled in a cross-sectional study in Germany, Italy, Spain, and the United Kingdom (Practices in Emergency and Rescue medication For Epilepsy managed with Community-administered Therapy 3 [PERFECT-3]). Clinicians, parents/guardians, and patients completed web-based questionnaires regarding clinical characteristics, PACS frequency, and day-to-day impairment. Patients' HRQoL was rated by clinicians, parents/guardians, and patients themselves using the 5-dimension EuroQol questionnaire (EQ-5D) and summarized as a utility score. Potential predictors of poor HRQoL were tested in individual univariate generalized linear models and a global multivariable model. ResultsEnrolled children (N = 286) had experienced 1–400 PACS (median: 4) in the past year. Clinicians reported that 216/281 patients (76.9%) had learning disabilities of varying severity. Mean EQ-5D utility scores rated by clinicians (n = 279), parents (n = 277), and patients (n = 85) were 0.52 (standard deviation: 0.41), 0.51 (0.39), and 0.74 (0.29), respectively. Increasing PACS frequency, increasing severity of learning disability, and specialist school attendance were significantly associated with decreasing EQ-5D utility score. In the multivariable model, having learning disabilities was the best predictor of poor HRQoL. SignificanceHealth-related quality of life was very poor in many children with epilepsy whose PACS were managed with rescue medication in the community, with learning disability being the most powerful predictor of patients' HRQoL. Mean EQ-5D utility scores were lower (worse) than published values for many other chronic disorders, indicating that optimal treatment should involve helping children and their families to manage learning disabilities and day-to-day impairments, in addition to preventing seizures.

Buccal Midazolam Solution for the Management of Prolonged Acute Convulsive Seizures: A Cost Analysis.

BackgroundThere is little published evidence on how pack size impacts on health system costs. In the UK, children and adolescents aged 10 to < 18 years with prolonged acute convulsive seizures (PACS) occurring in the community setting are usually managed by the administration of buccal midazolam: Epistatus® or Buccolam®. These two preparations have markedly differing cost structures, being sold at different prices and presented as single units versus 4-packs, respectively. Consequently, the cost-per-PACS and overall budget impact of the two products cannot be simply inferred but is instead dependent on the likelihood of use. Also relevant to its likelihood of use is midazolam’s status as a controlled substance under the Misuse of Drugs Act.Objective and MethodsThe purpose of this economic analysis was to present the cost implications of single-unit versus multi-pack prescribing of a rescue medication based on likelihood of use. There is little published evidence to inform the likelihood of a midazolam dose being used once prescribed. A Delphi survey was conducted with physicians (n = 5), nurses (n = 11) and pharmacists (n = 24) from the community and hospital healthcare settings in the UK to explore the frequency distribution of prolonged seizures in the general epileptic population per 6-month period, along with common patterns of prescribing. This informed a model of the budgetary impact of single-unit (Epistatus®) versus 4-pack (Buccolam®) prescribing.ResultsRespondents cited both ‘wastage’ and ‘dispensing more than is likely to be used of a controlled drug’ as poor clinical practice, which suggests that prescribing in multiples of four should be reserved for patients who are likely to experience PACS at a higher frequency. The Delphi survey and subsequent regression analysis found that PACS frequency distribution follows an exponential drop, with over half (55%) of patients experiencing zero to one prolonged seizure(s) per 6-month period. Despite this, the majority (70%) of low PACS frequency patients are prescribed buccal midazolam in multiples of four by their treating physician. When looking at overall budgetary impact, the strategy of prescribing single-unit Epistatus® versus 4-pack Buccolam® is cost saving in low PACS frequency patients who do not require multiple units (referred to as spare loading), at − £15.33 per patient per 6 months. If spare loading is universally applied to all patients irrespective of seizure frequency, the mean incremental cost of single unit Epistatus® instead of 4-pack Buccolam® equates to £51.23 per patient per 6 months. If spare loading is reserved for higher PACS frequency patients (two or more per 6 months), the universal prescribing of single-unit Epistatus® versus 4-pack Buccolam® would result in a mean incremental cost of £17.82 per patient per 6 months.ConclusionsThe availability of single-unit Epistatus® allows for greater flexibility in prescribing. Physicians should attempt to categorise patients according to past PACS frequency with low PACS patients being prescribed single unit Epistatus® (with/without spare loading) and 4-pack Buccolam® reserved for patients in whom a high volume of usage is anticipated.Electronic supplementary materialThe online version of this article (10.1007/s41669-019-0164-x) contains supplementary material, which is available to authorized users.

Effect of rescue medication on seizure duration in non-institutionalized children with epilepsy.

Characterize the real-world management of and outcomes for children with epilepsy receiving rescue medication for prolonged acute convulsive seizures (PACS) in the community. PERFECT-3 (Practices in Emergency and Rescue medication For Epilepsy managed with Community-administered Therapy 3) was a European, retrospective observational study. Eligible patients were non-institutionalized children with epilepsy aged 3-16 years who had experienced ≥1 PACS in the past year and had ≥1 currently prescribed PACS rescue medication. Investigators provided clinical assessments and parents/guardians completed questionnaires. Statistical tests were post hoc; p values are descriptive. At enrollment (N=286), most patients had prescriptions for diazepam (69.2%) and/or midazolam (55.9%); some had two (26.6%) or three (2.4%) prescribed rescue medications. Most patients experienced PACS despite regular anti-epilepsy medication. According to parents, the average duration of their child's seizures without rescue medication was <5min in 35.7% of patients, 5-<20min in 42.6%, and ≥20min in 21.7% (n=258); withrescue medication seizure duration was <5min in 69.4% of patients, 5-<20min in 25.6%, and ≥20min in 5.0%. Rescue medication use was significantly associated with average seizures lasting <5min (χ2=58.8; p<0.0001). At the time of their most recent PACS, 58.5-67.8% of children reportedly received rescue medication within 5min of seizure onset, and 85.4-94.1% within 10min. This study provides the first real-world data that rescue medications administered in the community reduce the duration of PACS in children with epilepsy. Study limitations including potential recall bias are acknowledged.

Oromucosal midazolam in patients with prolonged acute convulsive seizures: An Italian experience

Objective: In pediatric age, convulsive seizures lasting more than 5 minutes represent a life- threatening condition. Oromucosal midazolam is a promising first-line treatment option, which is approved in the EU for the treatment of prolonged, acute, convulsive seizures (PACS), in patients aged between 6 months and 18 years. The aim of this study is to evaluate the effectiveness of oromucosal midazolam and, to compare with rectal diazepam efficacy. Methods: We included all consecutive patients followed-up at Bambino Gesù Children's Hospital in Rome who received oromucosal midazolam treatment between January 2015 and July 2016. A telephone survey was carried out to evaluate effectiveness, tolerability and convenience of the administration route of oromucosal midazolam in terminating PACS. Moreover, when rectal diazepam was previously used, has been asked a comparative effectiveness between the two benzodiazepines. Results: We enrolled 293 patients (149 males), aged between 6 months and 18 years (9±4,61 years old; median: 9 years) at the time of prescription, with a 16-month follow-up in average (16±5,24 months). Most of them (98/203, 48%) had a symptomatic epilepsy and 90% (268/273) received oromucosal midazolam care plan for the first time. We will present the results of the telephone survey. Conclusion: In the previous reported clinical trials, oromucosal midazolam was at least as effective as rectal diazepam in the treatment of PACS in children and was generally well tolerated. The results of this survey showed that oromucosal midazolam has several advantages if compared with rectal diazepam, the previous gold standard of treatment, such as having a more convenient and socially acceptable administration route.

PP07.13 – 2777: Disease characteristics and learning disabilities in a European survey of children with epilepsy who experience prolonged acute convulsive seizures

Objective To survey epilepsy aetiology, seizure frequency, and educational needs in children with epilepsy who experience prolonged acute convulsive seizures (PACS). Methods Practices in Emergency and Rescue medication For Epilepsy managed with Community-administered Therapy 3 (PERFECT-3) was an international, cross-sectional, observational study. Eligible patients were non-institutionalized children with epilepsy (aged 3–16 years) who had experienced ≥1 PACS within the last 12 months and had current prescription(s) for PACS rescue medication. Investigators provided clinical assessments and patients' parents/guardians completed web-based questionnaires. Results A total of 286 patients were enrolled in Germany (n=92 [32.2%]), Italy (n=75 [26.2%]), Spain (n=77 [26.9%]) and the UK (n=42 [14.7%]). Their mean age was 8.9 years (standard deviation [SD], 3.8) and 54.9% were male. The median time since diagnosis was 4 years (range, 0–16). Epilepsy aetiology was genetic in 30.6%, structural in 29.9%, other/unknown in 37.7% and metabolic in 1.8% of patients. In the 12 months before enrolment, patients had experienced 1–400 PACS (median, 4; mean, 23.6 [SD, 59.8]); 54.9% experienced 1–5 and 9.8% experienced ≥51. Parents (n=258) reported that their children experienced PACS lasting >5 minutes daily (4.7%), weekly (10.2%), monthly (10.5%), every two (8.6%) or three (17.2%) months, or 2–3 times per year (44.9%). The majority of patients (52.7%) could not undertake typical day-to-day activities and most (76.9%) had learning disabilities. Of these, 28.2%, 41.7% and 30.1% had severe, moderate or mild learning disabilities, respectively. Only 42.0% of parents reported that their child attended mainstream school. Conclusions The frequency of PACS ranged widely in this European cross-sectional survey. The study confirmed that children with epilepsy who experience PACS often face learning disabilities and need specialist education. Study funded by ViroPharma (part of the Shire Group of Companies).

PP07.10 – 2874: Frequency of ambulance use and hospital admission following prolonged acute convulsive seizures in a European survey of children with epilepsy

Objective To explore patterns of healthcare utilization in children with epilepsy who experience prolonged acute convulsive seizures (PACS) and have prescribed rescue medication for PACS. Methods Practices in Emergency and Rescue medication For Epilepsy managed with Community-administered Therapy 3 [PERFECT-3]) enrolled non-institutionalized children (aged 3–16 years) who had been diagnosed with epilepsy ≥12 months previously, had experienced ≥1 PACS within the last 12 months, and had currently prescribed rescue medication(s) for PACS. Patients' parents/guardians completed web-based questionnaires. Results Parents of 258 patients in Germany (n=87), Italy (n=74), Spain (n=72) and the UK (n=25) completed the survey. Rescue medication was always carried by 42.4% of children, was carried by an accompanying adult for 44.0%, and was sometimes or never carried by 6.6% and 7.0%, respectively. For 220 patients (87.3%), the first event following PACS was usually administration of rescue medication at the seizure location. An ambulance was called for 34/171 (19.9%) children whose most recent prolonged seizure occurred at home and for 18/32 (56.3%) at school. In the last three months, an ambulance was called at least once for 54 patients (21.5%), 75 (30.0%) were treated at least once in an emergency department or as outpatients, 21 (8.4%) were admitted at least once to an intensive-care or high-dependency unit, and 32 (12.7%) were admitted at least once to another hospital ward following a seizure. In the last 12 months, an ambulance was called for 100 patients (39.4%), 150 (59.1%) were taken to hospital and 129 (50.8%) were admitted to hospital. Conclusions Although rescue medication was usually carried and usually given at the seizure location, healthcare utilization was high in this European survey of children with epilepsy who experience PACS. Study funded by ViroPharma (part of the Shire Group of Companies)

P46 – 2873: Frequency of rescue medication administration and its effect on seizure duration in a European survey of children with epilepsy who experience prolonged acute convulsive seizures

Objective To compare parent-reported seizure duration with and without rescue medication in children with epilepsy who have prolonged acute convulsive seizures (PACS). Methods Practices in Emergency and Rescue medication For Epilepsy managed with Community-administered Therapy 3 (PERFECT-3) was a cross-sectional study conducted in Germany, Italy, Spain and the UK. Eligible patients were non-institutionalized children aged 3–16 years who had been diagnosed with epilepsy ≥12 months previously, had experienced ≥1 PACS within the last 12 months and had currently prescribed rescue medication(s) for PACS. Investigators provided clinical assessments and parents/guardians completed web-based questionnaires. Statistical tests were post hoc; p values are descriptive, non-inferential and uncorrected for multiple comparisons. Results At baseline, most of the 286 enrolled patients had prescriptions for diazepam (69.2%) or midazolam (55.9%), and some had two (26.6%) or three (2.4%) prescribed rescue medications. Parents reported that the average length of children's prolonged seizures without rescue medication was 0 to Conclusions In this parent-reported survey of children with epilepsy who had ≥1 PACS in the previous year, significantly more children's seizures lasted

Uso benzodiacepinas en crisis prolongadas y estado epiléptico en la comunidad

Prolonged seizures and status epilepticus are common neurological medical emergencies. Early and appropriate treatment is essential to reduce morbidity and mortality. Most seizures occur in the community, so parents and caregivers must be prepared for their management. Benzodiazepines (BZD) are the first-line drugs used, with rectal diazepam (DZPr) being the most commonly used in pre-hospital treatment in Spain. In September 2011, the European Medicines Agency (EMA) authorized the use of oromucosal midazolam (MDZb) for the treatment of prolonged acute convulsive seizures in patients aged 3 months to <18 years. MDZb has a rapid onset, short duration of effect, and avoids first-pass hepatic metabolism. MDZb has shown to be at least as or more effective than DZPr to stop the seizures. Buccal administration is easier and more socially accepted, especially in adolescents and adults. It is a safe drug with similar effects to other BZD; MDZb improves the overall cost-effectiveness of seizures management.

A comparison of the cost-effectiveness of treatment of prolonged acute convulsive epileptic seizures in children across Europe.

In the majority of children and adolescents with epilepsy, optimal drug therapy adequately controls their condition. However, among the remaining patients who are still uncontrolled despite mono-, bi- or tri-therapy with chronic anti-epileptic treatment, a rescue medication is required. In Western Europe, the licensed medications available for first-line treatment of prolonged acute convulsive seizures (PACS) vary widely, and so comparators for clinical and economic evaluation are not consistent. No European guidelines currently exist for the treatment of PACS in children and adolescents and limited evidence is available for the effectiveness of treatments in the community setting. The authors present cost-effectiveness data for BUCCOLAM® (midazolam oromucosal solution) for the treatment of PACS in children and adolescents in the context of the treatment pathway in seven European countries in patients from 6 months to 18 years. For each country, the health economic model consisted of a decision tree, with decision nodes informed by clinical data and expert opinion obtained via a Delphi methodology. The events modelled are those associated with a patient experiencing a seizure in the community setting. The model assessed the likelihood of medication being administered successfully and of seizure cessation. The associated resource use was also modelled, and ambulance call-outs and hospitalisations were considered. The patient’s quality of life was estimated by clinicians, who completed a five-level EuroQol five dimensions questionnaire from the perspective of a child or adolescent suffering a seizure. Despite differences in current therapy, treatment patterns and healthcare costs in all countries assessed, BUCCOLAM was shown to be cost saving and offered increased health-related benefits for patients in the treatment of PACS compared with the current local standard of care.

The administration of rescue medication to children with prolonged acute convulsive seizures in a non-hospital setting: an exploratory survey of healthcare professionals’ perspectives

Timely administration of rescue medication for prolonged convulsive seizures lasting more than 5 min is necessary to prevent progression to status epilepticus in children. The Practices in Emergency and Rescue Medication for Epilepsy Managed with Community Administered Therapy (PERFECT™) initiative was set up to gain a better understanding of how prolonged convulsive seizures in children are managed when they occur outside of the hospital. We present the findings from an exploratory telephone survey of 128 healthcare professionals (HCPs) (85 pediatric neurologists and neurologists, 28 community pediatricians, and 15 epilepsy nurses) from six EU countries, conducted as part of the PERFECT™ initiative. Among HCPs, there was greater awareness of local protocols and lesser awareness of national or international guidelines. HCPs were not very aware of how prolonged convulsive seizures were managed outside of the hospital and had few professional links to schools or other settings where these seizures were most likely to occur. Approximately one third believed that lack of confidence and fear of liability were barriers to caregivers administering treatment in schools, as was insufficient training of caregivers in the wider community on the management of prolonged convulsive seizures. Results of this HCP survey have identified several clear gaps that need to be addressed: clearer guidance that spans all settings of care, greater dissemination of such guidelines across the chain of care, more open communication and better links between HCPs and schools, and systematic training of all relevant caregivers on the appropriate management of prolonged convulsive seizures.

P75 – 1611 Midazolam oromucosal solution versus rectal diazepam for prolonged acute convulsive epileptic seizures: Italian cost-effectiveness analysis

P75 – 1611 Midazolam oromucosal solution versus rectal diazepam for prolonged acute convulsive epileptic seizures: Italian cost-effectiveness analysis

P78 – 1596 The cost effectiveness of midazolam oromucosal solution for the treatment of prolonged acute convulsive epileptic seizures in France

P78 – 1596 The cost effectiveness of midazolam oromucosal solution for the treatment of prolonged acute convulsive epileptic seizures in France

P76 – 1607 Guidelines on the management of prolonged acute convulsive seizures in out-of-hospital settings: a gap to be filled

P76 – 1607 Guidelines on the management of prolonged acute convulsive seizures in out-of-hospital settings: a gap to be filled

PND35 Buccolam® (Licensed Oromucosal Midazolam) Versus Rectal Diazepam for Acute Epileptic Seizures: Italian Cost-Effectiveness Analysis

BUCCOLAM® (LICENSED OROMUCOSAL MIDAZOLAM) VERSUS RECTAL DIAZEPAM FOR ACUTE EPILEPTIC SEIZURES: ITALIAN COST-EFFECTIVENESS ANALYSIS Gladwell D1, Aneli M2, Batty A1, Lee D1 1BresMed, Sheffield, UK, 2Keypharma SRL, Milan, Lombardy, Italy OBJECTIVES: Current care in Italy for first-line treatment of seizures consists of rectal diazepam with some use of intravenous treatments (diazepam, midazolam and lorazepam) in a hospital setting. In the community there can be reluctance to administer rectal diazepam due to dignity and social acceptability issues. BUCCOLAM (oromucosal midazolam), the first product to receive a Paediatric-Use Marketing Authorisation (PUMA), is approved for the treatment of prolonged, acute, convulsive seizures (PACS) in children and may be used by parents and other carers. A decision-tree model was developed to assess the cost effectiveness of BUCCOLAM compared to rectal diazepam for the treatment of (PACS) initially occurring in the community setting. METHODS: The model allows for different routes though the treatment pathway that include whether or not 1) a carer administers treatment, 2) an ambulance is required and patients are taken to hospital; and 3) inpatient stay is re;uired. Clinical effectiveness data were obtained from McIntyre et al (2005) and a Delphi panel. Costs were taken from published sources. The price proposed for BUCCOLAM reimbursement to the Italian National Health Service is used. Rectal diazepam is not reimbursable therefore its cost is not included. Estimates of the number of seizures per year where BUCCOLAM might be used were taken from published sources. RESULTS: Over one year, compared to rectal diazepam, BUCCOLAM showed a reduction in per patient costs of €1,467. The largest saving came from an estimated reduction in inpatient costs of €919 per patient per year. Patients treated with BUCCOLAM also had a higher health related quality of life than those treated with rectal diazepam; treatment with BUCCOLAM is therefore dominant. CONCLUSIONS: Treatment with BUCCOLAM is cost saving, through a reduction in the need for ambulance call outs and hospital stays, and is more socially acceptable than treatment with rectal diazepam.

PND15 Cost-Effectiveness of Buccolam® (Licensed Oromucosal Midazolam) Compared to Benzodiazepines for the Treatment of Acute Prolonged Epileptic Seizures in Germany

BUCCOLAM (oromucosal midazolam) is approved for the treatment of prolonged, acute, convulsive seizures in children and was the first product to receive a Paediatric-Use Marketing Authorisation (PUMA) in September 2011. The product label includes use by parents and other carers such as teachers. Current care in Germany for first line treatment consists mainly of rectal diazepam with some use of buccal lorazepam, clonazepam and chloral hydrate. Some non-family carers can be reluctant to administer these products due to concerns about social acceptability, dignity or labelling issues. A decision tree model has been developed to assess the cost of BUCCOLAM compared to current care for prolonged acute convulsive seizures initially occurring in the community setting. The model evaluates costs along the treatment pathway when a child has a seizure including whether or not carers administer treatment, whether an ambulance is required and whether or not patients are taken to hospital and require an inpatient stay. Data were obtained from a variety of sources including clinical effectiveness estimates from McIntyre et al. 2005, and a Delphi panel. Costs were taken from published sources. Estimates of the total eligible population were taken from epilepsy prevalence data and the Delphi panel. Over one year, compared to the mix of treatments representing current care, BUCCOLAM showed a reduction in per patient costs of €3,469. Compared to treatment with rectal diazepam alone, the most commonly used treatment, BUCCOLAM showed a cost reduction of €3,533. It was expected that ∼36,000 patients would be eligible. At an uptake of 20% BUCCOLAM would reduce health care expenditure by €19.4 million in the first year. Treatment with BUCCOLAM is cost-saving compared to current care and treatment with rectal diazepam through a reduction in the need for ambulance call-outs and hospital stays.

Oromucosal Midazolam

Oromucosal midazolam (Buccolam™) is a benzodiazepine approved for the treatment of pediatric patients with acute, prolonged, convulsive seizures. This article reviews the pharmacologic properties of oromucosal midazolam and its clinical efficacy and tolerability for the treatment of prolonged acute convulsive seizures in pediatric patients aged 3 months to <18 years. Midazolam exerts its action by enhancing the effects of γ-aminobutyric acid (GABA) on GABA(A) receptors, resulting in neural inhibition. Oromucosal midazolam has a rapid onset (<10 minutes; due to rapid absorption across the buccal membrane and high lipophilicity) and short duration of effect (categorized by the short elimination half-life of midazolam and its active metabolite). The oromucosal administration of the drug avoids first-pass hepatic metabolism; as a result, it has a higher bioavailability than oral midazolam. Oromucosal midazolam is at least as effective at seizure cessation as rectal or intravenous diazepam and appears as well tolerated as these diazepam formulations in pediatric patients with acute convulsive seizures (additionally, midazolam has been available for use for decades in various formulations, and is historically well tolerated). Moreover, oromucosal midazolam was associated with a similar or shorter time to response than rectal diazepam. While the time to response was longer with oromucosal midazolam than with intravenous diazepam, the latter took significantly longer to apply than the former, leading to a significantly shorter overall controlling time with oromucosal midazolam. Respiratory depression occurred at a similar rate in recipients of oromucosal midazolam to that observed in recipients of rectal diazepam. Overall, oromucosal midazolam is at least as effective as rectal diazepam and as effective as intravenous diazepam in the treatment of children with prolonged acute convulsive seizures, and is generally well tolerated in this population. It has several advantages over rectal diazepam, the previous gold standard of treatment, such as having a more socially acceptable administration route and having a likely more predictable absorption profile. Oromucosal midazolam is a promising first-line treatment option for children with prolonged acute convulsive seizures, in particular where intravenous access is precluded.

Buccolam® (buccal midazolam): a review of its use for the treatment of prolonged acute convulsive seizures in the dental practice

This article is published in response to a query from reader Sarah Clements, based at Golding House Dental Practice Ltd in Kent, regarding the BDJ paper entitled 'Updated guidance on medical emergencies and resuscitation in the dental practice' (BDJ 2012; 212: 41-43). Sarah wished to be provided with further clarification on the ordering, prescribing and administration of midazolam.