LAUSR

Repetitive and prolonged seizures as well as status epilepticus represent life-threatening neurologic emergencies with serious cerebral and systemic sequela [1]. High morbidity and mortality associated with untreated or uncontrolled seizures call for emergency treatment including airway management, hemodynamic and metabolic stabilization, protection from physical injuries, administration of emergency anti-seizure medication, and the identification and treatment of underlying pathologies. Despite the fact that randomized controlled trials in this context are mostly limited to firstline anti-seizure medication (i.e., benzodiazepines) [2–5], international collaborations of experts including epileptologists, neurologists, neurointensivists, neurosurgeons, and pharmacologists led to the development of treatment guidelines for prolonged seizures and status epilepticus across the age spectrum [6, 7]. However, such guidelines focus on the in-hospital setting and, despite a number of studies on the efficacy and safety of emergency first-line anti-seizure medication, studies regarding the quality of translation of such guidelines into outpatient settings are scarce. A recent study regarding the emergency response to out-of-hospital status epilepticus in adult patients revealed that first-line anti-seizure treatment was not administered by emergency medical services in a third of the patients with recognized status epilepticus and in more than half of the patients with diagnosed non-convulsive status epilepticus [8]. However, further insight into the actual quality of practice regarding the prescription and utilization of emergency anti-seizure medication is scarce but essential to improve the quality of pre-hospital emergency management and to guide the development of more efficient and informative treatment guidelines. In a recent issue of CNS Drugs, the German study group of Dr. Strzelczyk presents a multicenter questionnaire-based survey analyzing aspects determining the quality of firstline emergency anti-seizure treatment in adult patients with epilepsy in the outpatient setting [9]—results that enhance our knowledge on the quality of prescription, use, and tolerability of first-line anti-seizure medication. All adult patients with epilepsy attending the epilepsy outpatient clinics of the university hospitals in Frankfurt and Marburg in 2015 were asked to participate in this questionnaire-based retrospective survey. The authors carefully assessed the demographics, clinical variables, and treatment characteristics of all patients. Of 481 participating patients, 134 (27.9%) reported on the prescription of an emergency anti-seizure medication during the past year. The most frequently used firstline anti-seizure medications were oral lorazepam tablets, buccal midazolam, and rectal diazepam. The most common situations for administering these anti-seizure drugs were seizures continuing for several minutes and a third of all patients receiving anti-seizure medications stated that these drugs were given during or after every seizure. For more than a third of patients, sedation was a major or moderate problem. Multivariate logistic regression analysis revealed young age, active epilepsy, structural etiology, presence of generalized tonic-clonic seizures, past medical history of status epilepticus, and a housing situation in the presence of another person as independently associated with the prescription of emergency anti-seizure drugs. The findings, that first-line anti-seizure drugs were frequently administered in the post-ictal phase and that compounds with slow absorption rates were often used to treat seizures, raise great concerns. Delayed administration of first-line anti-seizure drugs may result in insufficient treatment baring the risk of the transformation of seizures into status epilepticus. The administration of slow absorbing This comment refers to the article available at https ://doi. org/10.1007/s4026 3-018-0544-2.