Seizing child recieving IN treatmentTherapeutic Intranasal Drug Delivery

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Nasal seizure medication overview

Topic summary:

Prolonged seizures and status epilepticus are extremely anxiety provoking for observers and dangerous to the patients. While the "gold standard" treatment is an IV benzodiazepine as initial therapy, this is often not possible outside the confines of an inpatient setting and it requires highly skilled personnel to safely and effectively deliver. The traditional outpatient treatment is rectal diazepam - but this drug is only about 60% effective and for some reason is very expensive (U.S. charges can exceed $200/dose). More recently a large study suggests that intramuscular injections of benzodiazepines are as effective as IV therapy and should displace both rectal and IV drugs as initial treatment. However, this requires an injection (not ideal for a parent to administer to a child) and will likely also be very expensive to justify the costs of bringing the drug to market. Interestingly, some thoughtful clinicians have been working on another concept - nasal delivery of generic benzodiazepine.  Based on a moderately extensive bit of literature, nasal midazolam or lorazepam appears to be as effective as IV benzodiazepines, faster to deliver, and safe in terms of not inducing respiratory depression. They are more effective than rectal medication in most of the studies done, they can be safely delivered by parents at home - eliminating the need to call and ambulance and freeing the family up to travel further distances from the hospital, and they do not require much training to be effective. Finally, intranasal benzodiazepines are quite inexpensive - probably under $15 per dose including the delivery device. These insights are slowly beginning to push the use of nasal midazolam and/or lorazepam into the mainstream and increasingly pediatric neurologists and parents with epileptic children are becoming interested in this concept. This overview section provides a quick look at the topic and provides dosing and protocols. Digging deeper behind this page is an extensive review the literature with supporting references. (Click here to skip the overview below and to go directly to the deeper discussion).

Key Concepts regarding delivery of any nasal medication to the systemic circulation and brain

Use the right dose!

Minimize volume, maximize concentration of the drug

Large volumes are lost into the pharynx or out the nostril.

Maximize total absorptive surface area

Use a delivery system that maximizes mucosal surface area coverage and minimizes loss to the environment and runoff

Be thoughtful about anatomic issues and head positioning to enhance delivery

Key Concepts related to nasally delivered sedatives

Dosing: See below for doses supported by the literature. Failure to use the adequate dose will likely lead to failure to control seizures.

Respiratory depression: Generic midazolam delivered intranasally does not lead to respiratory depression. Click here for a brief but more in depth discussion on this concept.

Titration: Repeated doses (or half doses) can be given every 10-15 minutes for the benzodiazepines can lead to more titrated effect.

Dosing information and delivery protocol

Protocol for intranasal midazolam, lorazepam to treat seizures

Commonly used generic intranasal medications - single page dosing summary (click here)

In Depth literature review, discussion, bibliography (Click here)