2025 Southeastern Residency Conference

Title: The Role of Lacosamide in the Treatment of Status Epilepticus within a Large, Academic Health-System
Authors: Mojibola Awe, Alexander Aubin, Krista Dumkow, Neha Naik, Chelsea Wamsley 


Background: Status epilepticus (SE) is a neurologic emergency that requires prompt treatment to prevent irreversible neurologic deterioration or death. There is variance in treatment strategy after first-line administration of benzodiazepines, due to lack of clinical data to support the use of a specific second-line antiseizure medication (ASM) in SE. Lacosamide (LCM) is an ASM with compelling attributes to be considered a second-line agent, including its ability to be administered as an undiluted intravenous push and its minimal drug interactions and adverse effects. This study aimed to evaluate the current role of LCM in the treatment of SE within a large, academic health-system. 
Methods: A multi-center retrospective chart review of patients admitted to Emory Healthcare hospitals between December 2020 and August 2024 was performed. Patients must have had a documented episode of SE and received at least one dose of intravenous LCM within the first 24 hours of admission to be included. The primary endpoint was the incidence of seizure termination within 6 hours of LCM administration without subsequent ASM use. Secondary outcomes reported include time from initial presentation to seizure cessation and LCM administration, incidence of LCM as the termination drug, cessation of seizure activity within an hour following LCM administration, and 24-hour seizure free period following LCM. Additional secondary outcomes reported include average LCM loading and maintenance dosing, incidence of mechanical ventilation, and time to mechanical ventilation from LCM administration.  
Results: Of 143 patients with a documented status epilepticus diagnosis code reviewed, 26 met inclusion criteria for this study. Among these patients, a majority were male with a median age of 60.5 years (IQR 53.5–67). Most patients required ICU admission (88.5%). Patients who were included had a past medical history of epilepsy (65.3%), stroke (30.8%), and alcohol/drug use (26.9%). Prior to hospitalization, 42.3% of patients were not on ASM; 38.5% were on levetiracetam monotherapy and 19.2% of patients were on multiple ASMs. Median time from admission to LCM administration was 156 minutes (IQR 149–165) and seizure cessation occurred at a median of 172 minutes (IQR 163–187) post-administration. LCM was effective in achieving seizure cessation within six hours without additional ASM in 19.2% of patients and served as the final ASM in 26.9% of cases. Across Emory Healthcare institutions, LCM was most frequently used as the second ASM for status epilepticus treatment (35%). A shorter time to LCM administration appeared to correlate with faster seizure cessation but did not impact the incidence of mechanical ventilation. 
Conclusions: LCM was identified as the final ASM administered in 26.9% of patients in this study, highlighting its potential role as a terminating agent for SE. However, this percentage is lower than findings from other studies which report intravenous LCM as the last ASM administered before seizure termination in 44% or more of cases. Additionally, LCM was most frequently used as the second ASM after benzodiazepines or levetiracetam for SE management across Emory Healthcare institutions. This trend may reflect an increasing recognition of LCM’s utility earlier in the SE treatment algorithm, particularly in situations where other ASMs may be contraindicated or less accessible. Furthermore, shorter time to LCM administration appeared to correlate with faster seizure cessation, suggesting the importance of early intervention. However, this correlation did not extend to the incidence of mechanical ventilation, indicating that other factors besides seizure cessation may influence this outcome.