Comparison of lacosamide, levetiracetam, and valproate as second-line therapy in adult status epilepticus: Analysis of a large cohort

We compared the efficacy of lacosamide to other frequently used second-line anti-seizure medications (ASMs) for adult status epilepticus (SE) by conducting a retrospective analysis of an institutional SE registry between January 2013 and December 2022. Clinical outcomes assessed at discharge were categorized as return to baseline, new disability, or death; we also considered SE termination after the second-line ASM and the need for mechanical ventilation. Potential confounders included the Status Epilepticus Severity Score (STESS), sex, adequacy of initial SE treatment, treatment delay, and potentially fatal etiology. Over 10 years, 961 adult SE episodes were analyzed; 868 were treated with the following second-line ASMs: 413 levetiracetam (47.6%), 110 valproate (12.7%), and 75 lacosamide (8.6%), as well as lower rates of 18 other ASMs including benzodiazepines (not further analyzed). Univariable analysis identified STESS, treatment delay, and adequacy of initial SE treatment as potential confounders. On multivariable analysis adjusting for these variables, patients with episodes treated with second-line lacosamide, levetiracetam, or valproate demonstrated statistically equivalent rates of seizure cessation, need for mechanical ventilation, and clinical outcomes at hospital discharge. We conclude that lacosamide appears to represent a reasonable alternative to levetiracetam and valproate, and warrants consideration for inclusion in future randomized controlled trials for control of SE.