In pediatric patients indicated for status epilepticus, benzodiazepines are considered first line therapy. Lorazepam is not FDA approved for this indication, but studies show it may be more effective and safe.
A double-blind, randomized clinical trial was conducted from March 1, 2008 to March 14, 2012 using 273 patients aged 3 months to younger than 18 years. Patients included in the trial had generalized tonic-clonic status epilepticus, which is defined as, 3 or more convulsions within the preceding hours and currently experiencing a convulsion, 2 of more convulsions in succession with no recovery of consciousness and currently experiencing a convulsion, or a current single convulsion with a duration of least 5 minutes.
140 were given 0.2 mg/kg diazepam IV and 133 were given 0.1 mg/kg lorazepam IV. In the diazepam group, 72.1% of patients had cessation of the status epilepticus and in the lorazepam group, 72.9% of patients had cessation of the status of epilepticus. Sedation was seen in 50% of patients taking diazepam and 66.9% of patients taking lorazepam.
It was determined that between the 2 medications, there were no significant differences in primary efficacy and safety outcomes. This does not support the theory that lorazepam is the superior treatment. This is interesting because the study showed that the medications have fairly equal efficacy, but lorazepam has an increase risk of producing sedation. Pharmacists should be aware of this when recommending medications for pediatric patients.
When a patient walks into a pharmacy and says they are having trouble remembering to take a medication, there are problems that arise when determining the degree of nonadherence. First of all, patients will undoubtedly underestimate the amount of times the have missed their medication. In addition, if a patient is not stating any issues with adherence, pharmacists can only truly observe refill behavior to monitor adherence. Only the date the prescription is filled can be recorded, so often monitoring adherence can be difficult.
But here is why Dr. Crowe, PharmD, is stating that adherence is “overrated” – patients can be perfectly adherent, never missing a single dose and still experience ineffective drug therapy. Dr. Crowe feels that the focus of pharmacists should lie on making sure the drug therapy regimen is efficacious, no matter the adherence of the patient. Because pharmacists see patients several times in between visits with their physician, they can be the one to monitor symptoms and side effects in between the visits. Dr. Crowe states that this is important because “when patients hold up their end of the adherence bargain, they [should be] doing so with an effective medication.” He uses the example of multiple sclerosis (MS) and how pharmacists can not only monitor the symptoms, but the relapse frequency. If this frequency becomes too high, they can recommend a switch in therapy.
This is a great concept that I have never thought of before in the way that was described by the article. It makes sense that if patients are doing everything they should be, they should be getting the best possible benefits from their medication. As far as monitoring symptoms to check for medication efficacy, I immediately thought of antidepressant medications. Because they take several weeks to work, it would be helpful for the pharmacist to check in on the patient when they are refilling a prescription to see how their mood has improved. If there is no improvement after one or two refills, they can contact the physician to recommend a change in therapy. I hope that this mentality is one that every pharmacist uses or is introduced to during their career, in addition to monitoring adherence.
Crowe, Michael. “Adherence is Overrated.” Pharmacy Today. 21.7 (1 July 2015). 63. Web. 17 February 2016.