First‐Line Benzodiazepine Treatment for Convulsive Status Epilepticus in Adults: A Systematic Review and Meta‐Analysis

ABSTRACT Convulsive status epilepticus (CSE) is a life‐threatening neurological emergency that requires prompt intervention. While several benzodiazepines are available as first‐line treatments, the optimal choice among them remains unclear. Therefore, we conducted a systematic review and meta‐analysis to evaluate the comparative effectiveness of these benzodiazepines for CSE. We conducted a comprehensive literature search of MEDLINE, the Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi. We included randomized controlled trials involving adult patients with CSE who received benzodiazepines as first‐line treatment. Prehospital studies were also considered eligible. Two reviewers independently screened the studies and extracted relevant data. The outcomes were seizure termination, mortality, intubation, favorable neurological outcomes, seizure recurrence, and duration of hospitalization. Risk ratios (RRs) with 95% confidence intervals were calculated using a random‐effects model with inverse variance weighting. Among 3478 studies screened, three randomized controlled trials met the inclusion criteria: two comparing intravenous lorazepam with intravenous diazepam, and one comparing intramuscular midazolam with intravenous lorazepam. Intravenous lorazepam was associated with a higher seizure termination rate (RR 1.24, 95% CI: 1.03–1.49) to intravenous diazepam without an increase in adverse outcomes. Similarly, intramuscular midazolam was associated with higher seizure termination rates than intravenous lorazepam in prehospital settings (RR 1.16, 95% CI: 1.06–1.27). The present study demonstrated that intravenous lorazepam is more effective than intravenous diazepam. Furthermore, intramuscular midazolam may be more associated with higher seizure termination rates than intravenous lorazepam. Further evidence is needed to clarify the efficacy of intravenous lorazepam and both intravenous and intramuscular midazolam in adult patients.