Evaluating Treatment Dynamics in Refractory Status Epilepticus: A Retrospective Observational Cohort Study

Background and Purpose: Status epilepticus (SE) is a life-threatening emergency associated with high morbidity and mortality. Limited guidance exists on optimal therapy for refractory SE (RSE), which may include administration of repeat second-line IV-antiseizure medications (IV-ASMs) or escalation to IV-anesthesia (IVA). This study examined real-world treatment dynamics and outcomes of hospitalized patients with RSE in the United States. Methods: A retrospective, cross-sectional analysis of hospitalized patients with SE between 2018-2022 was performed using PINC AI™ Healthcare Database. Patient encounters for RSE were categorized into RSE-no IVA (≥2 IV-ASMs without IVA) and RSE-IVA (≥1 IV-ASMs with IVA and concomitant mechanical ventilation). RSE-no IVA episodes were further stratified by exposure to 2 IV-ASMs and ≥3 IV-ASMs. Results: Across 140 538 SE episodes in 113 229 unique patients, 44% were RSE. IV-ASM and IVA exposure, as well as time to escalation varied widely across SE episodes. Compared to RSE-no IVA episodes (59%), RSE-IVA episodes (41%) were associated with increased ICU length of stay (LOS; 5 vs 3 days), hospital LOS (9 vs 6 days), and in-hospital mortality (25% vs 12%). Compared to patients with RSE-no IVA administered 2 IV-ASMs, those administered ≥3 IV-ASMs had increased ICU admission (73% vs 62%), longer ICU LOS (4 vs 2 days), and hospital LOS (9 vs 5 days). Conclusions: Heterogeneity in RSE treatments management is prominent, with variation in IV-ASM treatment sequencing and escalation timing. Both increased IV-ASM utilization and IVA exposure were associated with similarly worse outcomes and healthcare utilization. Rapidly effective anti-SE treatments remain an urgent unmet need in this patient population.