I think the paper did not stress the appropriate point. That is although
i.v. diazepam worked faster than i.n. midazoalm the fits stopped earlier
with midazolam from time of admission simply because the medic didn't have
to get iv access first with in midazolam. So midazolam i.n. worked faster.
Having tried the intranasal route myself in fitting children I can vouch for
it's speed of onset. I.M. midazolam could obviously be used by medics, but
the intranasal route could be used by parents, paramedics and by nursing
staff in institutions with epileptics.
I agree that a comparison with rectal diazepam might be useful, but in view
of the poor bioavailability via the rectal route (15%-20%) compared to the
intranasal route (55%) I suspect there would be a significant difference.
But worth doing. This route for stopping fits has been known for several
years now, so it's about time UK Paediatric Doctors started contributing to
the investigation of the route instead of just being critical (possibly
because they didn't think of it first!)
I've forwarded your comments onto the authors to see if they have any
comments.
Regards
Ray McGlone
----- Original Message -----
From: Rowley Cottingham <[log in to unmask]>
To: <[log in to unmask]>
Cc: <[log in to unmask]>
Sent: Friday, July 14, 2000 11:38 PM
Subject: Re: Intranasal Midazolam
> I have read this paper from Israel carefully, and I am not at all happy
with either the methods
> or the conclusion for several reasons.
>
> 1. There is an assumption that any child who is still fitting on admission
must have been
> fitting for 10 minutes for geographical reasons.
>
> 2. Only 3 children from their cohort (47, I think) were excluded as they
had stopped fitting by
> the time treatment was contemplated.
>
> 3. There is no mention of the standard treatment for febrile convulsions
which is to reduce the
> core temperature.
>
> 4. The midazolam stopped the fitting later than the diazepam (hopefully
emulsion) did.
>
> 5. Intranasal midazolam needs to be compared with intramuscular midazolam
or rectal diazepam
> as both are preferable treatments to intravenous diazepam - for many of
the reasons Lahet et al
> give.
>
> I am analysing a convenience sample of the last 50 or so children who
presented over the last
> 6 months to our A&E with an diagnosis on leaving A&E of febrile
convulsion. Only 4 were
> still fitting on admission, and this suggests that the total number of
children being dealt with
> by the Israeli group must be astronomical. If 4 out of a total attendance
in that period (6
> months) of approximately 3,600 children were fitting and Lahet gathered
his in a year it
> suggests that either he sees approximately 72,000 children annually or
there is something very
> strange about either his patient population or mine. Furthermore, the
group still fitting in my
> sample were much older than the mean (sorry, figures still being worked on
but it is
> screamingly obvious) and I suspect 2 at least would have a different final
diagnosis as they
> were both already taking epilim.
>
> I do not see the point of this paper. It does not advance our knowledge on
the
> pharmacodynamics of the agent, and as Ray McGlone points out, the
technique has already
> been described. I am not convinced that it is the treatment of choice,
with the options I have
> described above already preferable. I am concerned that the patient
population seems
> inexplicably atypical, and I would like some assurance on the assumptions
made. I distinguish
> this from Ray's work which is useful, and his published work honestly
shows that ketamine is
> probably preferable.
>
> What is the general view?
>
> Best wishes,
>
>
> Rowley Cottingham
>
> [log in to unmask]
>
>
>
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