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When convulsive status epilepticus persists after benzodiazepines, clinicians need a rapid second-line treatment. The ESETT randomized trial compared levetiracetam, fosphenytoin and valproate in children, adults and older adults with established benzodiazepine-refractory status epilepticus. Across all three age groups, treatment success—defined by seizure cessation with improved consciousness and no additional antiseizure medication at one hour—occurred in roughly half of patients. No meaningful difference in efficacy was detected between the three agents, and serious safety outcomes were broadly comparable. The importance of ESETT is practical: it supports more flexible second-line selection when one agent is contraindicated, unavailable or less suitable for a particular patient. The trial also demonstrates that treatment failure after benzodiazepines remains common, emphasising the need for rapid escalation and close cardiorespiratory monitoring. For HCPs, the message is not to delay treatment while searching for a “best” second-line drug. Instead, clinicians can choose among evidence-supported options according to comorbidities, drug interactions, local availability and familiarity, while preparing for further escalation when seizures continue.
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When convulsive status epilepticus persists after benzodiazepines, clinicians need a rapid second-line treatment. The ESETT randomized trial compared levetiracetam, fosphenytoin and valproate in children, adults and older adults with established benzodiazepine-refractory status epilepticus. Across all three age groups, treatment success—defined by seizure cessation with improved consciousness and no additional antiseizure medication at one hour—occurred in roughly half of patients. No meaningful difference in efficacy was detected between the three agents, and serious safety outcomes were broadly comparable. The importance of ESETT is practical: it supports more flexible second-line selection when one agent is contraindicated, unavailable or less suitable for a particular patient. The trial also demonstrates that treatment failure after benzodiazepines remains common, emphasising the need for rapid escalation and close cardiorespiratory monitoring. For HCPs, the message is not to delay treatment while searching for a “best” second-line drug. Instead, clinicians can choose among evidence-supported options according to comorbidities, drug interactions, local availability and familiarity, while preparing for further escalation when seizures continue.
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