Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children

Phenytoin is the current standard of care for second-line treatment of paediatric convulsive status epilepticus after failure of first-line benzodiazepines, but is only effective in 60% of cases and is associated with considerable adverse effects.

This multi-centre trial conducted in New Zealand and Australia compares treatment of these patients with phenytoin or levetiracetam.

233 children aged between 3 months and 16 years with convulsive status epilepticus that failed first line treatment were randomly assigned to treatment with phenytoin or levetiracetam. The primary outcome was clinical cessation of seizure activity five minutes after the completion of infusion of the study drug.

The results demonstrated that levetiracetam is not superior to phenytoin in the treatment of paediatric convulsive status epilepticus.

Lancet 2019; 393:2135-45

Early or delayed cardioversion in recent-onset atrial fibrillation

Patients with recent-onset atrial fibrillation commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion. In this study the question is raised whether immediate restoration of sinus rhythm is necessary as the arrhythmia often terminates spontaneously.

In this multicentre trial based in the Netherlands the researchers randomly assigned patients with hemodynamically stable, recent-onset (<36 hours), symptomatic atrial fibrillation in the emergency department to be treated with a wait-and-see approach (delayed-cardioversion group) or early cardioversion. The wait-and-see cohort were treated with rate control medication and were cardiovented if the fibrillation had not resolved within 48 hours.

It was concluded that patients presenting to the emergency department with recent-onset, symptomatic atrial fibrillation, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.

N Engl J Med 2019; 380:1499-508

Incidence of type 2 diabetes mellitus in men receiving steroid 5α-reductase inhibitors

The objective of this population based cohort study was to investigate the incidence of new onset type 2 diabetes mellitus in men receiving steroid 5α-reductase inhibitors (dutasteride or finasteride) for long term treatment of benign prostatic hyperplasia.

Cohorts of men receiving treatment with dutasteride or finasteride were matched with men being treated with tamsulosin for benign prostatic hyperplasia.

It was found that the risk of type 2 diabetes was increased by approximately 30% over 11 years in men receiving treatment with finasteride or dutasteride compared with tamsulosin. Monitoring of blood glucose might be advisable in men receiving either of these medications.

BMJ 2019; 365:1204

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