The current clinical practice and experiences in buccal midazolam prescribing in community for status epilepticus termination in the United Kingdom: The Rescue Epilepsy Medication and Training (REMIT) study

Background: Epilepsy is one of the commonest neurological conditions worldwide and confers a significant mortality risk, partly driven by status epilepticus (SE). Terminating SE is the goal of pharmaceutical rescue therapies. This survey evaluates UK-based healthcare professionals’ clinical practice and experience in community-based rescue therapy prescribing. Methods: A cross-sectional, 21 item questionnaire composed of Likert-style and free-text based questions was administered online. It was distributed through a non-discriminative snow-balling methodology to members of the Epilepsy Specialist Nurses’ Association (ESNA) and the British International League Against Epilepsy (ILAE). Quantitative analysis used Chi-squared, Fishers’ exact and Mann-Whitney tests. Qualitative data were analysed through NVivo 14 software, following Braun and Clarke methodology. Results: 86 participants comprising of nurses (n = 64) and doctors (n = 21) responded. Participants’ responses reflected guideline-concordant use of emergency management plans and buccal midazolam (BM) as a first-choice therapy for terminating tonic-clonic seizures in SE. However, significant variation (P < 0.05) was found between doctors and nurses in prescribing practices of BM including maximum dose prescribed/day, withdrawal plans and the use in multimorbid patients. Eight themes were identified with some suggestive of concerns of overuse, misuse and abuse of BM by patients/carers. Conclusion: This is the first study to give insights to community management of SE using rescue therapies particularly BM. Further evidence-based guidelines are needed for BM use in multimorbid patients and for its deprescribing. Robust safeguarding protocols and vigilance is needed to regulate BM's misuse and abuse potential. Oncoming community-based technology could provide objective assurance for evidencing utility of rescue medications.