A Multicenter, Randomized, Blinded, Comparative Effectiveness Study of Fosphenytoin, Valproic Acid, or Levetiracetam in the Emergency Department Treatment of Patients With Benzodiazepine-refractory Status Epilepticus.
Phase: PHASE3
Conditions: Benzodiazepine Refractory Status Epilepticus
Sponsor: University of Virginia

 
 
 
 
STUDY PROTOCOL  
 
Established Status Epilepticus Treatment Trial (ESETT) 
A multicenter, randomized, blinded, comparative effectiveness study of fosphenytoin, valproic 
acid, or levetiracetam in the emergency department treatment of patients with 
benzodiazepine-refractory status epilepticus. 
 
Study Chair: 
Jaideep Kapur, MD, Professor, University of Virginia 
Supported by:
The National Institute of Neurological Disorders and Stroke (NINDS) 
1 U01 NS088034 01 
 
ClinicalTrials.gov ID: NCT01960075 
 
Sponsor of IND:
Jaideep Kapur, IND 119,756 
 
Version:
2 (5 December 2016) 
 
previous version 22 December 2014 
 
 
 
adapted for the NETT from the NIND phase III template at: 
http://www.ninds.nih.gov/research/clinical_research/toolkit/protocoltemplate.htm 
 
 
 
 
 
 
1 

 
PROTOCOL CHANGES 
If amended versions of this protocol are required, this page will be populated with a specific log 
of all changes. 
 
Version 1 
Version 2 
Section 
Page 
Previous text 
Page 
New text 
 
5 
 
7-8 
IN   Intranasal 
PB   Per Buccal 
PE   Phenytoin Equivalents 
Synopsis 
11 
subjects greater than or equal to 40 kg 
13 
all adults and those children greater than 
or equal to 32 kg 
2.3 
17 
Pharmacokinetics, dose and rate of 
administration:  
19 
Pharmacokinetics, dose and rate of 
administration:  By convention, FOS is 
dosed in phenytoin equivalents (PE). In 
this protocol, all FOS doses given in mg 
indicate mg PE whether explicitly stated 
or not.  
4.1 
27 
...for those greater than or equal to 40 
kg. For children less than 40 kg... 
29 
...for all adults and those children greater 
than or equal to 32 kg. For children less 
than 32 kg... 
4.1 
28 
In Table 1. Those ≥ 40 kg 
30 
In Table 1.  For all adults and those 
children ≥ 32 kg 
4.1 
28 
 
30 
In Table 1.  For purposes of this study IO 
is considered equivalent to IV.  For 
midazolam, IN or PB are considered 
equivalent to IM. 
4.2 
29 
In Table 2.  Opt-out identification 
31 
In Table 2.  ​Opt-out identification or 
otherwise known to be previously 
enrolled in ESETT 
7.2 
42 
... and flushing the line at the end of 
infusion ... 
44 
... and removing the line at the end of 
infusion .. 
7.2 
43 
In Table 3.  FOS mg 
45 
In Table 3.  FOS mg PE 
7.2 
43 
In Table 3.  Subject Wt column shows 
lower end of each range 
45 
In Table 3.  Subject Wt column now 
shows weight ranges on each row 
7.4 
44 
...2-18 years, 19-65 years, …. 
46 
...less than 18 years, 18-65 years, ... 
7.5 
44 
4-8 °C 
46 
2-8 °C 
7.6 
45 
FOS 16.66 mg/ml….FOS 20 mg/kg 
47 
FOS 16.66 mg PE/ml….FOS 20 mg PE/kg 
 
 
2 

 
8.2 
47 
1. Contemporaneous direct data entry.  If 
the primary outcome is directly entered 
into the CRF in WebDCU at the bedside, 
the CRF itself will be considered the 
primary source document. 2. Study book 
form worksheet.  If a paper version of the 
CRF is used as a worksheet, that 
worksheet will be used to complete the 
CRF in WebDCU and must be maintained 
in the study binder and considered the 
primary source document. 3. Protocol 
Assist Device.  The primary outcome 
recorded on the protocol assist device 
will be treated as a source document and 
may be used as an electronic CRF 
worksheet from which to complete the 
CRF. 4. Medical Record - study note 
template.  The clinical medical record 
may also be the source document.  A 
templated study note takes precedence 
among medical records. 5. Medical 
Record - adjudicated.  If there is no 
structured source of the primary 
outcome, the medical record will be the 
source and the adjudicated primary 
outcome used. 
49 
1. Contemporaneous observation and 
documentation.  The primary outcome is 
observed by the study team at the 
bedside and directly recorded on the CRF 
or on the study book worksheet.  Direct 
data entry in WebDCU is preferred but 
not required.  2. Direct communication 
with the clinical team.  The study obtains 
the primary outcome data by direct 
explicit communication with the treating 
ED attending physician.  Communication 
should occur and be documented as close 
to the time of assessment as possible. 3. 
Protocol Assist Device.  The primary 
outcome explicitly recorded on the 
protocol assist device will be treated as a 
source document and may be used to 
complete the CRF if contemporaneous 
recording or direct communication with 
the study team are not available. 4. 
Medical Record - explicit study specific 
documentation.  If the medical record is 
used as a source document, the 
adjudicators will determine the primary 
outcome from an explicit study specific 
template note if available in precedence 
among available documentation. 5. 
Medical Record - implicit review.  If the 
medical record is used as a source 
document, and no explicit study specific 
template note is available, the 
adjudicators will determine the primary 
outcome from their interpretation of 
provided documentation. 
8.3 
47 
...Richmond agitation and sedation score 
(RASS) at 60 minutes,... 
 
(duplicative listing deleted) 
9.5 
52 
RASS 
54 
(erroneous bullet deleted) 
10.2 
53 
 
55 
Emergency unblinding performed prior to 
60 minutes or prior to determination of 
the primary outcome, because of 
physician judgment that it is necessary 
for the safety or care of the patient, or 
because of unanticipated situations is 
accommodated by calling the hotline but 
is a deviation from this protocol. 
14 
62 
REFERENCES 
64 
New section 14 INTEGRATED 
SUB-STUDIES has been added. 
REFERENCES is now section 15 
 
 
3 

 
 
 
 
 
4 

 
PROTOCOL SIGNATURE PAGE  
I have read the attached clinical protocol titled Established Status Epilepticus Treatment Trial 
(ESETT) Version 2, dated 24 October 2016.  My signature assures that this study will be 
conducted according to all stipulations of the protocol, including all statements regarding 
confidentiality. 
 
24  October  2016
__________________________________________________________________________ 
Sponsor's Signature                                                                                            Date of Signature 
I have read this protocol and agree that it contains all necessary details for carrying out the 
study as described. 
I will conduct this protocol as outlined herein, including all statements regarding confidentiality. 
I will make all reasonable effort to complete the study within the time designated. I will provide 
copies of the protocol and access to all information furnished by the Sponsor to study 
personnel under my supervision. I will discuss this material with them to ensure that they are 
fully informed about the drug and the study. I understand that the study may be terminated or 
enrollment suspended at any time by the Sponsor, with or without cause, or by me if it 
becomes necessary to protect the interests of the study subjects. 
  
I agree to conduct this study in full accordance with all applicable regulations and Good Clinical 
Practices (GCP). 
____________________________________________________________________________ 
Investigator's Signature                                                                       Date of Signature 
 
 
 
5 

 
CONTACT INFORMATION 
For updated contact information, including the Emergency 24/7 Toll Free Contact Number, 
please refer to the study website ​ESETT.org​  or the study Manual of Procedures. 
 
Jaideep Kapur, MD 
Principal Investigator, Study Chair 
jk8t@virginia.edu  
Robert Silbergleit, MD  
Principal Investigator, NETT 
robert.silbergleit@umich.edu  
James Chamberlain, MD 
Principal Investigator, PECARN 
jchamber@childrensnational.org  
Jordan Elm, PhD 
Trial Biostatistician, NETT 
elmj@musc.edu  
 
Neurological Emergencies Treatment Trials 
Clinical Coordinating Center 
University of Michigan 
24 Frank Lloyd Wright Dr. 
Suite H3100 
Ann Arbor, MI  48106 
734-232-2142 
 
 
 
 
 
6 

 
TABLE OF ABBREVIATIONS 
 
AE 
Adverse Event 
CCC
Clinical Coordinating Center 
cEEG
Continuous Electroencephalogram Monitoring 
CNS 
Central Nervous System 
CRF 
Case Report Form 
CTCAE
Common Terminology Criteria for Adverse Events Version 3.0 
DCR 
Data Clarification Request 
DCU 
Data Coordination Unit 
DSMB 
Data and Safety Monitoring Board 
ED 
Emergency Department 
ECG
Electrocardiogram 
EEG 
Electroencephalogram 
EFIC 
Exception from Informed Consent 
EMS 
Emergency Medical Services 
ESE
Established Status Epilepticus  
ESETT
Established Status Epilepticus Treatment Trial 
ET 
Endotracheal 
FDA 
Food and Drug Administration 
FOS
Fosphenytoin 
GCP
Good Clinical Practice 
GMP 
Good Manufacturing Practice 
ICH 
International Conference on Harmonization 
ICU 
Intensive Care Unit 
IM 
Intramuscular 
IND 
Investigational New Drug 
IN
Intranasal 
IO 
Intraosseous 
IRB 
Institutional Review Board 
ITT 
Intent to Treat 
IV 
Intravenous 
kg 
Kilogram 
LAR 
Legally Authorized Representative 
LEV
Levetiracetam 
mg 
Milligram 
Min 
Minute 
mL 
Milliliter 
mm 
Millimeter 
mmHg
Millimeters of Mercury 
MoP 
Manual of Procedures 
MM 
Medical Safety Monitor 
MUSC 
Medical University of South Carolina 
NETT 
Neurological Emergencies Treatment Trials 
 
 
7 

 
NINDS
National Institute of Neurological Disorders and Stroke 
PB
Per Buccal 
PE
Phenytoin Equivalents 
PECARN
Pediatric Emergency Care Applied Research Network 
PGS
Purple Glove Syndrome 
PHT
Phenytoin 
PHTSE 
Pre-hospital Treatment of Status Epilepticus Trial 
PI 
Principal Investigator 
PR
Per Rectum 
RAMPART
Rapid Anticonvulsant Medication Prior to Arrival Trial 
RAR
Response Adaptive Randomization 
RASS
Richmond Agitation and Sedation Score 
RBC
Red Blood Cell 
SAE 
Serious Adverse Event 
SDMC
Statistical & Data Management Center 
SE 
Status Epilepticus 
SSL 
Secure Socket Layer 
SOP
Standard Operating Procedures 
VAL
Valproic acid 
WebDCU
Web-based Clinical Trial Management System 
 
 
 
 
8 

 
TABLE OF CONTENTS 
 
PROTOCOL CHANGES 
PROTOCOL SIGNATURE PAGE 
CONTACT INFORMATION 
TABLE OF ABBREVIATIONS 
TABLE OF CONTENTS 
SYNOPSIS 
1. STUDY OBJECTIVES 
1.1 Primary Objective 
1.2 Secondary Objectives 
2. BACKGROUND 
2.1 Rationale 
2.2 Study Drugs 
2.3  FOS (fosphenytoin) 
2.4  LEV (levetiracetam) 
2.5  VPA (valproic acid) 
2.6  Systematic comparison of FOS, VPA, and LEV for the treatment of ESE 
3. STUDY DESIGN 
4. SELECTION AND ENROLLMENT OF SUBJECTS 
4.1 Inclusion Criteria 
4.2 Exclusion Criteria 
5. Informed Consent and Exception from Informed Consent (EFIC) 
5.1  Enrollments all performed under EFIC 
 
 
9 

 
5.2  Consent to Continue Participation 
5.3  Assessment of Notification and Consent Processes 
5.4  Compliance with Criteria and Processes Required for EFIC 
6. STUDY ENROLLMENT PROCEDURE 
6.1  Screening 
6.2  Enrollment 
6.3  Study Team Arrival 
6.4  Blood Draw 
6.5  Enrollment Flow Diagram 
7. STUDY INTERVENTIONS 
7.1  Determination of subject weight 
7.2  Study drug administration 
7.3  Study Drug Infusion Precautions 
7.4  Randomization 
7.5  Study Drug 
7.6  Study Drug Packaging 
7.7  Protocol Assist Device 
8.  OUTCOME ASSESSMENT AND POST-INTERVENTION 
8.1  Assessment of treatment effect 
8.2  Determination of primary outcome 
8.3  Determination of secondary outcomes 
8.4  Endotracheal intubation 
8.5  Rescue anticonvulsants 
8.6  Continuous EEG 
 
 
10 

 
8.7  Standard supportive care 
9. ADVERSE EVENTS 
9.1 Definitions of Adverse Events: 
9.2 Grading of Adverse Events 
9.3  Relationship to Study Treatment 
9.4  Adverse Event Reporting 
9.5 Expected Adverse Events 
9.6  Clinical Management of Adverse Events 
10. STATISTICAL CONSIDERATIONS 
10.1 Randomization 
10.2 Blinding and unblinding: 
10.3 Primary outcome: 
10.4 Secondary outcomes. 
10.5  Primary Analysis 
10.6  Frequentist Analysis of the Primary Outcome 
10.7  Interim Analyses 
10.8  Estimated accrual 
10.9  Sample size considerations 
10.10  Missing Data and Non-compliance 
10.11 Secondary Analyses 
10.12  Analysis of Secondary Outcomes 
10.13  Pediatric Subgroup Analysis 
11. DATA COLLECTION 
11.1  Study activity and data collection 
 
 
11 

 
11.2  Data Collection Schedule 
11.3  Quality assurance 
11.4  Data management 
11.5  Clinical adjudication Core 
12. HUMAN SUBJECTS 
12.1  Institutional Review Board (IRB) Review 
12.2  Data and safety monitoring board (DSMB) 
12.3  Subject Confidentiality 
12.4 Study Modification/Discontinuation 
13. PUBLICATIONS AND DATA SHARING 
14. INTEGRATED SUB-STUDIES 
14.1 Pharmacokinetics/Pharmacodynamics (PK/PD) 
14.2 Emergent Electroencephalography (eEEG) 
15. REFERENCES 
 
 
 
 
 
 
 
12 

 
SYNOPSIS 
Established Status Epilepticus Treatment Trial (ESETT) 
A multicenter, randomized, blinded, comparative effectiveness study of fosphenytoin, valproic 
acid, or levetiracetam in the emergency department treatment of patients with 
benzodiazepine-refractory status epilepticus. 
Objectives:  ​The ​primary ​objective is to determine the most effective and/or the least effective 
treatment of benzodiazepine-refractory status epilepticus (SE) among patients older than 2 
years.  There are three active treatment arms being compared:  fosphenytoin (FOS), 
levetiracetam (LEV), and valproic acid (VPA).  The ​second ​objective is comparison of three drugs 
with respect to secondary outcomes.  The final objective is to ensure that the trial is 
informative for treatment of established SE in children by describing the effectiveness, safety, 
and rate of adverse reactions of these drugs in children. 
Primary outcome:  ​The  primary outcome is clinical cessation of status epilepticus, determined 
by the absence of clinically apparent seizures and improving responsiveness, at 60 minutes 
after the start of study drug infusion, without the use of additional anti-seizure medication. The 
following​ ​are ​secondary outcomes​: occurrence of life threatening hypotension or cardiac 
arrhythmia, time to termination of seizures, intubation, admission to ICU, seizure recurrence, 
length of stay in the ICU and hospital, mortality, and Richmond agitation and sedation score at 
60 minutes, will be compared between treatment groups.  
Methods:​ This is a randomized, multicenter,  Bayesian response adaptive comparative 
effectiveness trial of three active treatments in patients with status epilepticus who have failed 
treatment with benzodiazepines.  Each subject will be followed until discharge or 30 days from 
enrollment, whichever comes first. This trial will be monitored for early success and futility.  
Inclusion:​ Patients greater than or equal to 2 years of age, witnessed to have a clinically 
apparent seizure in the ED, 5-30 minutes after already having received at least an adequate 
dose of benzodiazepines for generalized, tonic-clonic convulsion(s).  Adequate doses of 
benzodiazepines for this study are defined as:  diazepam 10 mg IV, lorazepam 4 mg IV, or 
midazolam 10 mg IV or IM for all adults and those children greater than or equal to 32 kg, and 
diazepam 0.3mg/kg IV, lorazepam 0.1 mg/kg IV or midazolam 0.3mg/kg IM or 0.2 mg/kg IV for 
those children less than 32 kg.  These drugs may have been administered in two or more 
divided doses, including in the out-of-hospital setting. 
Interventions and Duration:​ The required concentrations of the study drugs (FOS 16.66 mg/ml, 
VPA 33.33 mg/ml and LEV 50 mg/ml) will be produced, packaged and labeled by the  University 
of California at Davis Good Manufacturing Practice (GMP) facility and shipped to the study sites. 
The study drugs are identical in appearance, formulation, packaging, and administration 
 
 
13 

 
(including volume and rate of infusion).​  ​The assigned treatment dose (FOS 20 mg/kg, LEV 60 
mg/kg or VPA 40 mg/kg) will be infused over 10 minutes.  The​ ​study participants will be 
observed for 20 minutes, while the duration of clinical seizures and response to verbal or 
painful stimuli is recorded.  At 60 minutes from start of study drug infusion, the primary 
outcome is determined. 
Randomization:​ Any patient witnessed to have seizures in the emergency department (ED) will 
be evaluated for enrollment based on inclusion and exclusion criteria.  Enrollment will occur 
under exception from informed consent rules (EFIC) due to the emergent and life-threatening 
nature of SE.  This is an intent-to-treat study so all subjects randomized will be included in the 
primary analysis.  Time of randomization is the time when the infusion pump, connected to 
study drug vial and patient’s IV catheter, is switched on. The randomization scheme will be 
equal allocation (1:1:1) for the first 300 patients. Once 300 subjects are randomized, 
response-adaptive randomization (RAR) will be utilized with the goal of maximizing the 
likelihood of identifying the most effective treatment arm.  
Interim  Analyses: ​Interim monitoring for success and futility will begin after 400 subjects have 
been enrolled and will be repeated after every additional 100 subjects are enrolled . This trial 
will stop early for success if the analysis identifies the maximum effective treatment with at 
least 97.5% probability. 
Sample Size: ​This study will  randomize a maximum target of 795 subjects over 4 years, at an 
accrual rate of approximately 16.5 subjects per month.  This sample size provides 
approximately  90% power to identify the most effective treatment when one treatment arm 
has a true response rate of 65% and the true response rate is 50% in the other two arms (an 
absolute difference of 15% ).  A 15% difference is the minimum clinically important difference 
sufficient to change clinical practice. The trial operating characteristics for this adaptive design 
were determined via an extensive simulation study, which ensures the type I error probability is 
less than 0.05 under a variety of scenarios.​37 
Participating Sites:​ Patients will be recruited by two national emergency research networks: 
Neurological Emergencies Treatment Trials (NETT) network and Pediatric Emergency Care 
Applied Research Network (PECARN).  Each network has successfully participated in SE 
treatment trials in compliance with EFIC regulations.  
 
 
 
14 

 
1. STUDY OBJECTIVES 
1.1 Primary Objective 
The primary objective is to determine the most effective and/or the least effective treatment 
(between fosphenytoin, levetiracetam and valproic acid) of benzodiazepine-refractory SE 
among patients greater than or equal to 2 years.  ​ ​The  primary outcome is clinical cessation of 
status epilepticus, determined by the absence of clinically apparent seizures and improving 
responsiveness, at 60 minutes after the start of study drug infusion, without the use of 
additional anti-seizure medication.  
1.2 Secondary Objectives 
Secondary objectives include: determination of the relative safety of the treatment arms on 
defined safety outcomes and all adverse events, analysis of secondary efficacy outcomes, and 
evaluation of both effectiveness and safety in the pediatric subpopulation.  
 
 
 
 
15 

 
2. BACKGROUND 
2.1 Rationale 
SE is defined as a prolonged self-sustaining seizure or recurrent seizures without recovery of 
consciousness between seizures (Lowenstein 1999).  Epidemiological studies carried out in 
Richmond, VA, found an annual incidence of SE ranging from 41/100,000-61/100,000 
(DeLorenzo 1996).  Based on these studies, there are approximately 120,000-180,000 episodes 
of convulsive SE each year in the US.  SE affects individuals of all ages from the very young to 
the elderly.  It complicates many neurological and systemic illnesses.  The mortality associated 
with SE is estimated as 17%.  SE also leads to morbidity including cognitive defects and 
neurological injury.  The morbidity and mortality of SE is determined by the underlying cause of 
the SE and the length of time in SE (Neligan 2010; Towne 1994). The Febrile status epilepticus 
study (FEBSTAT) suggests that SE, but not individual seizures, injures the hippocampus (Nordli, 
2012; Shinnar 2012).  Early termination of SE can limit development of refractory SE, 
neurological injury and mortality in experimental animals (Fujikawa 2005; Kapur 1997).  SE is 
particularly common in children (Shinnar . 1997).  Although multiple different etiologies such as 
infection, tumors, fever, preexisting neurological injury or brain malformation cause SE, the 
primary goal of treatment is prompt termination of seizures because adverse consequences of 
SE increase with seizure duration (Chen 2007; Lothman 1990; Meldrum 1973; Meldrum 1986).  
SE is initially treated with benzodiazepines. This selection is based on three double-blind, 
randomized, controlled clinical trials (Alldredge 2001; Treiman 1998, SIlbergleit 2012).  In the 
VA Cooperative Study (Treiman 1998), intravenous lorazepam was found to be superior to 
phenytoin.  In the Pre-hospital Treatment of Status Epilepticus (PHTSE) study (Alldredge 2001), 
lorazepam and diazepam were found to be superior to placebo.  In these studies, lorazepam 
was effective in terminating SE in 55-65% of patients. The recently published RAMPART study 
compared intramuscular midazolam to intravenous lorazepam for the initial treatment of SE 
(Silbergleit 2012).  It concluded that intramuscular midazolam is at least as safe and effective as 
intravenous lorazepam for patients in convulsive status epilepticus (Silbergleit 2012). 
Benzodiazepines are also the first treatment of choice in children (Loddenkemper 2011).  The 
recently published Pediatric Seizure Study found that lorazepam was not superior to diazepam 
for pediatric SE (Chamberlain 2014).  Unfortunately, approximately 35-45% of patients are 
refractory to benzodiazepines. Benzodiazepine-refractory SE is also called established SE. 
ESETT is a clinical trial testing the relative efficacy and safety of three treatments in patients 
who do not respond to benzodiazepine treatment (Cock 2011; Prasad 2005).  The need for such 
a trial has been emphasized in review articles, guidelines and by experts in the field (Lowenstein 
2005;Meierkord 2010; Wheless 2008). 
For the purpose of this trial, “established SE (ESE)” is defined as an episode of generalized 
convulsive SE in which seizure activity continues despite administration of adequate doses of 
 
 
16 

 
benzodiazepines.  It has long been recognized that SE is a dynamic and rapidly evolving 
condition which eventually becomes self-sustaining (Lothman 1990; Lothman 1989; Treiman 
1990; VanLandingham 1991a; VanLandingham 1991b).  Ongoing seizures rapidly modify 
neuronal activity and synaptic function (Chen 2007; Macdonald 1999).  This rapid neuronal 
plasticity is manifested in changes in seizure behavior, EEG patterns, sensitivity to drugs, and 
evolution of neuronal injury and death.  EEGs recorded from patients soon after onset of 
generalized convulsive SE demonstrate discrete seizures interspersed with normal activity, 
which evolves to continuous waxing and waning spike–wave discharges (Treiman 1990). 
Benzodiazepines given soon after the onset of generalized convulsive status epilepticus are 
effective in terminating seizures in 60-72% of patients.  As time passes,  these drugs become far 
less effective, terminating seizures in less than 25% of patients (Treiman 1998). 
Benzodiazepines act on GABA-A receptors and enhance inhibitory synaptic transmission 
(Goodkin 2009).  In experimental animals, benzodiazepines terminate seizures effectively if 
they are given soon after the start of seizures--when EEG demonstrates recurrent seizures and 
behavioral seizures are mild.  Benzodiazepines are less effective in treating longer lasting SE, 
especially after electrographic seizures have merged and 10 or more minutes have elapsed 
since first generalized tonic-clonic seizure (Jones 2002; Kapur 1997; Walton 1988; Wang 2009). 
Studies further reveal that inhibitory synaptic transmission mediated by GABA-A receptors is 
reduced in the hippocampi of animals in ESE (Goodkin 2008; Kapur 1995; Kapur 1997; Naylor 
2005; Terunuma 2008). Biochemical studies reveal a decrease in the number of functional 
receptors on the post-synaptic membrane in the hippocampi of animals in established SE 
(Goodkin 2005; Goodkin 2008; Naylor 2005; Terunuma 2008).  This rapid receptor plasticity is 
believed to be mediated by prolonged seizures, which activate many second messenger 
pathways (Brunig 2001; Pal 2001).  In summary, prolonged seizures modify GABA-A receptors 
and lead to ESE.  
Further treatment should ideally focus on mechanisms other than GABA-A receptors, such as 
sodium channels, calcium channels, or glutamatergic transmission. Currently, there are several 
drugs available in the intravenous formulation that can modify these systems.  Lacosamide and 
FOS modify sodium channels.  LEV modifies glutamatergic synaptic transmission by binding to 
the synaptic vesicle proteins.  VPA  has multiple actions on several neurotransmitter systems 
and ion channels.  These mechanisms are described in the respective package inserts. 
  
2.2 Study Drugs 
The primary goal of treatment of ESE is to terminate seizures rapidly, without causing 
respiratory or cardiovascular compromise, or coma.  The active form of the drug must enter the 
brain rapidly, access its target and stop ESE. Three drugs were selected for this study based on 
 
 
17 

 
current recommendations of professional groups, current clinical practice, and safety and 
efficacy data. 
Recently, the Status Epilepticus Guideline Writing Committee of the Neurocritical Care Society 
(NCS) reviewed current evidence and classified it according to American Heart 
Association/American College of Cardiology guidelines for evidence rating (Brophy 2012).  The 
Neurocritical Care Society rated common anticonvulsants for the treatment of SE as follows: 
VPA​:  Class IIa, level A—weight of evidence/opinion is in favor of usefulness/efficacy based on 
data derived from multiple randomized clinical trials. 
FOS​:  Class IIa, level B--weight of evidence/opinion is in favor of usefulness/efficacy based on 
data derived from a single randomized trial or nonrandomized trials. 
LEV​:  Class IIb, level C--weight of evidence/opinion is in favor of usefulness/efficacy based on 
consensus opinion of experts. 
These three medications are sometimes referred to by certain brand names.  Fosphenytoin may 
referred to as Cerebyx or, inaccurately, as Dilantin, the brand name of the active metabolite of 
this pro-drug.  Levetiracetam may be referred to as Keppra.  Valproic acid may be referred to as 
Depacon or Depakote. 
The NCS guidelines recommended use of either FOS or VPA for the treatment of established SE 
(Brophy 2012). 
To identify current practice, a critical care pharmacy group studied the patterns of 
anticonvulsant use for benzodiazepine refractory status epilepticus in the neurocritical care 
units.  This survey analyzed the medical records of 10-20 recent SE patients from the critical 
care units at 15 academic medical centers.   Among the 150 patients studied, benzodiazepines 
were the most commonly used first agent (75%) for treatment of SE.  FOS was the most 
commonly used second anticonvulsant (33%).  LEV was less commonly used (10%) and VPA was 
rarely used (<2 %) (Cook 2012).  The NCS Status Epilepticus Guideline Writing Committee 
reported the preferences of 50 identified experts among neurointensivists, neurologists and 
epileptologists for the treatment of ESE.  Among the respondents for this survey, 80% chose 
FOS (or phenytoin), 6% chose LEV and 2% chose VPA (Riviello 2006).  In a survey of 21 pediatric 
ED directors from the Pediatric Emergency Care Applied  Research Network (PECARN), FOS was 
the most commonly used treatment for ESE in pediatric patients followed by LEV, 
phenobarbital, and VPA. 
Intravenous formulations are available for FOS, LEV, VPA, lacosamide and  phenobarbital. Of 
these drugs, phenobarbital causes sedation and respiratory depression, especially in those who 
have been treated with benzodiazepines. This side effect limits the popularity of phenobarbital 
 
 
18 

 
as a second line agent for SE.  The safety of rapid intravenous administration of lacosamide has 
been established in adults but not in children (Fountain 2012).  Children constitute a large 
fraction of patients with SE.  Three hundred thirty-six of approximately 795 of subjects to be 
randomized into this study will be children.  There are limited data on the efficacy of 
lacosamide in established SE, especially in children.  For these reasons, lacosamide and 
phenobarbital were not included in the study. 
2.3  FOS (fosphenytoin) 
FOS is the most commonly recommended treatment for ESE in many current treatment 
guidelines (Brophy 2012; Loddenkemper 2011; Meierkord 2010) and is generally considered the 
standard of care.  In a survey of critical care neurologists published in 2003, 95% of responders 
(n= 106) used FOS or phenytoin for the treatment of ESE (Claassen 2003).  Two more recent 
surveys suggest that it is currently the most commonly used drug for the treatment of ESE in 
the US (Cook 2012; Riviello 2012). A survey of pediatric ED physicians belonging to the Pediatric 
Emergency Care Action Research Network (PECARN) reported that the majority of physicians 
treating children use FOS for the treatment of ESE. 
Pharmacokinetics, dose and rate of administration:  By convention, FOS is dosed in phenytoin 
equivalents (PE). In this protocol, all FOS doses given in mg indicate mg PE whether explicitly 
stated or not.  In order to achieve rapid termination of seizures, drugs need to be administered 
rapidly.  Drugs are delivered over a 10 minute infusion period in ESETT.  FOS can  be 
administered at a maximum rate of 150 mg/min in order to avoid hypotension and cardiac 
arrhythmias (see boxed warning, package insert).  This limits the maximum dose of the drug 
that can be administered safely over 10 minutes to 1500 mg.  The recommended loading dose 
of FOS is 18-20 mg/kg.  Therefore, patients weighing less than 75 kg will receive a loading dose 
20 mg/kg over 10 minutes.  Those weighing 75 kg or more will receive a fixed dose of 1500 mg 
over 10 minutes.  Because more than 65% of adult men and 45% of adult women weigh more 
than 75 kg, weight-based dosing will typically apply to children and fixed dosing to adults.  This 
dosing regimen is consistent with current recommendation for the use of anticonvulsants, 
where children are dosed on a mg/kg basis while adults are given fixed doses (see package 
insert phenytoin, LEV, and VPA).  In general, children are given larger doses of anticonvulsants 
because of differences in the pharmacokinetics. 
 
 
19 

 
Figure 1.  (Fischer 2003)  
The pharmacokinetics of FOS (1200 mg) administered at the rate of 150 mg phenytoin 
equivalents (PE)/min is illustrated in Figure 1 (Fischer 2003). Most clinically relevant is panel d 
showing unbound (free) phenytoin plasma concentrations following administration.  These 
remain in 2.0- 3.0 mg/L range 90 minutes after administration.  The accepted therapeutic range 
of unbound plasma concentration is 1 to 2 mg/L.  Patients receiving a single dose of FOS (1500 
mg) are expected to maintain a free phenytoin concentration above 2 mg/L for 90 to 120 
minutes. It is thus reasonable in the patient who has stopped seizing to wait for 2 hours from 
start of infusion to start or restart anticonvulsant medication. 
FOS is a prodrug which must be converted to phenytoin (PHT) to exert its action (Walton 1990). 
FOS has to undergo dephosphorylation before it can enter the brain. Figure 2 illustrates the 
rate of accumulation of PHT in rat plasma and brain after single intraperitoneal injection of FOS 
(called ACC 9653 at the time of publication) or PHT (Walton 1990). Note that peak plasma PHT 
concentration was achieved 30 minutes after FOS injection. The peak brain PHT level was 
attained 60 minutes after administration. PHT is effective against partial onset seizures and 
secondarily generalized seizures, but its efficacy in primary generalized seizures is not 
established.  It exerts its anticonvulsant action by stabilizing the inactivated state of sodium 
channels (Macdonald 1994). FOS gets converted into phenytoin and enters the brain. FOS can 
be administered faster than phenytoin.  
 
 
20 

 
       Figure 2.  (Walton 1990) 
Safety:  According to the package insert, the dose of IV FOS (15 to 20 mg PE/kg) that is used to 
treat status epilepticus is administered at a maximum rate of 150 mg PE/min to avoid 
cardiovascular side effects.  Hypotension may occur, especially after IV administration at high 
doses and high rates of administration.  Severe cardiovascular reactions and fatalities, such as 
atrial and ventricular conduction depression and ventricular fibrillation, have been reported 
following PHT administration, especially in elderly or gravely ill patients. These complications 
are less frequent with FOS, but careful cardiac monitoring is still needed when administering IV 
loading doses of FOS. Reduction in rate of administration or discontinuation of dosing may be 
necessary. This ESETT protocol calls for these reductions if needed while administering the 
study drug.  
Rash: Exfoliative, purpuric, or bullous, rashes, Stevens-Johnson syndrome, or toxic epidermal 
necrolysis are known to occur with chronic administration of PHT.  
Hepatotoxicity: Cases of acute hepatotoxicity, including infrequent cases of acute hepatic 
failure, have been reported with phenytoin. These incidents have been associated with a 
hypersensitivity syndrome characterized by fever, skin eruptions, and lymphadenopathy, and 
usually occur within the first 2 months of treatment. Other common manifestations include 
jaundice, hepatomegaly, elevated serum transaminase levels, leukocytosis, and eosinophilia. 
The clinical course of acute phenytoin hepatotoxicity ranges from prompt recovery to fatal 
outcomes. 
Hemopoietic system:  thrombocytopenia, leukopenia, granulocytopenia, agranulocytosis, and 
 
 
21 

 
pancytopenia with or without bone marrow suppression have been reported. 
Prenatal exposure to phenytoin was not found to have additional significant clinical risk in a 
recent Cochrane meta-analysis (Bromley 2014).  Theoretical risks are related to prolonged 
exposures rather than single dose exposures as in this trial.  Theoretical risks include  congenital 
malformations and other adverse developmental outcomes. Increased frequencies of major 
malformations (such as orofacial clefts and cardiac defects), minor anomalies (dysmorphic facial 
features, nail and digit hypoplasia), growth abnormalities (including microcephaly), and mental 
deficiency have been reported among children born to epileptic women who took phenytoin 
alone or in combination with other antiepileptic drugs during pregnancy. Patients known to be 
pregnant will be excluded from this trial anyway as per the secretarial waiver allowing studies 
with EFIC. 
Efficacy in animal studies:  Fosphenytoin and PHT are not effective in termination of 
benzodiazepine refractory SE in animal model ESE.  In an electrical stimulation model where 
excitatory inputs to the hippocampus were stimulated (perforant path) for 60 minutes, the 
resulting in-animal model ESE was not terminated by phenytoin ( 50 mg/kg) given intravenously 
(Mazarati 1998).  In another animal model of ESE based on electrical stimulation of the 
hippocampus for 90 minutes, phenytoin did not suppress seizures (Prasad 2002).  Finally, in a 
cholinergic stimulation (nerve agent-induced) animal model ESE, FOS had little or no 
therapeutic effect either administered alone or in combination with diazepam (McDonough 
2004). 
Efficacy in open studies:  In open-label studies for initial treatment of SE, the reported efficacy 
of PHT in terminating SE ranges from 44-88%  (Trinka 2009).  In the VA Cooperative study 
(Treiman 1998), PHT was effective in initial treatment of convulsive SE in 42% of patients, but in 
only 7.7 % patients with subtle SE.  Effectiveness in ESE was not studied.   A systematic, 
retrospective analysis concluded that phenytoin was effective in 58.6% of patients with SE who 
did not respond to benzodiazepines (Alvarez 2011).  
2.4  LEV (levetiracetam) 
Recently published guidelines for  the treatment of ESE in adults and children recommend LEV 
as an alternative to FOS (Brophy 2012; Loddenkemper 2011; Meierkord 2010).  In surveys of 
experts and pediatric ED physicians, LEV is the second most commonly used drug for the 
treatment of ESE in neurological intensive care units (Cook 2012; Riviello 2012).  It is used for 
the treatment of partial and generalized tonic-clonic seizures, myoclonic seizures and seizures 
associated with juvenile myoclonic epilepsy.  It binds to synaptic vesicle protein 2 (SV2)  and 
modulates neurotransmission.  An intravenous formulation of the drug has been available for 
several years and it is labelled for use when patients cannot swallow or for initiating therapy for 
 
 
22 

 
seizure.  
Pharmacokinetics & safety:  Doheny et al investigated the plasma and brain concentrations of 
LEV after bolus intraperitoneal injection of 20, 40 or 80 mg/kg of the drug to rats. Serum LEV 
concentration increases and peaks rapidly,  but brain accumulation is slow and peaks 90-100 
minutes after administration (Doheny 1999).  
Dose and rate of administration:  The recommended LEV dose in children up to 40 kg is 20-60 
mg/kg per day (package insert).  In adults, the recommended dose range is 1-3 g per day, but 
higher doses up to 6 g per day are commonly used.  The safety of rapid intravenous 
administration of LEV has been assessed.  Intravenous doses of 2500 mg have been 
administered over 5 minutes and doses of 4000 mg have been given over 15 minutes safely in 
adults (Ramael 2006a).  The common adverse effects in these patients were dizziness, 
somnolence, irritability and headache (Ramael 2006a). Based on these considerations, subjects 
weighing up to 75 kg will receive a loading dose 60 mg/kg over 10 minutes.  Those weighing 75 
kg or more will receive a fixed dose of 4500 mg over 10 minutes. 
  Figure 3.  (Ramael 2006b) 
Figure 3 demonstrates the pharmacokinetics of LEV following injection of 2000, 3000 or 4000 
mg of the drug (Ramael 2006b).  It is noteworthy that within 15 minutes of injection the plasma 
concentration of LEV peaks and remains above 40 µg /ml for 9 hours. The therapeutic 
concentration of LEV is considered to be 12 to 46 µg /ml.  Therefore, patients treated with LEV 
are likely to have therapeutic concentrations of the drug for 8 to 10 hours after the start of 
infusion. 
Safety: Suicidal ideation: Chronic administration of LEV increases the risk of suicidal thoughts or 
behavior. Patients treated with LEV for should be monitored for the emergence or worsening of 
depression, suicidal thoughts or behavior, and/or any unusual changes in mood or behavior. 
 
 
23 

 
Risk of suicidal ideation associated with a single dose of LEV is unknown.  
CNS:  CNS effects include somnolence and fatigue, coordination difficulties, and behavioral 
abnormalities observed in pediatric and adult population. 
Hematopoietic:  Minor, but statistically significant, decreases in total mean RBC count (0.03 x 
106/mm3), mean hemoglobin (0.09 g/dL), and mean hematocrit (0.38%), were seen in 
LEV-treated adult and pediatric patients in placebo-controlled trials. 
Pregnancy Risks:  The best available evidence is that there are no risks related to pregnancy 
from the administration of levetiracetam in humans.  Current data suggests that the overall risk 
of major malformation after first trimester exposure to levetiracetam is within the population 
baseline risk of 1-3%, with no apparent adverse effects on long term child development. The 
effect of a single dose of LEV has not been studied, but would be of lower risk than repeated 
dosing (Chaudhry SA, 2014, Bromley 2014).  
Efficacy in animal model ESE:  LEV administered alone reduced the duration of  perforant path 
stimulation–induced animal ESE (Mazarati 2004).  When used in combination with diazepam, 
low doses of LEV rapidly terminated behavioral and EEG seizures (Mazarati 2004).  In the 
cholinergic stimulation animal model of ESE, LEV administered alone suppressed behavioral 
seizures, but EEG seizures continued unabated (Zheng 2010). 
Efficacy in open studies:  Although no randomized controlled clinical trial for this agent has 
been performed, a large number of open case series and reports have been published.  An 
analysis of publications until 2009 reported that 707 patients with various forms of SE had been 
treated with LEV.  The success rate was about 70% (Trinka 2011).  In ESE, the efficacy of LEV is 
reported as 51.7 % in one study (Alvarez 2011) and 73.2% in another study (Tripathi 2010).  
2.5  VPA (valproic acid) 
VPA was recommended for the treatment of ESE in recent guidelines (Brophy 2012; Meierkord 
2010). In surveys, VPA is the third or 4​th​ most commonly used drug for the treatment of ESE in 
the U.S. (Cook 2012; Riviello 2012).  VPA is an anticonvulsant commonly used for the treatment 
of primary generalized seizures, myoclonic seizures and focal seizures. The drug has multiple 
actions on the GABA neurotransmitter system and calcium channels (Macdonald 1995). 
Valproate sodium is the salt of the valproate ion which is synonymous with VPA. 
 
 
24 

 
  Figure 4.  (Limdi 2007) 
Pharmacokinetics:  Subjects weighing up to 75 kg will receive a loading dose of 40 mg/kg over 
10 minutes.  Those weighing 75 kg or more will receive a fixed dose of 3000 mg over 10 
minutes. Based on published pharmacokinetic data (Limdi 2007), serum VPA levels will peak 
between 150-200 mg/L within minutes of administration and then remain in the 50-150 mg/L 
range for the next 4 hours (see Figure 4).  Pharmacokinetics of IV VPA has been studied in 
children with epilepsy (Birnbaum 2003; Panomvana Na 2006; Ramsay 2003; Visudtibhan 2011; 
Williams 2012).  Recent studies suggest that the pharmacokinetics of rapid intravenously 
administered  VPA conforms to models developed using oral VPA in children and oral and 
intravenous VPA in adults (Williams 2012).  Intravenous VPA is safe in acutely ill children with 
recurrent seizures and in those with epilepsy (Birnbaum 2003; Ramsay 2003). 
Dose and rate of administration: Recommended VPA dose ranges from 15-45 mg/kg/day.  VPA 
has been administered rapidly by the intravenous route.  In one study it was administered at 
the rate of up to 10 mg/kg/minute for doses up to 30 mg/kg (Limdi 2005).  In another study in 
children it was given at rates up to 11 mg/kg/min for dose up to 40 mg/kg (Venkataraman 1999; 
Wheless 2004). The most common adverse events were injection site pain, pain with infusion, 
dizziness, and somnolence. Based on these considerations, subjects weighing up to 75 kg will 
receive a loading dose of 40 mg/kg over 10 minutes.  Those weighing 75 kg or more will receive 
a fixed dose of 3000 mg over 10 minutes. 
Safety in pregnant women  Children born to mothers taking long durations of high doses of VPA 
during pregnancy may have a higher than expected  incidence of reduced  cognitive 
performance at ages 3 and 4.5 (McVearry 2009; Meador 2009; Werler 2011).  These risks  are 
dose dependent and vary across studies.  They have only been found to be are associated with 
chronic administration of VPA (Bromley 2014).  There is no evidence that a single dose of VPA 
 
 
25 

 
given during pregnancy can cause birth defects. 
In a series of reviews of hepatotoxicity associated with VPA, Dreifuss and colleagues concluded 
that the​ ​ primary risk of fatal hepatic dysfunction (1/500) was found in children 0 to 2 years old 
receiving VPA as polytherapy. The risk declined with age and was low in patients receiving VPA 
as monotherapy (1/37,000). No hepatic fatalities occurred in patients above the age of 10 years 
receiving VPA as monotherapy (Bryant 1996; Dreifuss 1987; Dreifuss 1989).  There are reports 
that polymerase c gene (POLG) determines the risk of VPA -induced hepatotoxicity (Stewart 
2010).   However, the POLG polymorphisms were discovered in patients who had been 
chronically treated with VPA and had elevated hepatic enzymes.  The authors concluded that 
the genetic variants reduced the regenerative capacity of the hepatocytes following injury. 
Patients with mutations in POLG have metabolic encephalopathy. There is no report of 
hepatotoxicity associated with a single dose of VPA.  Patients below age 2, and those with 
known or suspected metabolic encephalopathy are excluded from  ESETT.  
Exclusion of patients known to be pregnant, younger than 2 years and with known or suspected 
metabolic encephalopathy will reduce the possibility of VPA exposure to the population at risk 
for toxicity.  There is a small risk that a pregnant patient who is not identified as pregnant by 
history or physical examination will be included in the study.  The risk of toxicity is mitigated by 
the fact that a single dose of VPA will be used.  This risk should be weighed against the known 
morbidity and mortality of ESE and compared to the risk of administering FOS. 
Clinical studies:  VPA has been used for the treatment of SE in prospective or retrospective 
series and two randomized open trials (Trinka 2009). An analysis of these trials reported that 
693 adults or children in SE have been treated with VPA and the response rate ranging from 60- 
83% of patients.  A pilot prospective randomized open study reported a trend towards 
superiority of VPA to phenytoin in treatment of SE (Misra 2006).  Another study reported that 
VPA controlled SE refractory to PHT (Agarwal 2007). 
2.6  Systematic comparison of FOS, VPA, and LEV for the treatment of ESE 
There is one systematic study of treatment of ESE (Alvarez 2011).  In a retrospective analysis of 
protocol-driven treatment of ESE,  279 adult episodes of SE were identified prospectively in 
which either PHT or VPA or LEV was given in a non-randomized un-blinded fashion after 
benzodiazepines failed (labeled Alvarez in figure 5 below). VPA failed to control SE in 25.4%, 
PHT in 41.4% and LEV in 48.3% of episodes.  Because patients were not balanced with regards 
to etiology and severity of SE, a post-hoc adjustment for severity and etiology was performed. 
After this adjustment the authors reported that LEV failed more often than VPA (Odds ratio 
(OR) 2.69: 95% confidence interval 1.16-6.08)).  PHT was not significantly different from the 
other two compounds. The authors concluded that LEV is less effective than VPA for control of 
 
 
26 

 
ESE and called for a prospective randomized trial of these agents.  
Two ESE treatment studies were open-label, randomized, prospective studies.  In the first study 
(labeled Agarwal on figure 5), one hundred patients aged two or older who had failed IV 
diazepam were randomized to either 20 mg/kg of VPA or 20 mg/kg of PHT.  SE was controlled in 
44 (88%) patients treated with VPA and 42 (81%) patients treated with PHT (Agarwal 2007).  No 
significant difference was found between VPA and PHT in this open-labeled study.  In the 
second study (Tripathi 2010)  patients were randomized  to IV LEV or IV VPA after failing 
diazepam treatment of SE.  Status epilepticus was terminated by IV LEV in 30 patients and by IV 
VPA in 28 patients.  In this study as well, there was no significant difference between LEV and 
VPA.  In summary, one large head-to-head comparison of these three agents raised the 
possibility that VPA is superior to LEV for the treatment of ESE.  The other studies were 
inconclusive.  Expert evaluation of the published data suggests that VPA (Class IIa level A) may 
be superior to  FOS (Class IIa level B), which may be superior to LEV (class IIb level C). 
 
 
Figure 5.  (Agarwal 2007, Alvarez 2011, Tripathi 2010) 
In summary, current practice is to treat ESE with FOS or LEV.  However no randomized 
controlled trials have demonstrated their efficacy in terminating ESE.  Non-randomized and 
pilot studies suggest VPA may be more efficacious than LEV.  Most expert ED physicians, 
neurologists, neuro-intensivists and pediatric neurologists believe that the next logical step is a 
randomized, blinded comparative efficacy study to decide the best treatment for ESE (Brophy 
2012; Cock 2011; Loddenkemper 2011; Shorvon 2011; Trinka 2009). 
 
 
 
27 

 
3. STUDY DESIGN 
This is a multicenter, randomized, Bayesian response-adaptive comparative effectiveness trial 
of three active treatments in patients with established SE who have failed treatment with 
benzodiazepines. Subjects will initially be randomized in a 1:1:1 ratio. Once 300 subjects are 
randomized, response-adaptive randomization (RAR) will be utilized with the goal of 
maximizing the likelihood of identifying the most effective treatment arm.  Interim analyses are 
planned after 400, 500, 600, and 700 subjects are enrolled.  At each interim analysis, there may 
be updates to the randomization probabilities. At each interim analysis, the trial may stop early 
for success or futility. The maximum approximate sample size is 795 subjects total.  
 
Figure 6. 
 
 
 
28 

 
4. SELECTION AND ENROLLMENT OF SUBJECTS 
4.1 Inclusion Criteria 
Patients will be included in this study if they are aged 2 or older, have been treated for 
generalized convulsive seizure of greater than 5 minutes duration with adequate doses of 
benzodiazepines, and who continue to have persistent or recurrent convulsions in the 
emergency department at least 5 minutes and no more than 30 minutes after the last dose of 
benzodiazepine.  The inclusion criteria is intended to describe the population of patients for 
whom progression to second line anticonvulsants are indicated.  The seizure and its initial 
treatment may have occurred prior to arrival in the ED. 
Adequate doses of benzodiazepines for this study are determined to be: diazepam 10 mg IV, 
lorazepam 4 mg IV or midazolam 10 mg IV or IM for all adults and those children greater than 
or equal to 32 kg.  For children less than 32 kg adequate doses are: diazepam 0.3 mg/kg IV, 
lorazepam 0.1 mg/kg IV and midazolam 0.3mg/kg IM or 0.2 mg/kg IV.  These drugs may have 
been administered in two or more divided doses.  The last dose of benzodiazepine must be 
given at least 5 minutes prior study drug initiation to provide this dose sufficient time to act. 
The last dose of benzodiazepine must be given within 30 minutes of study drug initiation to 
avoid enrolling patients in whom re-dosing of benzodiazepines may be more appropriate. 
Transmucosal benzodiazepines such as rectal diazepam or buccal midazolam given at home 
prior to EMS arrival may be included in the calculation of the cumulative adequate 
benzodiazepine dose, but at least one dose of benzodiazepines must be also given by EMS or in 
the ED between 5 and 30 minutes of study drug administration. There is no maximum dose of 
benzodiazepines  imposed by this trial.  Although these doses are considered the minimum 
adequate doses based on common clinical practice, it is recommended that the best practice 
(subject to local standards of care) is to administer 20 mg of diazepam, 8 mg of lorazepam, or 
20 mg of midazolam in adults prior to progression to enrollment. 
 
 
 
 
29 

 
 
Table 1.  Inclusion criteria and rationale 
Inclusion criteria 
Measure 
Rationale 
Patient witnessed to seize for 
greater than 5 minute duration 
prior to treatment with study 
drug 
Witness or EMS report or clinical 
observation 
PHTSE and RAMPART study suggest that 
the treatment of SE should begin when 
single seizure or recurrent seizures 
without recovery of consciousness have 
lasted more than 5 minutes.  
Patient received adequate 
dose of benzodiazepines. The 
last dose of a benzo was 
administered in the 5-30 
minutes prior to study drug 
administration. 
The doses may be divided.  
  
  
EMS or ED record of treatment:  
For all adults and those children ≥ 32 
kg adequate doses are: 
diazepam 10 mg IV or PR, or  
lorazepam 4 mg IV, or  
midazolam 10 mg IM or IV. 
For children <32 kg adequate doses 
are: diazepam 0.3 mg/kg IV or PR, or 
lorazepam 0.1 mg/kg IV, or  
midazolam 0.3mg/kg IM - 0.2 mg/kg IV 
For purposes of this study, IO is 
considered equivalent to IV.  For 
midazolam, IN or PB are considered 
equivalent to IM. 
According to current treatment 
guidelines initial therapy for SE is 
appropriate doses of these drugs.  
The 5 to 30 minute window is intended 
to provide the last dose sufficient time 
to act and to avoid enrolling patients in 
whom the last dose may have already 
worn off. 
Continued or recurring seizure 
in the Emergency Department 
Clinical observation 
When patient fails to respond to 
adequate doses of benzodiazepines, a 
second line agent is needed to 
terminate SE. 
Age 2 years or older 
Caretakers report of age or clinical 
observation 
The causes and treatment of SE in 
patients  less than 2 years of age are 
different from those in older children 
and adults. 
 
 
 
 
 
 
30 

 
4.2 Exclusion Criteria 
ESETT is intended to be broadly inclusive of the target population.  The purpose of the exclusion 
criteria to prevent enrollment for three narrow categories of patients:  those who can or should 
not be enrolled under EFIC, those who have already received confounding therapy, and those 
with medical contraindications to the study drugs or an indication for alternative treatment. 
Specific contraindications are listed and explained in table 2. 
 
Table 2.  Exclusion criteria and rationale 
Criteria 
Measure 
Rationale 
Known pregnancy 
History and physical 
exam* 
Pregnant women are excluded from studies 
performed under exception from informed 
consent (EFIC). 
Prisoner 
Look for prison guards 
Prisoners are excluded from studies  performed 
under exception from informed consent (EFIC). 
Opt-out identification or otherwise 
known to be previously enrolled in 
ESETT 
Look for medical-alert 
jewelry, bracelets, or 
trial-specific wrist bands 
labelled with “ESETT 
declined” 
Provides a mechanism for those who wish to 
identify themselves prospectively to opt out of 
EFIC, or to identify and exclude cooperative 
potential re-enrollers. 
Treatment with a second line 
anticonvulsant (FOS, PHT, VPA, LEV, 
phenobarbital or other agents defined 
in the MoP) for this episode of SE 
Medication 
administration record 
The use of any second line agents prior to 
enrollment in the study would confound 
determination of the effects of the study drugs. 
Treatment with sedatives with 
anticonvulsant properties other than 
benzodiazepines (propofol, etomidate, 
ketamine or other agents defined in 
the MoP) 
Medication 
administration record 
Anticonvulsant sedative drugs are used for 
sedation and rapid sequence intubation. These 
drugs could terminate SE and would confound 
the primary efficacy outcome.  
Endotracheal Intubation 
History and examination 
Prevents evaluation of patient for 
responsiveness. 
Acute traumatic brain injury 
Clinical history, 
evidence of head 
trauma  
Other care, often requiring sedation, takes 
precedence. 
Known metabolic disorder 
Clinical history* 
Patients with metabolic disorders are at risk for 
liver failure when treated with VPA (VPA 
package insert). 
 
 
31 

 
Known liver disease 
Clinical history* 
Patients with liver disease are at risk for liver 
failure when treated with VPA (VPA package 
insert) 
Known severe renal impairment 
Clinical history* 
Severe renal impairment has been associated 
with reduced plasma protein binding of valproic 
acid and fosphenytoin, resulting in substantially 
elevated free concentrations of these drugs 
Known allergy or other known 
contraindication to FOS, PHT, LEV, or 
VPA 
Clinical history 
As per package inserts for FOS, LEV, and VPA. 
Hypoglycemia < 50 mg/dL 
Finger-stick glucose 
SE due to hypoglycemia is first treated by giving 
glucose and correcting it. 
Hyperglycemia > 400  mg/dL 
Finger-stick glucose 
SE due to hyperglycemia is first treated by 
reducing glucose and correcting it. 
Cardiac arrest / post-anoxic seizures 
History and ECG rhythm 
strip 
Prognosis of SE due to anoxia and cardiac arrest 
is uniformly poor and distinct from other 
causes. 
* Laboratory testing is not indicated to screen for these exclusion criteria because the risk of 
delay in treatment is much greater than the risk enrollment with these conditions. 
 
 
 
32 

 
5. Informed Consent and Exception from Informed Consent (EFIC) 
Respect for human subjects and their safety are paramount in this trial.  Research involving 
subjects who have SE, however, presents an ethical challenge.  Protecting patient autonomy 
through the informed consent process is typically an ethical cornerstone of human subjects 
research, but because patients in generalized SE are unconscious, an informed consent process 
is not possible and patients cannot say whether or not they would want to participate in the 
research.  Furthermore the alternative process of identifying and obtaining surrogate informed 
consent from a legally authorized representative (LAR) is not practicable in SE, because the 
emergency treatment being studied must be initiated as quickly as possible to safely care for 
the patient.  Identification of the optimal emergency care for those in SE in this trial can 
therefore only be conducted with exception from informed consent (EFIC) for emergency 
research.  This section will explain the processes used in this trial and the detailed rationale for 
compliance with the FDA regulations for EFIC found at 21 CFR 50.24. 
5.1  Enrollments all performed under EFIC 
All participants will be enrolled under EFIC.  In this trial there will be no circumstance in which 
an informed consent process can be meaningfully or safely performed.  All patients eligible for 
this trial must be unconscious from generalized SE, so no one can consent for themselves, and 
the rapidity with which treatment is needed for SE precludes obtaining consent from parents 
and other legally authorized representatives (LAR) even if they are present.  Emergency 
treatment must be given quickly because every minute of delay decreases the likelihood that an 
anticonvulsant medication will be effective at terminating seizures, and patient morbidity and 
mortality increase with increasing seizure duration.  Therefore, the delay related to any 
meaningful and compliant informed consent process is unsafe, impracticable, and would not be 
ethical.  It is also not practicable to identify and consent patients prior to developing SE as 
35-50% of patients who have SE are new onset, and even in patients with epilepsy, SE is a 
relatively uncommon and unpredictable manifestation.  It is not possible to predict who will 
have SE.  
A more detailed EFIC Plan document for the trial can be found in the Manual of Procedures 
(MoP).  The investigational new drug application for this trial is identified as using EFIC. 
Investigators at each site will perform community consultation and public disclosure as 
discussed below, and these will be reviewed and approved by local institutional review boards 
prior to starting the trial at the site.  
5.2  Consent to Continue Participation  
Subjects or their LAR will be notified of enrollment as early as possible and consent to continue 
participation in the study will be sought for all subjects.  
 
 
33 

 
Attempts are typically initiated in the ED by the study team to discuss the enrollment with the 
subject in those subjects who are waking up, or to locate and communicate with an LAR for 
subjects who are not waking up.   When a subject or LAR are first available to participate in an 
informed consent process, they will be asked to continue participation in the study. 
Continuation in the study only involves further review of the subject’s medical record through 
the shorter of hospital discharge or 30 days.  Those wishing to continue will have the informed 
consent document explained to them, will have any questions answered, and they will be asked 
to review and sign the informed consent document.  In those who wish to discontinue 
participation, no further data will be collected.  Data collected prior to withdrawal will remain 
in the study database as per FDA requirements and guidance.  Those wishing to discontinue 
participation will also have the informed consent document explained to them, will have any 
questions answered and will be asked to review and sign an informed withdrawal from the 
study, however, subjects are not required to complete this document in order to withdraw. 
Standard consent procedures will be used. A copy of a model informed consent document will 
be provided to sites. 
If a subject is randomized into ESETT and dies before a legally authorized representative or 
family member can be contacted, a reliable mailing address for the subject’s family or LAR will 
be obtained.  After allowing a two to four week period of grieving, the site study team will send 
a letter with basic information about the clinical investigation, the subject’s inclusion, and 
contact information so that families can call or write to obtain more information or to get 
questions answered if desired. 
5.3  Assessment of Notification and Consent Processes  
Notification and informed consent logs are incorporated in the study case report forms and will 
allow tracking and reporting of the timeliness of these processes.  In addition, subjects and 
LAR’s participating in notification and consent processes may be offered an opportunity to 
share their experience and attitudes by answering a standardized survey up to day following an 
informed consent or withdrawal.  This information will be used for process improvement and to 
better understand the subject or LAR perspective on emergency research. 
5.4  Compliance with Criteria and Processes Required for EFIC 
FDA regulations identify the specific circumstances in which EFIC is appropriate.  ESETT fulfills 
these requirements for emergency research.  In the following section, the components of the 
regulation are reproduced, along with an explanation of how ESETT will comply with each 
requirement.  
SE is life-threatening and available treatments are unsatisfactory or unproven. 
21 CFR 50.24(a)(1) The human subjects are in a life-threatening situation, available treatments are 
 
 
34 

 
unproven or unsatisfactory, and the collection of valid scientific evidence, which may include 
evidence obtained through randomized placebo-controlled investigations, is necessary to determine 
the safety and effectiveness of particular interventions. 
Population studies of the incidence of SE report an incidence of between 41-61/100,000.  The 
mortality rate is estimated to be greater than 17% (Neligan 2010). 
The Cochrane review of anticonvulsant therapy for SE found eleven studies with 2017 subjects. 
The review concluded that lorazepam was the most effective agent and will terminate SE in 
only 60-70% of patients with this life-threatening condition.  Because 30-40% of patients do not 
respond to first-line therapy for SE, benzodiazepines are unsatisfactory on their own.  The three 
anticonvulsant medications studied in this trial are often used as second-line therapy to treat 
these patients but are unproven.  There are no randomized, prospective, adequately controlled 
trials to confirm whether one or more of these medications are either effective or safe in these 
patients.  
Clinical trials are clearly needed.  No blinded, sufficiently powered prospective, randomized 
controlled trial has compared treatments for seizures refractory to initial benzodiazepine 
treatment. Currently published treatment guidelines recommend intravenous FOS as 
second-line treatment, with LEV and VPA as alternatives (Brophy 2012; Loddenkemper 2011; 
Meierkord 2010).  However, there are small, open-label randomized studies that suggest the 
potential efficacy of VPA over LEV in treatment of ESE (Alvarez 2011).  A series of clinical 
observations suggest that LEV and VPA are safe and effective in the treatment of ESE (Trinka 
2009; Trinka 2011). 
Obtaining prospective informed consent is not feasible.  
21 CFR 50.24(a)(2) Obtaining informed consent is not feasible because: (i) the subjects will not be 
able to give their informed consent as a result of their medical condition; (ii) the intervention under 
investigation must be administered before consent from the subjects' legally authorized 
representatives is feasible; and (iii) There is no reasonable way to identify prospectively the 
individuals likely to become eligible for participation in the clinical investigation. 
Subjects in generalized status epilepticus are unconscious and unable to provide informed 
consent due to their medical condition. The care of patients in status epilepticus must be 
initiated immediately, which, in the Emergency Department care of patients with 
benzodiazepine refractory SE is the immediate initiation of second line anticonvulsant therapy.  
Complications of prolonged seizures include impaired ventilation and subsequent pulmonary 
aspiration, cardiac dysrhythmias, derangements of metabolic and autonomic function, and 
direct injury to the nervous system.  Seizures of short duration may be clinically benign, but 
longer durations are associated with increasingly severe morbidity and mortality. There is no 
specific identifiable threshold for seizure duration that predicts the onset of morbidity, and 
 
 
35 

 
thus, clinical practice is geared toward terminating seizures as quickly as possible.  
Clinical data have demonstrated the duration of SE is associated with death and unfavorable 
neurologic outcomes (Maegaki 2005, Holtkamp 2005). While many of these data concern long 
durations of SE lasting hours or days, data also suggest that differences of as little as a few 
minutes in seizure duration are also associated with differences in outcome. Patients found in 
SE by paramedics who had termination of their seizures prior to arrival to the emergency 
department have an ICU admission rate of 32% as compared to 73% in patients whose seizures 
persisted on arrival to the ED. In a randomized trial, patients with SE treated with lorazepam or 
diazepam in the field by paramedics had mortality at hospital discharge of 7.7% and 4.5% 
respectively, which was less than half the mortality of 15.7% for patients in whom 
benzodiazepines were given only after arrival in the ED (Alldredge 2001). 
The benefits of emergent treatment and termination of SE likely result from minimizing the 
consequences of impaired ventilation, pulmonary aspiration, hemodynamic instability, or 
metabolic derangements associated with prolonged convulsions. Rapid termination of seizures 
may also prevent kindling effects demonstrated in animal models in which seizures become 
more refractory to subsequent treatment as the duration of seizure increases (Morimoto 2004). 
Rapid treatment may also prevent the neuronal cell injury and loss that occurs with increasing 
duration of seizures due to duration dependent cytokine mediated effects (Ravizza 2005). 
Since status epilepticus is precipitated by a variety of acute and unpredictable etiologies, there 
is no reasonable way to identify prospectively the individuals likely to become eligible for 
participation in the research. Furthermore, status epilepticus is often an initial presenting 
manifestation of disease, precluding prospective identification. This was confirmed in data from 
Baren et al that found prospective identification of subjects for the PECARN Pediatric Seizure 
Study to be infeasible (Baren 2006). 
Participation holds prospect of direct benefit to subjects 
21 CFR 50.24(a)(3) Participation in the research holds out the prospect of direct benefit to the 
subjects because: (i) subjects are facing a life-threatening situation that necessitates intervention; 
(ii) appropriate animal and other preclinical studies have been conducted, and the information 
derived from those studies and related evidence support the potential for the intervention to provide 
a direct benefit to the individual subjects; and (iii) risks associated with the investigation are 
reasonable in relation to what is known about the medical condition of the potential class of 
subjects, the risks and benefits of standard therapy, if any, and what is known about the risks and 
benefits of the proposed intervention or activity. 
Participation in ESETT holds out the prospect of direct benefit to subjects. Subjects may directly 
benefit from participation because status epilepticus is a life-threatening condition and some of 
the interventions used in this study may be more effective than others.   Studies in 
experimental SE in animals suggest that LEV may terminate established SE but that FOS, the 
 
 
36 

 
treatment most commonly used, fails to do so (Mazarati 1998; McDonough 2004; Prasad 2002). 
Some observational clinical data also suggests that FOS or its active metabolite PHT are not the 
most effective second-line agents (Agarwal 2007, Alvarez 2011).  The use of response adaptive 
randomization in this trial increases the probability that those enrolled later in the trial will be 
more likely to be randomized to the more effective arm if there is a more effective arm. 
The trial can not be practicably carried out without exception from informed consent 
21 CFR 50.24(a)(4) The clinical investigation could not practicably be carried out without the waiver. 
This research could not be carried out without EFIC because treatment for SE needs to begin 
immediately upon ED arrival.  Since SE patients are unable to consent for themselves and there 
is not time to obtain consent from an LAR, all patients must be enrolled under EFIC.  A 
meaningful informed consent process requires that the LAR have time to understand the 
material presented, be able to ask questions and have time to think about what the patient 
would want.  This is not possible in the brief period in which the study drug is obtained and 
initiated.  In ESE, time to treatment is especially critical.  Inability to obtain informed consent 
can limit the ability to discover better treatments for this critical and life-threatening condition.  
Need for immediate treatment of status epilepticus precludes consent from an LAR 
21 CFR 50.24 (a)(5) The proposed investigational plan defines the length of the potential therapeutic 
window based on scientific evidence, and the investigator has committed to attempting to contact a 
legally authorized representative for each subject within that window of time and, if feasible, to 
asking the legally authorized representative contacted for consent within that window rather than 
proceeding without consent. The investigator will summarize efforts made to contact legally 
authorized representatives and make this information available to the IRB at the time of continuing 
review. 
The narrow therapeutic window described above, the inability of patients with SE to 
communicate, and the inherent delay in delivery of standard therapy in attempts to contact 
and discuss consent with a surrogate decision maker preclude the possibility of obtaining 
informed consent for any potential subject in ESETT.  Attempts to contact LAR for notification 
and consent to continue participation will be tracked and can be summarized and reported to 
the IRB at the initial and continuing reviews. 
Provision of an informed consent document 
21 CFR 50.24(a)(6) The IRB has reviewed and approved informed consent procedures and an 
informed consent document consistent with Sec. 50.25. These procedures and the informed consent 
document are to be used with subjects or their legally authorized representatives in situations 
where use of such procedures and documents is feasible. The IRB has reviewed and approved 
procedures and information to be used when providing an opportunity for a family member to 
object to a subject's participation in the clinical investigation consistent with paragraph (a)(7)(v) of 
this section. 
A written informed consent document prepared at each site for this study must be reviewed 
 
 
37 

 
and approved by participating IRB’s approving this clinical investigation. Subjects enrolled in 
ESETT, or their legally authorized representatives (LAR) or family, are informed of the subject’s 
inclusion in the clinical investigation at the earliest possible opportunity. The study team is 
immediately notified of the arrival of treated subjects in the emergency department (ED). An on 
call study team member quickly responds to the ED to complete the subject enrollment. The 
subject (or LAR or family) is approached, and an informed consent process initiated as soon as 
possible. The study team notifies the subject or LAR/family about the subject’s enrollment, 
provides information about the study and about the subject’s rights and the responsibilities of 
the investigators, and answers any questions about the study and further participation. A 
written informed consent document is used to reinforce the information provided verbally and 
to document a decision to either continue in the study or to not participate any further. A copy 
of this form is provided to the subject and another copy is placed in the research record.  
Community Consultation 
21 CFR 50.24(a)(7) Additional protections of the rights and welfare of subjects will be provided, 
including, at least: (i) consultation (including, where appropriate, consultation carried out by the 
IRB) with representatives of the communities in which the clinical investigation will be conducted 
and from which the subjects will be drawn 
The community will be consulted prior to the initiation of research.  With guidance from the 
each site’s IRB, the community will be asked to give their opinions of the research.  A menu of 
options is included in the detailed EFIC plan in the MoP and includes mechanisms such as 
community meetings, town hall meetings, focus groups, meetings with established community 
advisory boards, in-person surveys, and random-digit dialing surveys.  The specific type of 
community consultation will be determined by each site’s IRB.  Reporting of community 
consultation results will be standardized across the ESETT sites. 
Public Disclosure 
21 CFR 50.24(a)(7) Additional protections of the rights and welfare of subjects will be provided, 
including, at least: 
.(ii) Public disclosure to the communities in which the clinical investigation will 
be conducted and from which the subjects will be drawn, prior to initiation of the clinical 
investigation, of plans for the investigation and its risks and expected benefits; (iii) Public disclosure 
of sufficient information following completion of the clinical investigation to apprise the community 
and researchers of the study, including the demographic characteristics of the research population, 
and its results 
Public disclosure is the primary element in making certain that ESETT is conducted in an entirely 
transparent manner. Methods of announcing information about the trial, and the development 
of advertising and other materials about the trial, will take place both locally and nationally. 
Public disclosure will be initiated prior to approval of the trial, may continue during enrollment, 
and will conclude with dissemination of study results after the trial is completed. A menu and 
discussion of many public disclosure methods and procedures is detailed in the EFIC plan in the 
 
 
38 

 
MoP.  Each site IRB will determine the type and form of local public disclosure.  Reporting of 
public disclosure efforts will be standardized. Summaries of public disclosure will be reported to 
each IRB, and composite reports of local and national public disclosure at the trial-level will be 
provided to the FDA docket. 
Data Monitoring Committee 
21 CFR 50.24(a)(7) Additional protections of the rights and welfare of subjects will be provided, 
including, at least: 
.(iv) Establishment of an independent data monitoring committee to exercise 
oversight of the clinical investigation; 
A Data and Safety Monitoring Board (DSMB) is appointed by the NINDS to provide ongoing 
evaluation of safety data as well as the overall conduct of the trial, per institute guidelines. The 
members will have a meeting with the study team prior to study commencement to discuss the 
protocol as well as content and format of the DSMB reports. The SDMC will prepare requested 
reports at specified time intervals. Data and safety monitoring will be performed consistent 
with the guidance provided by the NIH notices 98-084 “Policy for data and safety monitoring” 
and OD-00-038 “Further guidance on data and safety monitoring for phase I and phase II trials”, 
and by the NINDS document based on these notices “NINDS Guidelines for Data and Safety 
Monitoring in Clinical Trials”. 
Contacting Other Family 
21 CFR 50.24(a)(7) Additional protections of the rights and welfare of subjects will be provided, 
including, at least: 
. (v) If obtaining informed consent is not feasible and a legally authorized 
representative is not reasonably available, the investigator has committed, if feasible, to attempting 
to contact within the therapeutic window the subject's family member who is not a legally 
authorized representative, and asking whether he or she objects to the subject's participation in the 
clinical investigation. The investigator will summarize efforts made to contact family members and 
make this information available to the IRB at the time of continuing review. 
It will not be ethically possible in ESETT, for the reasons described above, to delay treatment of 
the seizing subject long enough to contact either an LAR or other family members. A provision 
of the protocol has been made to allow subjects that learn of the trial through public disclosure 
efforts or other means, and who would not want to participate if treated in the ED for status 
epilepticus, to communicate that decision to the ED without causing any delay in treatment. As 
part of the primary assessment of a seizing patient, ED providers already check for medical alert 
jewelry to ascertain emergent medical information about the patient. If the words “ESETT 
declined,” or alternative designation as defined in the MoP, are listed on the medical alert tag, 
the patient will not be enrolled in the clinical investigation. Medical alert tags are commonly 
used by people with epilepsy already, and provide a means of communication that does not 
require such patients to wear any extra marker. Since they are already worn daily, they do not 
require additional effort to use once information is added to the tag. The tags are common and 
effective for communicating information to medics while still being inconspicuous. Use of this 
 
 
39 

 
enrollment exclusion will be tracked and this information made available to IRBs at the time of 
continuing review. 
Post Enrollment Notification and Consent to Continue 
21 CFR 50.24(b) The IRB is responsible for ensuring that procedures are in place to inform, at the 
earliest feasible opportunity, each subject, or if the subject remains incapacitated, a legally 
authorized representative of the subject, or if such a representative is not reasonably available, a 
family member, of the subject's inclusion in the clinical investigation, the details of the investigation 
and other information contained in the informed consent document. The IRB shall also ensure that 
there is a procedure to inform the subject, or if the subject remains incapacitated, a legally 
authorized representative of the subject, or if such a representative is not reasonably available, a 
family member, that he or she may discontinue the subject's participation at any time without 
penalty or loss of benefits to which the subject is otherwise entitled. If a legally authorized 
representative or family member is told about the clinical investigation and the subject's condition 
improves, the subject is also to be informed as soon as feasible. If a subject is entered into a clinical 
investigation with waived consent and the subject dies before a legally authorized representative or 
family member can be contacted, information about the clinical investigation is to be provided to 
the subject's legally authorized representative or family member, if feasible. 
Subjects enrolled in ESETT, or their legally authorized representatives (LAR) or family, are 
informed of the subject’s inclusion in the clinical investigation at the earliest possible 
opportunity as detailed above and in the MoP. It is anticipated that the notification of subjects, 
or their families or LAR, will most commonly take place in the ED within hours of subject 
enrollment. Attempts to notify the subject or an LAR are repeated until successful. All 
notification attempts are logged and recorded in the subjects online case report form in 
WebDCU™. Reports of these logs will be available for inclusion in annual reports to the 
respective IRBs. 
Record Keeping 
21 CFR 50.24(c) Like other IRB records, records of the determinations above must be kept for a 
minimum of three years after the completion of the clinical investigation. Again, like other IRB 
records, these are subject to inspection and copying by FDA. 
Records documenting the enrollment of patients using EFIC, procedures for notification of 
enrollment, and informed consent forms will be kept for a minimum of three years after 
completion of the clinical investigation. 
IND Requirement 
21 CFR 50.24(d) Protocols involving an exception to the informed consent requirement under this 
section must be performed under a separate investigational new drug application (IND) or 
investigational device exemption (IDE) that clearly identifies such protocols as protocols that may 
include subjects who are unable to consent. The submission of those protocols in a separate IND/IDE 
is required even if an IND for the same drug product or an IDE for the same device already exists. 
Applications for investigations under this section may not be submitted as amendments under Secs. 
312.30 or 812.35 of this chapter. 
 
 
40 

 
This trial requires an IND, review and approval by the FDA. No enrollment can commence 
unless approval by the FDA and participating IRBs is obtained. The Study Principal Investigator 
serves as the sponsor of the IND. Discussions with the FDA have clarified that a single IND is 
appropriate for the proposed trial. 
Communication of IRB Determinations 
21 CFR 50.24(e) If an IRB determines that it cannot approve a clinical investigation because the 
investigation does not meet the criteria in the exception provided under paragraph (a) of this 
section or because of other relevant ethical concerns, the IRB must document its findings and 
provide these findings promptly in writing to the clinical investigator and to the sponsor of the 
clinical investigation. The sponsor of the clinical investigation must promptly disclose this 
information to FDA and to the sponsor's clinical investigators who are participating or are asked to 
participate in this or a substantially equivalent clinical investigation of the sponsor, and to other 
IRBs that have been, or are, asked to review this or a substantially equivalent investigation by that 
sponsor. 
If an application for ESETT is disapproved by a local IRB at any site, the Hub principal 
investigator will inform the ESETT principal investigator and IND sponsor and provide him with 
the written findings of that IRB. The Study PI/sponsor will promptly disclose this information to 
the FDA, and to all participating Hub PIs who will be instructed to submit these to all IRBs to 
which applications for ESETT have been submitted for review. If there is a change in the study 
protocol, then there must be a re-review of the protocol by all the IRBs of the participating 
institutions. 
 
 
 
 
 
 
41 

 
6. STUDY ENROLLMENT PROCEDURE 
6.1  Screening 
The goal is to include all eligible patients who present to participating EDs.  All patients 
presenting with a diagnosis of seizures or convulsions will be evaluated for participation in the 
study.  A screen failure log will include patients with a diagnosis of seizures or status epilepticus 
who are not randomized into ESETT.  
6.2  Enrollment 
Study processes will not delay clinical treatment.  When an eligible patient presents to the 
emergency department, the clinical team will access the age appropriate ESETT “use next” box. 
To ensure treatment is not delayed, the “use next” box must be easily accessible and 
maintained in proximity to patient care in the ED.  Most often, this will be in the secured ED 
medication dispensing system or the ED pharmacy.  
The clinical team opens the “use next” box.  The protocol assist device is activated.  The weight 
based infusion rate is determined from the dose administration chart.  If the patient is a child, 
the length based weight estimation tool is used to determine dose unless an accurate weight is 
known.  An infusion pump is programmed with the determined rate and the infusion line is 
primed.  The infusion is then started and the timer is started on the protocol assist device.  
The study team should be alerted at this time, if not already done. 
Study drug is administered by pump for ten minutes (except as noted in section 7.3).  The 
infusion is then discontinued and discarded.  The patient should then be observed for 10 more 
minutes, until 20 minutes after the start of study drug infusion.  Rescue therapy is not indicated 
during this period.  After 10 minutes from the end of study drug infusion, rescue therapy should 
be given as deemed clinically indicated by the care team for persistent or recurrent seizures. 
The primary outcome is determined at 60 minutes. 
6.3  Study Team Arrival 
The study team should be activated as early as possible without delaying treatment.  The care 
team follows the protocol but does not engage in research.  Questions about eligibility are 
determined by the study team.  The study team will arrive in the ED as soon as possible.  
Upon arrival, the study team will assist the clinical team in completing the protocol.  After 
arrival the study team will seek an LAR to notify of the subject’s participation and to determine 
consent to continue.  The study team maintains a log of attempts to locate an LAR, of 
notifications, and of consent decisions. 
 
 
42 

 
The study team will collect and complete the ED-enrollment case report form, will collect the 
spent “use next” box and protocol assist device, and will process, reload, and place a new “use 
next” box. 
6.4  Blood Draw 
Up to 2 tubes of blood, approximately 5 mL total (2.5 mL each), may be drawn from a subset of 
subjects after the study drug infusion to confirm drug levels and accurate assignment as needed 
to ensure study performance. 
6.5  Enrollment Flow Diagram 
 
Figure 7. 
 
 
 
 
43 

 
7. STUDY INTERVENTIONS 
7.1  Determination of subject weight 
The rate of study drug infusion is based on estimated patient weight.  The subject’s weight may 
be obtained from reliable caregivers or records.  In children, if an accurate weight is not known, 
dose will be determined using the length-based weight/dose estimation tool included in the 
“use next” box, (akin to the Broselow tape).  In adults and the elderly, weight will be estimated 
in the manner as in standard care for weight-based dosing of other resuscitation/critical care 
drugs.  A measured weight may also be used if available, but it is expected that the clinical 
scenario will usually preclude weighing the subject.  
7.2  Study drug administration 
Study drugs will be administered intravenously.  For purposes of this study, intraosseous (IO) 
access will always be considered equivalent to IV access.  Infusion pumps will be used to ensure 
that study drug is administered over 10 minutes.  
The infusion pump will be programmed to deliver the volume/rate indicated on the dose 
administration chart (table 3).  The volume and rate will be confirmed by a second nurse. 
Infusion will last 10 minutes.  Priming the line prior to infusion and removing the line at the end 
of infusion are performed in a manner that ensures the entire study volume of study drug is 
delivered in accordance with local nursing practice.  
 
 
 
 
 
44 

 
Table 3.  Dose Administration Chart 
Subject Wt 
(kg) 
Infusion Vol. 
(mL) 
Infusion Rate 
(mL/min) 
over 10 min 
FOS dose  
(mg PE) 
LEV dose 
(mg) 
VPA dose 
(mg) 
7.5 to <10 
9 
0.9 
150 
450 
300 
10 to <12.5 
12 
1.2 
200 
600 
400 
12.5 to <15 
15 
1.5 
250 
750 
500 
15 to <20 
18 
1.8 
300 
900 
600 
20 to <25 
24 
2.4 
400 
1200 
800 
25 to <30 
30 
3 
500 
1500 
1000 
30 to <35 
36 
3.6 
600 
1800 
1200 
35 to <40 
42 
4.2 
700 
2100 
1400 
40 to <50 
48 
4.8 
800 
2400 
1600 
50 to <60 
60 
6 
1000 
3000 
2000 
60 to <70 
72 
7.2 
1200 
3600 
2400 
70 to <75 
84 
8.4 
1400 
4200 
2800 
≥75 
90 
9 
1500 
4500 
3000 
 
7.3  Study Drug Infusion Precautions 
Study drug infusion precautions are the same as in standard care in patients with status 
epilepticus.  Heart rate and rhythm, blood pressure, and oxygen saturation are monitored.  
If hypotension or cardiac arrhythmia occur during study drug infusion, the infusion rate will be 
reduced by 50% (increasing the infusion time and maintaining the planned volume). 
In this context, hypotension is defined as sustained systolic blood pressure <90 mm Hg in 
subjects 13 years and older, <80 mm Hg for 7 years to <13 years, and <70 mm Hg for 2 years to 
<7 years.  Intravenous fluid may also be used for initial treatment of hypotension. 
If hypotension or cardiac arrhythmia persist, or as determined appropriate by the care team, 
the drug infusion will be discontinued.  Persistent hypotension or arrhythmia will be treated 
 
 
45 

 
according to local standard care after the study drug is stopped. 
Treatment with study drug may also be terminated for any serious adverse event during 
infusion that the treating physician believes is study drug related. 
Discontinuation of study drug does not affect participation of the subject in the study.  All 
subjects should be followed until they reach their end of study. 
7.4  Randomization 
Due to the emergency nature of ESE, randomization must not delay treatment.   To complete 
the randomization quickly, the study drug will be preassigned using a central randomization 
process via WebDCU.  The mortality associated with SE and etiology of SE varies with age. In 
addition, certain adverse effects of drugs such as hypotension are more common in the elderly 
compared to the pediatric age group. For these reasons, randomization assignments will be 
stratified by age group (less than 18 years, 18-65 years, and greater than 65 years).  
Prior to enrollment at each site, the randomization assignment is made [for each of the three 
age strata]. The assigned study drug is installed in the “use next” box.  When the next eligible 
subject at the clinical site is identified, the ED nurse or physician, selects the “use next” box [for 
that stratum].  
Once the infusion pump, connected to study drug vial and patient’s IV catheter, is turned on, 
the patient is considered to have been randomized into the study.  After a patient is 
randomized and the study team member enters the randomization form into WebDCU, the 
next treatment assignment is made, and a new “use next” box can be prepared.  Hence, after 
each subject is randomized, the treatment assignment is made for the subsequent subject 
(within that stratum) once the current subject’s randomization data are entered into WebDCU. 
Sites may also be contacted and asked to go to WebDCU to reassign the content of the “use 
next” box when randomization in the trial is updated.  
7.5  Study Drug 
Study drug will be produced at the central pharmacy, a GMP facility at University of California, 
Davis.  Diluted formulations are expected to remain stable for months when stored at 2-8 °C. 
Expiration dates for study drug will be determined and adjusted based upon ongoing stability 
testing performed on study drugs prepared at the GMP facility for the study. 
All three formulations will be pale yellow solutions.  None are reported to consistently cause 
infusion-site adverse effects.  The method of drug administration, including volume and rate of 
infusion is identical for all three drugs.  These factors ensure that drug administration will be 
 
 
46 

 
blinded. 
The drugs will be formulated in the following concentrations:  FOS 16.66 mg PE/ml, VPA 33.33 
mg/ml and LEV 50 mg/ml.  The dose will be FOS 20 mg PE/kg, VPA 40 mg/kg, and LEV 60 mg/kg, 
increasing up to a weight of 75 kg.  At this weight the maximum safe dose for a 10 minute 
infusion period for adults is reached.  A 10 kg patient would receive drug infusion at the rate of 
1.2 ml/min and those weighing 75 kg or more will receive drugs at an infusion rate of 9 ml/min.  
7.6  Study Drug Packaging  
Study drug will be prepared in 100 mL glass vials, labeled as investigational, and coded with 
unique human readable ID numbers and barcodes.  Because this is a blinded study, nobody at 
the site (local pharmacy, clinical team, and study team) will know whether the next assignment 
is FOS, VPA, or LEV.  
“Use next” boxes will be prepared at the site and contain:  1) a 100 ml glass vial containing 
either FOS, VPA, or LEV, 2) a dose administration chart, 3) a protocol assist device, and 4) a 
length based weight/dose estimation tape (similar to Broselow tape).  
7.7  Protocol Assist Device 
The protocol assist device is a mobile electronic platform, such as the Apple iPod Touch, with an 
ESETT app loaded on it.  It is intended to assist the clinical and study team in performing the 
study protocol.  The app will be started by the treating physician or nurse and will guide the 
team through the initial phase of the study. The device is intended to serve several functions 
including: confirmation of correct randomization code, time keeping during infusion and 
evaluation, supplemental data logging, and support of rapid emergency unblinding.  
The protocol assist device should be kept at subject’s bedside until retrieved by the study team. 
 
 
 
 
 
 
47 

 
8.  OUTCOME ASSESSMENT AND POST-INTERVENTION  
8.1  Assessment of treatment effect  
Assessment of treatment effect is performed at 20 minutes and 60 minutes after the start of 
study drug infusion.  
“Start of study drug infusion” is considered the time of randomization.  It is the time when the 
study drug infusion is begun by starting the IV infusion pump. 
Absence of clinically apparent seizure at 20 and 60 minutes is determined clinically.  Clinically 
apparent seizure is defined as obvious focal or generalized tonic clonic movements, nystagmoid 
or rhythmic eye movements, or generalized or segmental myoclonus at the time of assessment.  
Patient’s responsiveness to verbal command or noxious stimuli is observed at 20 and 60 
minutes.  Responsiveness at time of assessment is always compared to that at the time of 
randomization. Generally, improvements in responsiveness are characterized by purposeful 
responses to noxious stimuli, the ability to follow commands, or verbalization.  The Richmond 
Agitation Scale Score will be recorded and may be used to assist in this determination.  
8.2  Determination of primary outcome 
The primary outcome will be determined 60 minutes after the start of study drug infusion.  The 
primary outcome may be determined by the study team if present, or by a treating ED physician 
on the clinical team if the study team is not yet available.  The primary outcome is based upon 
the assessment of treatment effect at 60 minutes as defined above, and the use of additional 
anti-seizure medications.  Ongoing seizures at the time of determination of the primary 
outcome, whether persistently or recurringly, indicates a failure to meet the primary outcome. 
Transient seizure recurrence followed by cessation, however, is consistent with meeting the 
primary outcome.  
Medications qualifying as “anti-seizure medications” for the purpose of determining the 
primary outcome are detailed in the study Manual of Procedures.  The administration of the 
these anticonvulsant or sedative medications for recurrent seizures or any other reason, by any 
route, within 60 minutes after the start of study drug infusion indicates a failure to meet the 
primary outcome. 
The primary outcome should be based on the assessment of what the treatment effect and the 
condition of the patient were at 60 minutes after the start of study drug infusion based upon all 
information available to the assessor at the time the primary outcome is documented. 
Death prior to 60 minutes after the start of study drug infusion indicates a failure to meet the 
primary outcome.  
 
 
48 

 
The primary outcome may be documented in more than one location.  The highest level of 
source document in the established hierarchy will be considered the primary source document 
for the primary outcome.  The hierarchy of source documents that will be used to confirm the 
primary outcome outcome is: 
1.
Contemporaneous observation and documentation.  The primary outcome is observed 
by the study team at the bedside and directly recorded on the CRF or on the study book 
worksheet.  Direct data entry in WebDCU is preferred but not required.  
2.
Direct communication with the clinical team.  The study obtains the primary outcome 
data by direct explicit communication with the treating ED attending physician. 
Communication should occur and be documented as close to the time of assessment as 
possible. 
3.
Protocol Assist Device.  The primary outcome explicitly recorded on the protocol assist 
device will be treated as a source document and may be used to complete the CRF if 
contemporaneous recording or direct communication with the study team are not 
available. 
4.
Medical Record - explicit study specific documentation.  If the medical record is used as 
a source document, the adjudicators will determine the primary outcome from an 
explicit study specific template note if available in precedence among available 
documentation. 
5.
Medical Record - implicit review.  If the medical record is used as a source document, 
and no explicit study specific template note is available, the adjudicators will determine 
the primary outcome from their interpretation of provided documentation. 
8.3  Determination of secondary outcomes 
The primary safety outcome is the absence of life threatening hypotension and cardiac 
arrhythmia within 60 minutes of the start of study drug infusion.  
Life-threatening hypotension is defined as systolic blood pressure remaining below the 
age-specified thresholds on two consecutive readings at least 10 minutes apart and remaining 
below the age-specified thresholds for more than 10 minutes after reduction of the rate of 
study drug infusion rate (or its termination) and a fluid challenge.  The “age-specified 
thresholds” for systolic blood pressure are 90 mmHg in adults and children 13 years and older, 
80 mmHg in children 7 to 12 years old, and 70 mmHg in children through 6 years of age. 
Life-threatening cardiac arrhythmia is defined as any arrhythmia that persists despite reducing 
rate of study drug infusion, and that requires termination with chest compressions, pacing, 
defibrillation, or use of  an antiarrhythmic agent or procedure. 
Additional predefined safety outcomes include mortality, need for endotracheal intubation 
 
 
49 

 
within 60 minutes of start of study drug infusion, acute seizure recurrence within 12 hours, and 
acute anaphylaxis. 
Mortality is determined by survival to subject end-of-study (hospital discharge or 30 days, 
whichever comes first).  All causes of mortality are included. 
Need for endotracheal intubation within 60 minutes of start of study drug infusion includes any 
placement or attempt at placement of a definitive tracheal airway (orotracheal, nasotracheal, 
cricothyroidotomy, or tracheostomy) for support of respirations or protection of airway.  The 
use of non-definitive and/or non-tracheal airways (oral or nasal airways, laryngeal mask 
airways, or esophageal obturator airways) is not included if the patient is not subsequently 
intubated unless specifically deemed to have been used in lieu of tracheal intubation. 
The RASS may be determined by the care team or the study team.  The RASS scoring system is 
fully described in the manual of procedures. 
Acute recurrent seizure is defined as definitive convulsive or electroencephalographic seizure 
activity triggering further anticonvulsant therapy occurring between 60 minutes and 12 hours 
after the start of study drug infusion. This definition does not include those given further 
anticonvulsants as secondary prophylaxis or as treatment for vague or uncertain exam findings 
or nondiagnostic electroencephalography.  
Acute anaphylaxis is defined as a clinical presentation consistent with life threatening allergic 
reaction occurring within 6 hours of the start of study drug infusions and manifested as 
urticaria in combination with either (1) a systolic blood pressure of < 90 mmHg sustained for 
greater than 5 minutes, or (2) objective evidence of airway obstruction, and for which the 
patient was treated with antihistamines and/or steroids.  
Respiratory depression is defined as impairment of ventilation or oxygenation necessitating 
definitive endotracheal intubation and mechanical ventilation.  It is distinct from intubations 
performed only for airway protection in those with decreased levels of consciousness.   It does 
not include those getting only supraglottic airways or transient bag-valve-mask support. 
Secondary efficacy outcomes include time to termination of seizures, admission to ICU, and the 
length of ICU and hospital stays.  
The time to termination of seizures is the interval from the start of infusion of study drug to 
cessation of clinically apparent seizure in those who meet the primary outcome.  
Hospital and ICU admission from the ED, and length of stay, is abstracted from the hospital 
admission record. ICU admission is recorded as occurring only if the ICU is the initial inpatient 
unit for the patient.  Length of stay is determined by the number of calendar days after the day 
 
 
50 

 
of ED arrival until hospital discharge or subject end-of-study. 
8.4  Endotracheal intubation 
Elective or semi-elective endotracheal intubation (e.g. for imaging studies, etc.) should be 
delayed until after determination of primary outcome if possible.  Emergency endotracheal 
intubation should not be delayed.  The need for emergency intubation is determined by the 
care team.  It is generally not necessary to perform emergency endotracheal intubation for 
prolonged unresponsiveness alone in this patient population.  Emergent or elective 
endotracheal intubation and its indication should be carefully documented, including all 
medications administered.  
8.5  Rescue anticonvulsants 
Subjects who do not respond to the study drug and continue to seize >20 minutes after the 
start of study drug infusion (>10 minutes after the completion of study drug infusion) will need 
additional anticonvulsant therapy for SE at the discretion of the treating team. The treating 
physician will follow local practice guidelines in choice of a third line agent for the treatment of 
SE.  Appropriate third line choices include phenobarbital or a general anesthetic such as 
propofol, midazolam or pentobarbital when a second-line agent has failed.  Finally, some 
centers may choose to use another second line agent.  If the care team feels that another 
second line agent is indicated and that knowledge of the study drug given is needed to guide 
this selection, emergency unblinding should proceed as described below in section 10.2.  
8.6  Continuous EEG 
Continuous EEG should be performed as indicated by the care team consistent with standard 
clinical practice.  If indicated, cEEG should be initiated as early as possible.  
8.7  Standard supportive care 
Other than as indicated in this protocol, subjects will receive the usual care and evaluation 
provided at each site.  Sites may wish to reference the practice parameter recommendations 
for status epilepticus of the American Academy of Neurology (Riviello 2006).  
 
 
 
51 

 
9. ADVERSE EVENTS 
9.1 Definitions of Adverse Events: 
An Adverse Event (AE) is any unfavorable and unintended sign (including an abnormal 
laboratory finding), symptom, or disease temporally associated with the use of a medical 
treatment or procedure that may or may not be considered related to the medical treatment or 
procedure. An AE is a term that is a unique representation of a specific event used for medical 
documentation and scientific analyses.  
A Serious Adverse Event (SAE) is any adverse event that is fatal or life threatening, is 
permanently or substantially disabling, requires or prolongs hospitalization, results in a 
congenital anomaly, or requires intervention to prevent permanent impairment or damage. For 
the purposes of this study, we specifically exclude hospitalization for the sole purpose of 
observing a patient after SE as a Serious Adverse Event. 
9.2 Grading of Adverse Events 
All adverse events (AEs) occurring within 24 hours of treatment and all serious adverse events 
occurring during study participation will be documented on the AE case report form. The 
severity of adverse events will be graded using the NCI Common Terminology Criteria for 
Adverse Events (Version 4.03, June 2010, CTCAE). The CTCAE provides a grading (severity) scale 
for each AE term and AEs are listed alphabetically within categories based on anatomy or 
pathophysiology. The CTCAE (v 4.03) displays Grades 1-5 with unique clinical descriptions of 
severity for each AE based on this general guidance: 
Table 4.  
Grades 
Descriptions of severity for each AE based on this general guideline 
Grade 1 Mild 
Asymptomatic or mild  symptoms; clinical or diagnostic 
observations only; intervention not indicated 
Grade 2 Moderate 
minimal, local or noninvasive intervention indicated; limiting age-appropriate 
instrumental activities of daily living.  
Grade 3 Severe 
medically significant but not immediately life-threatening; hospitalization or 
prolongation of hospitalization indicated; disabling; limiting self care ADL 
Grade 4 Life-threatening  urgent intervention indicated 
Grade 5 Fatal 
Death related to AE 
 
Severity is not equivalent to seriousness. A serious adverse event (SAE) would be any event in 
category 4 or 5, and any event in category 3 that required or prolonged hospitalization. Not all 
 
 
52 

 
grades are appropriate for all AEs. Therefore, some AEs are listed with fewer than five options 
for Grade Selection i.e., Grade 5 (Death) is not appropriate for some AEs and therefore is not an 
option.  
9.3  Relationship to Study Treatment  
One of the most important components of AE reporting is determining the cause of the AE. It is 
imperative that the investigator assess AE causality in terms of overall study participation and 
make an independent determination as to whether the AE was thought to be related to any 
study-related activity (i.e., study intervention,). Determination may be particularly challenging 
in ESETT since typical criteria for assessing causality such as evaluation of the effects of 
de-challenge and re-challenge are not possible within the scope of this protocol in which study 
interventions are isolated single exposures of short acting medications. In addition the 
underlying cause of SE: stroke, infection, inflammation  etc.  cause adverse events. Finally, 
prolonged seizures of SE cause adverse events.  For each adverse event, the relationship to the 
study treatment must be recorded as definitely, probably, possibly, unlikely, not related.  The 
NETT modified “Algorithm to Determine Relationship of Adverse Event to Study Agent” will be 
used for all relatedness determinations in ESETT, and is found in the Manual of Procedures. 
9.4  Adverse Event Reporting 
All AEs occurring within 24 hours of study treatment and all serious adverse events (SAEs) 
occurring until participation in study has ended (discharge from the hospital, death, or 30 days 
since enrollment)  are recorded on the online AE case report form (CRF) through the 
WebDCU™. The site PI or Study Coordinator or designee is responsible for entering all AEs and 
SAEs and updating the information (e.g., date of resolution, action taken) in a timely manner. 
All non-serious AEs must be recorded on the electronic AE CRF within 5 days from the time it 
was discovered by the site study personnel. For SAEs, the data entry must take place within 24 
hours of discovery of the event. 
The site PI is responsible for the monitoring and follow-up of AEs until resolution (or end of 
study for that subject) and appropriate documentation in the subject research record. In 
addition to performing protocol-specified follow up, the participating PI must review all 
previously reported ongoing AEs to evaluate the current status. If an AE that was previously 
reported on the Adverse Event CRF fully resolves and then recurs at a later date, the second 
occurrence is considered a new AE and a new Adverse Event CRF must be completed. Likewise, 
if an SAE that was previously reported and subsequently fully resolved later recurs at a level 
requiring expedited reporting, the SAE must be reported as a new SAE on the Adverse Event 
CRF. 
 
 
 
53 

 
9.5 Expected Adverse Events 
Expected adverse events include side effects known to be potentially associated with the study 
medications as listed in the study drug package inserts, and complications that commonly occur 
as a result of the underlying condition or as a result of hospital care.  The outcomes and events 
defined below are likely and anticipated and will be closely tracked. 
These include the secondary safety outcomes previously defined in section 8.3: 
●
Life-threatening hypotension 
●
Life-threatening cardiac arrhythmia 
●
Mortality 
●
Need for endotracheal intubation 
●
Acute recurrent seizure  
●
Acute anaphylaxis 
●
Respiratory depression or failure resulting in intubation. 
Other defined expected adverse events include: 
Hepatic transaminase or ammonia elevations, defined as those levels determined by the site 
investigator to be greater than 3 times the upper limit of normal or otherwise clinically 
significant. 
Purple glove syndrome, defined as the presence of all three of the findings of objective edema, 
discoloration, and pain in the distal extremity in which study drug was administered, with or 
without known extravasation, and for which there is no other evident etiology. 
9.6  Clinical Management of Adverse Events 
All adverse events will be managed according to local institution guidelines and treating 
physician’s judgment. Specific recommendations for managing acute adverse events during 
drug infusion are included above in Section 7.3. 
 
 
 
 
54 

 
10. STATISTICAL CONSIDERATIONS 
10.1 Randomization 
The randomization scheme will be equal allocation (1:1:1) for the first 300 patients. Once 300 
subjects are enrolled, response-adaptive randomization (RAR) will be utilized with the goal of 
maximizing the likelihood of identifying the most effective treatment arm (Connor 2013). The 
target allocation ratio will be updated every 100 patients. We will use a “Step Forward” 
centralized randomization procedure developed for emergency treatment trials. (Zhao 2010) 
Randomization will be stratified by age. 
10.2 Blinding and unblinding: 
Patients and emergency department study team members are blinded to the treatment 
assignment, as are the PIs and clinical coordinating center (CCC). Blinding is provided by the use 
of the same color of formulations, same drug packaging, and same method of drug 
administration in every subject.  
Emergency unblinding may be required if the treating team feels that subjects’ care after the 
study intervention requires knowledge of what study drug was given.  Emergency unblinding 
will not be performed within 60 minutes of the start of study drug infusion.  The blind should be 
maintained until after the primary outcome has been collected.  
Emergency unblinding performed prior to 60 minutes or prior to determination of the primary 
outcome, because of physician judgment that it is necessary for the safety or care of the 
patient, or because of unanticipated situations is accommodated by calling the hotline but is a 
deviation from this protocol. 
10.3 Primary outcome 
A patient is considered a treatment success if they meet the definition of the primary outcome 
as defined above. 
10.4 Secondary outcomes 
Secondary outcomes are intended to show safety, congruence or divergence from the primary 
outcome, or to provide additional detail that helps to more fully describe or interpret the 
effects of the treatment, the study population, or the clinical scenario. 
10.5  Primary Analysis 
The posterior probabilities that each treatment is the most and least effective treatment will be 
calculated using Bayesian methods. This trial will be considered a success if the probability that 
a treatment is the most effective is greater than 0.975  or the probability that a treatment is the 
 
 
55 

 
least effective is greater than 0.975 for any treatment. 
Each of the three treatment arms is modeled independently.  We assume the probability of 
response has a uniform Beta(1,1) prior distribution.  We assume the number of responses on 
each treatment arm follows a binomial distribution.  We update the prior distribution with the 
observed data and use the resulting posterior distribution to calculate the probability that each 
treatment is the most effective and the probability that each treatment is the least effective. 
The posterior distribution for each treatment arm will therefore be Beta(1+ # of Successes, 1+ # 
of Failures). 
At the conclusion of the trial, we will report the response rates for each treatment group with 
95% credible intervals and the pairwise differences in responses rates and corresponding 95% 
credible intervals of those differences. 
10.6  Frequentist Analysis of the Primary Outcome 
At the final analysis, the global null hypothesis that the probabilities of success for all three 
treatment groups are equal will be tested in a chi-squared test with 2 degrees of freedom. If, 
and only if, the three-way, global null hypothesis is rejected, then all pairwise comparisons will 
be performed as a two-sample test of difference in proportions (Z - test). Although the 
Frequentist tests will only occur once, we will use Pocock boundaries to control the overall 
alpha. 
10.7  Interim Analyses 
Interim monitoring for success and futility will begin after 400 subjects have been randomized 
and will be repeated after every additional 100 subjects are randomized. This trial will stop 
early for success if we have identified the maximum effective treatment with a least 97.5% 
probability. 
There are two early futility criteria.  The first futility rule will stop the trial early if all treatment 
arms have a clinically unacceptable response rate.  The second futility rule will stop the trial 
early if all treatments are performing similarly and we will be unable to identify a most effective 
or least effective treatment. 
Following review of both the interim analysis results and safety data, the DSMB will make a 
recommendation regarding the above stopping rules.  
10.8  Estimated accrual 
Estimates of accrual for purposes of statistical planning assume 40 enrollment sites averaging 5 
subjects per year over a 4 year enrollment period.  
 
 
56 

 
10.9  Sample size considerations 
This study will enroll a maximum total sample size of approximately 795 patients over 4 years, 
at an accrual rate of approximately 16.5 patients per month. A sample size of 795 provides 
approximately 90% power to identify the most effective treatment when one treatment arm 
has a true response rate of 65% and the true response rate is 50% in the other two arms (an 
absolute difference of 15%). The trial operating characteristics were determined via an 
extensive simulation study. The statistical and full simulation details as well as the operating 
characteristics of the design have been published (Connor 2013). 
The expected response rates for FOS, LEV and VPA are based on the retrospective analysis of 
279 episodes of established SE in adults, who were treated with PHT, LEV or VPA (Alvarez 
2011).  The study reported 59.6% of patient episodes responded to PHT, 51.7% to LEV and 
74.6% to VPA. Based on this study and expert evaluation of all currently published data on the 
treatment of established SE, we expect that the worst drug will be effective in 50% of the 
patients. A 15% difference is the minimum clinically important difference sufficient to change 
clinical practice. 
The total sample size for this trial corresponds to the sample size that would be needed for a 
frequentist analysis. A sample size of 209/group (627 total) is needed for a chi-squared​ ​test with 
2 degrees of freedom of the overall test of equality of the three proportions with 90% power 
(assuming the smallest proportion is 0.50 and the largest proportion is 0.65 and the average 
proportion is 0.55, two-sided alpha 0.05). For a two-sample test of proportions (all pairwise 
comparisons of treatment groups), with equal allocation into each treatment group, when one 
treatment proportion is 0.50 and the other treatment proportion is 0.65, the sample size 
needed is 240 per group to detect an absolute treatment difference as small as 0.15 with 90% 
power (assuming two-sided alpha 0.05 and interim looks). Thus, a total sample size of 240*3 
groups=720 (uninflated for re-enrollers, missing data). Given the possibility of re-enrollers, 
protocol violations, and missing data, the maximum sample size was inflated from 720 up to 
795  by N`=720*R where R=(1/(1-.025)^2)*1.05. The sample size was inflated in two ways. First, 
for the re-enrollers (expected to be 5%) who will be excluded from the analysis. Secondly, to 
account for the impact of treatment cross-overs, protocol violations, and missing data on the 
ITT analysis (expected to occur 2.5% of the time). In order to determine the operating 
characteristics for this Bayesian adaptive design, simulations were performed assuming a 
maximum sample size of 720 (the uninflated maximum) and considering different response rate 
scenarios. 
10.10  Missing Data and Non-compliance 
The primary analysis will be analyzed under the intent-to-treat principle (ITT).  The ITT 
evaluable sample will include all subjects who are randomized. Subjects that are enrolled more 
 
 
57 

 
than once during the study period will have only their first enrollment included in the primary 
analysis. It is anticipated that a maximum of 5% of subjects will be re-enrolled. In an ITT 
analysis, missing data and treatment cross-overs can be problematic. Due to the short term 
endpoint, minimal missing data is expected for the primary outcome.  However the inability to 
administer the full dose of the study drug, or other protocol violations may occur and attenuate 
the treatment effect. It is anticipated that a maximum of 2.5% of data will be missing or involve 
treatment cross-overs. Any missing values will be considered a treatment failure.  
10.11 Secondary Analyses 
Secondary analyses of primary outcome will include an analysis of the adjudicated primary 
outcome, a re-enroller analysis, a per protocol analysis, an analysis by age. Exploratory analyses 
of the primary outcome will assess treatment differences adjusting for etiology, time from 
seizure onset to randomization, and enrolling site. Clinically important differences in the 
treatment effect due to sex/gender, racial, or ethnic differences are not expected, but will be 
explored. Secondary and exploratory  analyses will not be adjusted for multiple comparisons. 
10.12  Analysis of Secondary Outcomes 
The secondary outcomes will be compared by treatment group.  All secondary outcomes will be 
tested at a significance level of two-sided alpha of 0.05. Binary outcomes will be compared by 
first testing the null hypothesis that the proportion of responses for all three treatment groups 
are equal in a chi-squared test. If the three-way null hypothesis is rejected, then all pairwise 
comparisons will be performed as two-sample tests of proportions. Continuous outcomes will 
be compared in an F-test to test the null hypothesis that all three treatment groups are equal, 
followed by pairwise t-tests. Kaplan Meier curves and log rank tests will be used to compare 
time to event outcomes by treatment group. 
10.13  Pediatric Subgroup Analysis 
The interaction of age group and treatment group will be tested at each interim analysis. If 
there is sufficient evidence of an interaction, then the response-adaptive randomization will be 
stopped and randomization will revert to equal allocation until the end of the trial. 
Regardless of whether an interaction between age group and treatment is detected, the 
primary analysis will be redone by age group (children age 2-18, adult 19-65, and Seniors, >65). 
 
 
 
 
58 

 
11. DATA COLLECTION 
11.1  Study activity and data collection 
Follow up data collection: Very limited clinical data will be collected during hospitalization, 
beyond that available and collected in the ED.  Hospitalized subjects should be reevaluated the 
day after admission for adverse events.   At the end of hospitalization, subjects should again be 
evaluated for serious adverse events.  Seizure etiology and hospital/ICU length of stay are also 
determined at discharge. 
11.2  Data Collection Schedule 
Data elements will be detailed in the CRF study book which is available for download under 
Project Documents on WebDCU​TM 
 
 
 
 
 
59 

 
Table 8.  Schedule of Assessments 
  
Day 1 (data 
collected in the 
ED on the day of 
enrollment) 
Day 2 (24-48 
hours after 
study drug 
infusion)  
End of Study*  
Eligibility 
X 
  
  
Randomization 
X 
  
  
Primary outcome 
X 
  
  
Safety outcome: hypotension; cardiac arrhythmia 
X 
  
  
Richmond Agitation and Sedation score (RASS) 
X 
  
  
Demographics 
X 
  
  
Post enrollment consent to continue  
X** 
 
  
Probable cause of status epilepticus  
 
 
 X 
Adverse Events 
X 
X# 
X 
Endotracheal Intubation 
X 
X# 
  
EEG 
 
 
X 
Time to termination of seizures 
X 
 
 
Admission to ICU 
 
 
X 
ICU length of stay 
  
  
X 
Hospital length of stay 
  
  
X 
Study Drug infusion log  
X 
  
  
Prior/Concomitant meds 
X 
  
  
Vital Signs 
X 
 
 
End of Study 
  
  
X 
  
* Hospital Discharge or 30 days from enrollment whichever comes first 
** Or earliest opportunity if not possible in the ED 
#  Optional repeated forms 
 
 
60 

 
 
11.3  Quality assurance 
The study will be conducted in accordance with the ICH Guidelines for Good Clinical Practice 
and all relevant local, national and international regulations. 
Please refer to the NETT monitoring standard operating procedures (SOP) at 
http://nett.umich.edu​ . In brief summary, Hub investigators will provide quality assurance 
within their Hub spoke complex  in a process that, in this network, will be called Verification. 
This is independent of Monitoring, which, in this network, is used to mean only independent 
external monitoring by the NETT Project Monitor of the Clinical Coordinating Center (CCC). 
Data quality monitoring is performed continuously.  Out of range and logical errors are 
identified at the time of data entry.  
Site visits will be conducted periodically by the Project Monitor(s).  Details of the content of site 
visits are found in the monitoring plan in the MoP.  In brief, the primary purpose of the site visit 
is to confirm that local regulatory documents are being properly maintained, and to compare 
data reported on case report forms with source documents, including documentation of 
informed consent and proper reporting of adverse events.  
Some combination of risk based allocation of site and remote source document verification will 
be used over the course of the trial. 
11.4  Data management 
The NETT Statistical and Data Management Center (SDMC) will provide data management for 
the ESETT study. The SDMC is housed in the Data Coordination Unit (DCU) at the Medical 
University of South Carolina (MUSC). Data entry will occur at the enrolling sites using a 
web-based data entry system, WebDCU™.  A central reader form will be entered into WebDCU 
at the NETT CCC at the University of Michigan. 
11.5  Clinical adjudication Core  
The clinical adjudication core will determine key clinical characteristics for each patient enrolled 
including the etiology of status epilepticus and the duration of seizures prior to enrollment. 
The primary outcome is based on site determination, but the adjudication core will review all 
primary outcomes for consistency and will determine the reasons for failure of therapy in those 
patients who do not meet the primary outcome. Packets of de-identified medical records will 
be available to the adjudicators as needed.  The adjudicators will be blinded to treatment 
assignment.  
 
 
61 

 
12. HUMAN SUBJECTS 
The protection of human subjects is of primary importance in clinical research and in this 
clinical trial.  Clinical treatment teams must assess and treat patients with SE rapidly.  This trial 
has been designed to avoid delays of treatment of even just a few minutes because longer 
delays may increase morbidity or mortality.  See section 5 of this protocol for an extensive 
discussion of the use of EFIC and related processes in this trial. 
12.1  Institutional Review Board (IRB) Review 
This protocol and the informed consent document (see template) and any subsequent 
modifications will be reviewed and approved by the IRB for each site responsible for oversight 
of the study.  
12.2  Data and safety monitoring board (DSMB) 
A Data and Safety Monitoring Board (DSMB) appointed by the NINDS will provide ongoing 
evaluation of safety data as well as the overall conduct of the trial.  The DSMB will be formed by 
the NINDS as per institute guidelines. The SDMC statisticians will generate Data and Safety 
Monitoring (DSMB) Reports semi-annually or more frequently as needed. This review will aid in 
identifying any safety issues that may need to be addressed.  
12.3  Subject Confidentiality 
All data (case report forms, recordings, laboratory specimens, and other records) kept at the 
site will be  physically and electronically secured to maintain subject confidentiality.  Paper 
records and computers with subject data will be stored in locked office or cabinet.  Computer 
records will always be password protected, and encrypted when possible.  The study database 
is maintained behind a secure firewall, access is password protected and uses SSL encryption 
for all data entry and access.  Clinical information will not be released without written 
permission of the subject, except as necessary for monitoring by the sponsor, the CCC, the 
SDMC. the IRB, the FDA, the NINDS, or the OHRP.  
12.4 Study Modification/Discontinuation 
The study may be modified or discontinued at any time by the IRB, the NINDS, the sponsor, the 
OHRP, the FDA, or other government agencies as part of their duties to ensure that research 
subjects are protected. 
 
 
 
 
62 

 
13. PUBLICATIONS AND DATA SHARING 
Publication of the results of this trial will be governed by the policies and procedures developed 
by the Executive Committee, and all applicable regulations and rules including reporting to 
clinicaltrials.gov​ .  Refer to the MoP for further detail.  
 
 
 
 
63 

 
14. INTEGRATED SUB-STUDIES 
Consistent with pre-existing scientific aims of the research team, and with recommendations of 
peer review and trial oversight groups prior to initiation of the trial, the study leadership will, 
contingent on funding, fully integrate additional study procedures into the clinical trial protocol 
in support of specific supplemental aims.  As requested, the leadership has pursued ancillary 
grant support of these aims.  These supplemental procedures relate directly to providing a 
more complete and nuanced explanation of the trial’s outcomes, and a better understanding of 
the underlying mechanisms of treatment response.  These integrated sub-study procedures 
were created to ensure that they not interfere with other study procedures, and have been 
reviewed and approved by the ESETT Data and Safety Monitoring Board.  Sub-study aims and 
procedures are detailed in the ​MoP​. 
14.1 Pharmacokinetics/Pharmacodynamics (PK/PD) 
Blood sampling as previously described at section 6.4, is used to determine the plasma levels of 
study drugs in subjects at a fixed interval after administration.  It is anticipated that all sites 
participate, and that samples are collected from all subjects whenever possible.  This sub-study 
is led by Dr. Lisa Coles, with the advice and assistance of Dr. James Cloyd. 
14.2 Emergent Electroencephalography (eEEG)  
To characterize the electrographic outcomes of subjects with both clinical treatment success 
and clinical treatment failure after study drug administration, novel application of simplified 
EEG technology and procedures  is performed and evaluated in a subset of ESETT subjects at a 
selected number of performance sites.  The goal is for eEEG to be acquired as early after 
enrollment as possible and prior to the primary outcome.  Participation of sites is determined 
by availability of equipment, site accrual rates to date, and site ability to complete the testing. 
This sub-study is led by Drs. John Betjemann and Brian Litt. 
 
 
 
 
64 

 
15. REFERENCES 
 
Agarwal, P., Kumar, N., Chandra, R., Gupta, G., Antony, A.R., & Garg, N. 2007. Randomized 
study of intravenous valproate and phenytoin in status epilepticus. ​Seizure., 16, (6) 527-532 
available from: PM:17616473 
Alldredge, B.K., Gelb, A.M., Isaacs, S.M., Corry, M.D., Allen, F., Ulrich, S., Gottwald, M.D., O'Neil, 
N., Neuhaus, J.M., Segal, M.R., & Lowenstein, D.H. 2001. A comparison of lorazepam, diazepam, 
and placebo for the treatment of out-of-hospital status epilepticus. ​N.Engl.J.Med., 345, (9) 
631-637 available from: PM:11547716 
Alvarez, V., Januel, J.M., Burnand, B., & Rossetti, A.O. 2011. Second-line status epilepticus 
treatment: comparison of phenytoin, valproate, and levetiracetam. ​Epilepsia, 52, (7) 1292-1296 
available from: PM:21480881 
Baren J, Singh T, Davis C, Chamberlain J. Pre-Consent Does Not Increase Enrollment into a Time 
Sensitive Clinical Trial of Status Epilepticus in Children Compared to Standard Informed 
Consent. Acad Emerg Med 2006;13:S18-9 
Birnbaum, A.K., Kriel, R.L., Norberg, S.K., Wical, B.S., Le, D.N., Leppik, I.E., & Cloyd, J.C. 2003. 
Rapid infusion of sodium valproate in acutely ill children. ​Pediatric Neurology, 28, (4) 300-303 
available from: PM:12849885 
Bromley R1, Weston J, Adab N, Greenhalgh J, Sanniti A, McKay AJ, Tudur Smith C, Marson AG. 
Treatment for epilepsy in pregnancy: neurodevelopmental outcomes in the child.  Cochrane 
Database Syst Rev. 2014;10:CD010236 
Brophy, G.M., Bell, R., Claassen, J., Alldredge, B., Bleck, T.P., Glauser, T., Laroche, S.M., Riviello, 
J.J., Jr., Shutter, L., Sperling, M.R., Treiman, D.M., & Vespa, P.M. 2012. Guidelines for the 
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