title: Randomized evaluation of adverse events and length-of-stay with routine emergency department use of phenytoin or fosphenytoin.
abstract: Intravenous phenytoin has come under increased scrutiny with the introduction of the prodrug, fosphenytoin. We evaluated adverse events and length-of-stay using parenteral the two drugs in routine emergency department use. Open-label randomization of phenytoin or fosphenytoin in 256 Emergency Department patients prescribed 279 parenteral doses of a phenytoin-equivalent. All phenytoin was administered intravenously, and fosphenytoin was given intravenously or intramuscularly (physician preference). Adverse events and Emergency Department length-of-stay were recorded; re-presentation to the Emergency Department within three months was reviewed for evidence of the purple glove syndrome. Nonparametric statistics were used to analyze the data. Seventy-seven patients received phenytoin and 202 fosphenytoin; 28 (10.0%) received intramuscular fosphenytoin. The mean phenytoin-equivalent dose was similar between the groups. Eighteen patients required reduction in infusion rates because of an adverse event (phenytoin = 6.5%, fosphenytoin = 6.4%; OR 0.9, 95% CI 0.4 2.6; p = 1.0). Adverse events occurred with similar frequency (phenytoin 9.1%, fosphenytoin 15.8%; OR 0.7, 95% CI 0.3 1.4; p = 0.3). The most common events were: pruritus, pain on infusion, and paresthesias. One patient developed hypotension (fosphenytoin); there were no other serious adverse events, including phlebitis. Median Emergency Department length-of-stay was 6.7 h for phenytoin and 5.7 h for fosphenytoin (p = 0.6). In routine Emergency Department use, our data do not support formulary conversion from phenytoin to fosphenytoin, based on the incidence of adverse events or Emergency Department length-of-stay.
authors.affiliation: Departments of Neurology and Neurological Surgery, Wayne State University, 4201 St. Antoine-8D-UHC, Detroit, MI 48201, USA. wcoplin@med.wayne.edu
authors.forename: William M
authors.initials: WM
authors.lastname: Coplin
authors.forename: Denise H
authors.initials: DH
authors.lastname: Rhoney
authors.forename: Jill A
authors.initials: JA
authors.lastname: Rebuck
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Clements
authors.forename: Mary S
authors.initials: MS
authors.lastname: Cochran
authors.forename: Brian J
authors.initials: BJ
authors.lastname: O'Neil
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D004638:Emergency Treatment / Q000379:methods*; D004827:Epilepsy / Q000188:drug therapy*; D004834:Epilepsy, Post-Traumatic / Q000188:drug therapy*; D005119:Extravasation of Diagnostic and Therapeutic Materials / Q000503:physiopathology / Q000517:prevention & control; D005260:Female; D006801:Humans; D007022:Hypotension / Q000139:chemically induced / Q000503:physiopathology; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D010672:Phenytoin / Q000008:administration & dosage / Q000009:adverse effects* / Q000031:analogs & derivatives* / Q000627:therapeutic use
chemical_list: D010672:Phenytoin; C043114:fosphenytoin