title: Midazolam-ketamine dual therapy stops cholinergic status epilepticus and reduces Morris water maze deficits.
abstract: Pharmacoresistance remains an unsolved therapeutic challenge in status epilepticus (SE) and in cholinergic SE induced by nerve agent intoxication. SE triggers a rapid internalization of synaptic γ-aminobutyric acid A (GABAA ) receptors and externalization of N-methyl-d-aspartate (NMDA) receptors that may explain the loss of potency of standard antiepileptic drugs (AEDs). We hypothesized that a drug combination aimed at correcting the consequences of receptor trafficking would reduce SE severity and its long-term consequences.
  
  
  
  A severe model of SE was induced in adult Sprague-Dawley rats with a high dose of lithium and pilocarpine. The GABAA receptor agonist midazolam, the NMDA receptor antagonist ketamine, and/or the AED valproate were injected 40 min after SE onset in combination or as monotherapy. Measures of SE severity were the primary outcome. Secondary outcomes were acute neuronal injury, spontaneous recurrent seizures (SRS), and Morris water maze (MWM) deficits.
  
  
  
  Midazolam-ketamine dual therapy was more efficient than double-dose midazolam or ketamine monotherapy or than valproate-midazolam or valproate-ketamine dual therapy in reducing several parameters of SE severity, suggesting a synergistic mechanism. In addition, midazolam-ketamine dual therapy reduced SE-induced acute neuronal injury, epileptogenesis, and MWM deficits.
  
  
  
  This study showed that a treatment aimed at correcting maladaptive GABAA receptor and NMDA receptor trafficking can stop SE and reduce its long-term consequences. Early midazolam-ketamine dual therapy may be superior to monotherapy in the treatment of benzodiazepine-refractory SE.
authors: Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A.|Epilepsy Research Laboratory (151), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, U.S.A.
authors: Jerome
authors: J
authors: Niquet
authors: Epilepsy Research Laboratory (151), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, U.S.A.
authors: Roger
authors: R
authors: Baldwin
authors: Epilepsy Research Laboratory (151), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, U.S.A.
authors: Keith
authors: K
authors: Norman
authors: Epilepsy Research Laboratory (151), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, U.S.A.
authors: Lucie
authors: L
authors: Suchomelova
authors: US Army Medical Research Institute of Chemical Defense (USAMRICD), Aberdeen Proving Ground, Maryland, U.S.A.
authors: Lucille
authors: L
authors: Lumley
authors: Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A.|Epilepsy Research Laboratory (151), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, U.S.A.|Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A.
authors: Claude G
authors: CG
authors: Wasterlain
mesh_terms: D000818:Animals; D000927:Anticonvulsants / Q000627:therapeutic use*; D001921:Brain / Q000473:pathology; D018678:Cholinergic Agents / Q000633:toxicity*; D004195:Disease Models, Animal; D004357:Drug Synergism; D004359:Drug Therapy, Combination; D007649:Ketamine / Q000627:therapeutic use*; D007859:Learning Disabilities / Q000188:drug therapy* / Q000209:etiology; D018021:Lithium Chloride / Q000633:toxicity; D008297:Male; D018782:Maze Learning / Q000187:drug effects*; D008874:Midazolam / Q000627:therapeutic use*; D019832:N-Methylscopolamine / Q000633:toxicity; D010862:Pilocarpine / Q000633:toxicity; D051381:Rats; D017207:Rats, Sprague-Dawley; D013226:Status Epilepticus / Q000139:chemically induced / Q000188:drug therapy / Q000473:pathology; D014635:Valproic Acid / Q000627:therapeutic use
chemical_list: D000927:Anticonvulsants; D018678:Cholinergic Agents; D010862:Pilocarpine; D014635:Valproic Acid; D007649:Ketamine; D018021:Lithium Chloride; D008874:Midazolam; D019832:N-Methylscopolamine
keywords: Cholinergic seizures; Epileptogenesis; Hippocampal sclerosis; Neuronal injury; Refractory status epilepticus; Spatial memory