Flumazenil in ECT: New Study From Belgium

Effectiveness and Safety of Flumazenil Augmentation During Electroconvulsive Therapy.

Gistelinck L, Van de Velde N, Tandt H, Verslype P, Lemmens G.J ECT. 2024 Feb 12. doi: 10.1097/YCT.0000000000001003. Online ahead of print.PMID: 38373168

The abstract is copied below:

Introduction: Benzodiazepines are considered to negatively affect seizure quality and duration during electroconvulsive therapy (ECT). Several researchers have advocated the use of flumazenil, a competitive benzodiazepine receptor antagonist, for patients treated with benzodiazepines during ECT. However, clinical evidence regarding flumazenil use in ECT remains sparse. The aim of this study is to investigate the effects of flumazenil on seizure duration and adverse effects.

Methods: All patients with depressive disorders, treated with flumazenil during a course of ECT in 2019 in a tertiary hospital, were identified through a retrospective chart review. Seizure duration was recorded before and after flumazenil administration. Effectiveness of ECT was assessed using the Inventory of Depressive Symptomatology and the Bush-Francis Catatonia Rating Scale. Postictal agitation was ascertained by identifying patients who received additional sedatives immediately after ECT or who needed physical restraint.

Results: Twenty-six patients were included, receiving a total of 363 treatments, of which 263 were augmented with flumazenil. Flumazenil administration increased electroencephalogram seizure duration on average with 10.5 seconds comparing ECT with or without flumazenil (P = 0.003). In 21.8% of the cases, no increase in seizure duration was observed. Postictal agitation occurred at least once in 34.6% of the patients receiving flumazenil during their course of ECT.

Conclusion: Our results show that flumazenil increases seizure duration, albeit with limited clinical implications. Noteworthy, the prevalence of postictal agitation is high. When confronted with short seizures, clinicians should therefore deploy other available techniques to lower seizure threshold before considering flumazenil.

The report is here.

And from the text:

Here are interesting data from a site in Belgium about the use of adjunctive flumazenil. Seizure duration increased, but there was a high incidence of postical agitation. The ECT was very effective overall, but it is impossible to know if the flumazenil improved the outcome.

My position has always been use it only when you need it, and you only know if you need it by trying first without it (except in rare circumstances of very high bz on board and desperate illness). Routine prophylaxis with postical bz seems prudent, as recommended by many practitioners who use flumazenil.

 And when will the field come to accept that higher stimulus dose more likely decreases seizure length (Luccarelli et al. 2021)?

Adding flumazenil is a nice flourish, but until we have more data, in most cases it is not fully clear that it actually improves patient outcomes.