How do you approach tapering high dose continuous infusions for status epilepticus in patients experiencing serious medication-related toxicity?

The short answer is as quickly as possible. How you do it will somewhat depend on the need for ongoing continuous infusion of a sedative for treatment of status epilepticus. Probably the most severe toxicity syndrome is Propofol-Related Infusion Syndrome (PRIS), which if not recognized early, can lead to death. We trend CK and triglycerides daily or every other day and if there is signal of those markers rising, we will switch very early to a different agent, like midazolam or ketamine. If PRIS develops, or the patient is having refractory acidosis or cardiovascular issues, we are more aggressive with turning propofol off while we initiate the other agents. You should be able to transition to another sedative within 2-3 hours. If active ong...

This is done with continuous EEG monitoring. It depends on how long the patient has been on these infusions and what doses they are at, if there is sufficient coverage with non-infusion ASMs (either IV or oral). There is no one particular strategy, but what is typically done is reducing by up to 25% every 24 hours while monitoring the EEG. Start with one of the infusions; don't titrate all simultaneously. If the patient goes back into status, adjust other ASMs, leave on the infusions for another 24-48 hours before trying again.