Buccal (oromucosal) midazolam

This page explains about buccal midazolam, how it is given and some of its possible side effects. This leaflet should be read in conjunction with any information provided by the manufacturer.

Midazolam belongs to a group of medicines called benzodiazepines, which are used to treat several different conditions, including seizures. Midazolam is chemically related to diazepam, which is another medicine used to treat seizures.

If a seizure lasts for more than five minutes, it can be difficult to stop unless treatment is given. It is therefore important that rapid treatment is given to stop the seizures and therefore prevent status epilepticus.

Status epilepticus is a condition where a person has a seizure (convulsion or fit) or a series of seizures that last for 30 minutes or more, without a complete recovery of consciousness.

‘Buccal’ or ‘oromucosal’ is when a medicine is given by placing it directly against the gums and inside of the cheek. This is so it is absorbed directly into the blood stream.

It is important that these types of medicines are given in this way, as if they are swallowed accidentally, they might not work as quickly.

Buccal midazolam is available in either pre-filled liquid syringes, or as a liquid in a bottle.

Some examples include:

• Buccolam® containing midazolam hydrochloride available as pre-filled oral syringes of 2.5mg, 5mg, 7.5mg and 10mg.
• Epistatus® contains midazolam maleate 10mg in 1ml. It is a preparation in a 5ml bottle with four oral syringes in the packaging. This is an unlicensed product, available as a special. 
• Epistatus® is also available as pre-filled oral syringes of 2.5mg, 5mg, 7.5mg and 10mg. 

It is important to remember which brand and dose your child uses.

Your local medical team will train you how to prepare and give buccal midazolam.

• Always check the dose and expiry date before use.
• Give the medicine slowly to stop your child swallowing the medicine as this may cause them to choke.
• If buccal midazolam does not control the seizure within five minutes, follow the advice given by your doctor or call 999 for an ambulance.
• If you cannot give buccal midazolam for any reason, give first aid and call 999 for an ambulance.

How to use: 

1. Check the dose and expiry date of the pre-filled syringe.
2. Remove the syringe from its packaging.
3. Place the syringe into the side of your child’s mouth, between the gums and teeth.
4. If possible, give half the dose into one cheek and the remaining half into the other cheek.
5. Slowly push the plunger of the syringe down until the syringe is empty. 
6. Watch for any breathing difficulties.
7. Confirm that the seizure has stopped.
8. Dispose of the used syringe safely.

Important safety note for Buccolam® pre-filled oral syringes

• Buccolam® pre-filled syringes have a red protective cap which must be removed before use. Removing the red cap should also remove the translucent tip-cap underneath, but occasionally they do not come off together.
• Always check that the tip-cap underneath has been removed, as this may pose a choking hazard if it’s still in place when administering the medication.

You will need the following:

• Bottle of Epistatus®
• Oral syringe 

Preparing the dose: 

1. Check that the liquid is clear and that no crystals are visible. Discard if the liquid isn’t clear or you can see crystals.
2. Unscrew the bottle cap, keeping the bottle upright.
3. Insert a syringe into the centre of the stopper.
4. Turn the bottle upside down.
5. Slowly pull the plunger of the syringe back and then push back to prevent any air bubbles.
6. Slowly pull the plunger back again and draw up the prescribed amount of liquid. 
7. Turn the bottle the right way up.
8. Remove the syringe and put the cap back on the bottle.

How to give the dose: 

1. Place the syringe into the side of your child’s mouth, between the gums and teeth.
2. If possible, give half the dose into one cheek and the remaining half into the other cheek.
3. Slowly push the plunger of the syringe down until the syringe is empty.
4. Watch for any breathing difficulties.
5. Confirm that the seizure has stopped.
6. Dispose of the syringe safely.

Like all medicines, buccal midazolam can have side effects. These can include: 

• Drowsiness and feeling sleepy. Recovery from this is usually fast.
• Amnesia or short-term memory loss – your child may not remember having had a seizure.
• Your child’s breathing may become a little shallow for a while. Monitor their breathing until it returns to normal. If you think your child is not breathing or their lips get a blue tinge, call 999 for an ambulance straight away. Please note, that these colour changes may be harder to see on brown or black skin tones.
• Restlessness, agitation, and disorientation – these can occur but are usually rare.

• Give the medicine as prescribed by your child’s medical team.
• If your child stops using midazolam or it passes its expiry date, return it to your pharmacist. Do not flush it down the toilet or throw it away.
• Keep midazolam in a safe place where children cannot see it or reach it.
• Keep midazolam at room temperature (not in a fridge), away from bright light or direct sunlight and away from heat.
• Always check you have enough medicine and remember to order a new prescription in plenty of time.

If you have any questions or queries about the information in this leaflet, please speak with your local epilepsy nurse, or named GOSH epilepsy nurse through the MYGOSH app.

You can also contact the GOSH Pharmacy Medicine Information team through the Medications page on the MyGOSH app or by telephone.

Telephone: 020 7829 8608

The team are available Monday to Friday, 9am to 5pm (excluding Bank Holidays).

Please note this is not an emergency number.