What Are Nayzilam and Valtoco?
Nayzilam (midazolam nasal spray) and Valtoco (diazepam nasal spray) are FDA-approved rescue treatments for seizure clusters in patients aged 6 and older with epilepsy. Both are nasal sprays designed for rapid administration by caregivers during prolonged or repetitive seizures when oral drugs fail. Nayzilam was approved in 2019 by UCB, while Valtoco gained approval in 2020 from Neurelis.[1][2]
How Do They Work and What's the Efficacy Data?
Both contain benzodiazepines that enhance GABA activity to stop seizures quickly. Nayzilam uses midazolam, a short-acting agent, while Valtoco uses diazepam, which has a longer duration.
In trials:
- Nayzilam terminated 53% of clusters within 10 minutes (compared to 35% with placebo) and provided seizure freedom for 1 hour in 54% of cases.
- Valtoco ended 53.6% of clusters within 30 minutes across doses, with seizure freedom for 24 hours in up to 58% of patients.
Head-to-head data is limited, but midazolam's faster onset (about 10 minutes) edges out diazepam's (15-20 minutes) for initial control, though diazepam sustains effects longer.[3][4]
Dosing and Administration Differences
| Feature | Nayzilam | Valtoco |
|---------|----------|---------|
| Doses | Single-use 5 mg/0.1 mL spray per nostril (max 10 mg/series) | 5, 10, 15, or 20 mg (weight-based: 0.2 mg/kg) |
| Device | Ready-to-use, no assembly; one spray per nostril, 10 min apart if needed | Prefilled syringe with adapter; single nostril dose, repeat after 4-5 hours if required |
| Repeat Dosing | Second dose after 10 min; no more for 12 hours | Second dose after 4-5 hours; max 2/day |
Valtoco offers more flexible weight-based dosing for larger patients, while Nayzilam is simpler for quick use.[1][2]
Onset, Duration, and Safety Profile
Nayzilam acts faster (peak in 10-20 min) but wears off quicker (half-life ~1-4 hours), suiting acute clusters. Valtoco peaks slower (15-30 min) with a longer half-life (20-70 hours), better for preventing recurrence over hours.
Common side effects overlap (somnolence 23-49%, respiratory depression risk), but Nayzilam reports higher nasal discomfort (13%) and Valtoco more nasal irritation or congestion. Both carry black-box warnings for respiratory arrest; monitor breathing post-dose. No major efficacy difference in real-world use, per epilepsy forums and studies.[3][5]
Cost, Availability, and Insurance Coverage
Nayzilam lists at ~$700-900 per two-dose kit; Valtoco ~$800-1,000 for a carton (4 doses). Patient assistance programs exist for both. Coverage varies: many plans prefer one over the other based on prior auth, but copays average $25-100 with savings cards. Valtoco may be cheaper for bulk via 340B programs.[6]
Which to Choose for Rescue Treatment?
Nayzilam suits faster onset needs or simpler delivery; Valtoco fits higher doses or sustained control. Neurologists often pick based on patient weight, cluster patterns, and tolerance—midazolam for speed, diazepam for familiarity (from rectal gel legacy). Consult epilepsy specialists; no clear winner, but both outperform placebo significantly.4
Sources:
[1]: https://www.nayzilam.com/
[2]: https://www.valtoco.com/
[3]: FDA Labels (Nayzilam: NDA 211910; Valtoco: NDA 212847)
[4]: Epilepsy Study Consortium comparison (2021)
[5]: Post-marketing surveillance (AAN 2022)
[6]: GoodRx pricing data (2023)