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DOI: 10.1055/s-2006-940089
Der Stellenwert von Valproat in der Therapie von Altersepilepsien
Ergebnisse eines Expertentreffens, Zürich, 12. und 13. Mai 2006The Significance of Valproate in the Therapy for Epilepsy in the ElderlyResults of an Expert Meeting, Zurich, May 12 and 13, 2006Publication History
Publication Date:
21 August 2006 (online)
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Zusammenfassung
Bislang wird bei der Behandlung von Altersepilepsien in den deutschsprachigen Ländern trotz einer Reihe von Nachteilen Carbamazepin (CBZ) bei weitem am häufigsten eingesetzt. Die neueren Antiepileptika Gabapentin (GBP) und Lamotrigin (LTG) haben sich in kontrollierten randomisierten Studien bei Altersepilepsien zwar als vorteilhaft erwiesen, werden aber eher zurückhaltend eingesetzt. Valproat (VPA) ist ein preisgünstiges Antiepileptikum, das gerade bei älteren Patienten Vorteile bietet. Pharmakologisch sind insbesondere die fehlende Enzyminduktion (im Gegensatz zu CBZ), klinisch das breite Wirkungsspektrum gegen alle Anfallsformen bzw. alle Epilepsiesyndrome (im Gegensatz zu CBZ und GBP) sowie die Verfügbarkeit einer parenteralen Zubereitung (im Gegensatz zu CBZ, GBP und LTG) vorteilhaft. Weiterhin besteht im Vergleich zu LTG die Möglichkeit einer deutlich rascheren Aufdosierung. Die bekannten Probleme mit VPA bei der Behandlung jüngerer Patienten sind nicht beschrieben (z. B. Hepatotoxizität) oder nur selten relevant (z. B. Gewichtszunahme). Die Möglichkeit einer Enzephalopathie oder medikamentöse Interaktionen aufgrund einer Enzymhemmung müssen beachtet werden. Daten der Evidenzklassen III und IV sowie die klinische Erfahrung der Autoren sprechen aber dafür, dass VPA in der Behandlung von Altersepilepsien häufiger eingesetzt werden kann. Wir empfehlen eine initiale Zieldosis von 500 - 600 mg pro Tag verteilt auf zwei Einzeldosen.
Abstract
In German-speaking countries carbamazepine (CBZ) is by far the most frequently used antiepileptic drug (AED) in the therapy for epilepsy in the elderly in spite of several disadvantages. Although controlled randomised studies have documented an identical efficacy but better tolerability for the newer AEDs gabapentin (GBP) and lamotrigine (LTG), they are used rather reluctantly. Valproate (VPA) is a low-priced AED with several advantages, especially for elderly patients. Pharmacologically advantages are the absence of enzyme induction (in contrast to CBZ), the broad spectrum of efficacy against all seizure types and epilepsy syndromes (in contrast to CBZ and GBP) as well as the availability of a parenteral formulation (in contrast to CBZ, GPB and LTG). An additional advantage in comparison to LTG is the possibility of a rapid titration. The known disadvantages of VPA in the treatment of younger patients have not been described (e. g., hepatotoxicity) or are only rarely relevant (e. g. weight gain) for elderly patients. The possibility of an encephalopathy or drug interactions due to enzyme inhibition still have to be considered. Data of the evidence classes III and IV as well as the clinical experience of the authors argue for a more widespread use of VPA in elderly patients with epilepsy. We recommend an initial target dose of 250 to 300 mg b. i. d.
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Dr. med. Günter Krämer
Schweizerisches Epilepsie-Zentrum
Bleulerstr. 60
8008 Zürich · Schweiz
Email: g.kraemer@swissepi.ch