Moderne medikamentöse Epilepsietherapie im Alter

Zusammenfassung

Jenseits des 60. Lebensjahres beginnen ein Drittel aller Neuerkrankungen an Epilepsie. Die Behandlung mit Antiepileptika ist durch Veränderungen der Pharmakokinetik und Pharmakodynamik in dieser Patientengruppe besonders nebenwirkungsträchtig. Eine Kombination von Antiepileptika sollte möglichst vermieden werden. Es liegt nur eine Evidenzklasse-I-Studie zur Auswahl von Antiepileptika für ältere Menschen mit fokalen Anfällen vor. Bei ähnlicher Wirksamkeit waren in dieser Studie Lamotrigin und Gabapentin besser verträglich als unretardiertes Carbamazepin, und Lamotrigin wies in einer Evidenzklasse-II-Studie in geringerem Maße, Verträglichkeitsvorteile im Vergleich zu retardiertem Carbamazepin auf. Neben Gabapentin und Lamotrigin werden aufgrund Evidenzklasse-III-Studien und klinischer Beobachtungen sowie pharmakologischer Überlegungen Levetiracetam, Pregabalin,Topiramat in niedrig-mittleren Dosen und Valproat empfohlen. Es wird generell geraten nicht enzyminduzierende moderne Antiepileptika einzusetzen, anstelle der enzyminduzierenden älteren Antiepileptika. Insgesamt ist die Epilepsiebehandlung älterer Menschen bei niedriger Dosierung und adäquater Auswahl der Medikamente mindestens so erfolgreich wie bei jüngeren Patienten.

Summary

In one of three cases new-onset epilepsy begins beyond age 60. Pharmacokinetic and pharmacodynamic changes in the elderly makes them more susceptible to side effects. Slow dose escalation and lower-than-average doses of antiepileptic drugs (AED) are recommended. AED combination therapy should be avoided, and clear written instructions are important. Only one class I evidence study exists for guiding AED treatment in the elderly. Gabapentin and lamotrigine showed similar efficacy but were better tolerated than carbamazepine. In a class II study lamotrigine was better tolerated compared to slow-release carbamazepine. In addition to gabapentin and lamotrigine, expert opinion based on clinical observations and pharmacological rationale recommends levetiracetam, pre gabalin, topiramate and valproate. It is advisable to prefer non-enzyme inducing new AEDs such as gabapentin, lamotrigine, levetiracetam and low-to-moderate dosages of topiramate (for which however no Class I evidence exists) in the elderly instead of classic enzyme inducing CBZ, if possible. Oxcarbazepine is also less well suited because of the risk of hyponatremia in the elderly. Altogether, treatment of epilepsy in the elderly is as successful as in younger adults with low-dose monotherapy of well-suited, modern AEDs.

Schlüsselwörter

Antiepileptika - Epilepsietherapie - ältere Menschen - Arzneimittelinteraktionen - Kombinationstherapie - unerwünschte Nebenwirkungen

Keywords

Drug interactions - hypersensitivity reactions - elderly - antiepileptic drugs - early combination treatment - epilepsy treatment

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