Erster epileptischer Anfall und Epilepsien im Erwachsenenalter^[*]

Zusammenfassung

Hintergrund Das Manuskript ist eine aktualisierte und stark erweiterte Version der 2012 entstandenen DGN-Leitlinie zum ersten epileptischen Anfall und Epilepsien im Erwachsenenalter. Ziel der Leitlinie ist es, den gegenwärtigen Stand des Wissens zur Diagnostik und Therapie anhand der zur Verfügung stehenden wissenschaftlichen Literatur zusammenzufassen und damit zur Verbesserung der diagnostischen und therapeutischen Abläufe und deren Vereinheitlichung beizutragen.

Die Leitlinie behandelt ausschließlich Epilepsien im Erwachsenenalter, Epilepsien bei Kindern werden nicht berücksichtigt. Ebenso werden der Status epilepticus sowie Anfälle infolge von immunvermittelten Erkrankungen des Gehirns nicht behandelt, da hierzu eigene Leitlinien vorliegen.

Methodik Das Leitliniengremium wurde durch Experten der Neurologie gebildet, die eine besondere Expertise auf dem Gebiet der Epilepsie besitzen und sowohl aus dem klinischen als auch aus dem niedergelassenen Bereich kommen. Neben der Deutschen Gesellschaft für Neurologie (DGN) sind auch die Deutsche Gesellschaft für Neurochirurgie e. V. (DGNC), die Österreichische Sektion der Internationalen Liga gegen Epilepsie, die Schweizerische Liga gegen Epilepsie sowie die Luxemburgische Gesellschaft für Neurologie beteiligt. Es wurde darauf geachtet, auch Mitglieder der jüngeren Generation in das Redaktionskomitee aufzunehmen.

Die seit der letzten Ausgabe der Leitlinie 2012 neu erschienene Literatur wurde gesichtet und in die aktuelle Fassung eingearbeitet. Die Methodik der Leitlinienentwicklung entsprach einem nominalen Gruppenprozess und einem modifizierten Delphi-Verfahren (Vorlage zuvor produzierter Texte oder Tabellen, mehrstufige schriftliche Befragungsmethode, Rückkopplungsprozess, Information der Teilnehmer über die Gruppenantwort, Diskussion aller Kommentare mit ggf. daraus resultierender Überarbeitung des Entwurfes, Gruppenmitglieder haben die Möglichkeit einer Überprüfung bzw. eines Vergleichs ihrer Aussagen). Der Konsensprozess entsprach den Regeln der AWMF und der DGN zum Umgang mit potenziellen Interessenkonflikten.

Ergebnis Wichtigste Neuerung ist eine erneuerte Definition der Epilepsie, ein wesentlich neuer Aspekt dieser Definition ist die Frage, ob eine Epilepsie „überwunden“ werden kann. Auch zur Klassifikation von Anfällen und Epilepsien ist eine neue Version erschienen, die im Wesentlichen wieder der Version von 1989 entspricht.

Als wichtigste therapeutische Neuerung hat sich seit der letzten Fassung der Leitlinie von 2012 das Spektrum der Antiepileptika deutlich erweitert, neue Medikamente sind zugelassen worden (Perampanel, Brivaracetam) oder haben ihre Zulassung erweitert (Zonisamid, Lacosamid, Eslicarbazepinacetat). Der Einsatz von Valproinsäure bei Frauen und Mädchen wird zunehmend kritisch gesehen, in der Leitlinie wird ausführlich auf diese Problematik und die Behandlung von Frauen mit Epilepsie eingegangen. Neben der medikamentösen Therapie werden operative Therapien und Stimulationsverfahren behandelt.

Psychosoziale Aspekte sowie die Bereiche Fahrtauglichkeit, Ausbildung und Beruf sowie die Problematik des Absetzens von Medikamenten bei langjähriger Anfallsfreiheit werden umfangreicher als bisher diskutiert, auch wurden Abschnitte zur Mortalität, zu Erste-Hilfe-Maßnahmen und zu akuten symptomatischen Anfällen (ASA) neu in die Leitlinie aufgenommen.

Ein eigenes Kapitel zur Pharmakokinetik befasst sich mit dem Interaktionspotenzial von Antiepileptika mit anderen Medikamenten sowie dem möglichen Einfluss auf Vitamin- und Hormonspiegel. Insbesondere Therapien maligner Erkrankungen können durch Interaktionen kritisch beeinflusst werden.

Abstract

Background The manuscript is a current and significantly expanded version of the 2012 German Society of Neurology (DGN) Guidelines for the First Epileptic Seizure and Epilepsy in Adulthood. The goal of these guidelines is to summarize the present situation with regard to diagnostics and therapy along with the available scientific literature and thereby improve the diagnostic and therapeutic procedures and contribute towards their standardization.

The guidelines pertain exclusively to those epilepsies in adulthood. Children’s epilepsies will not be included, nor will status epilepticus or seizures resulting from an immune-mediated disease of the brain as these types of epilepsies already have their own set of DGN guidelines.

Methodology The guideline committee is comprised of neurology experts possessing special expertise in the area of epilepsy, as well as clinicians and independent physicians. In addition to the German Society of Neurology (DGN), the German Society of Neurosurgery (DGNC), the Austrian Chapter of the International League Against Epilepsy, the Swiss League Against Epilepsy as well as the Luxemburg Society of Neurology also participated. Special care was taken to also include younger members on the editorial board.

Literature that has been published since the 2012 edition was issued has been examined and incorporated in the current edition. The methodology utilized for guideline development is in accordance with standardized consensus techniques like a modified Delphi process (submission of previously produced text or tables, multi-step written questioning techniques, feedback process, participant information about the group responses, discussion of all comments and, if appropriate, the subsequent revisions; group members are able to examine a comparison of their statements). The consensus process corresponds to the rules of the Association of the Scientific Medical Societies in Germany (AWMF) and the DGN in order to address conflicts of interests.

Results The most important new feature is the development of a new epilepsy definition. A substantially new aspect of this definition is the question of whether or not epilepsy can be “resolved”. Also included is a new version of the classification for seizures and epilepsies which essentially corresponds to the 1989 version.

The most important therapeutic development since the 2012 edition has been the significant expansion of the anticonvulsive medication spectrum. New medications have been approved (Perampanel, Brivaracetam) or have extended their approval (Zonisamide, Lacosamide, Eslicarbazepine acetate). The administration of Valproic Acid to women and children is being viewed ever more critically. The guidelines explain, in detail, the problems related to treating women with epilepsy. In addition to drug therapy, operative therapies and stimulation procedures are also covered.

Psycho-social aspects, driving ability, education, vocation as well as the problems that arise when discontinuing medication after years of seizure freedom are more extensively discussed. Also, new sections on mortality, first-aid measures, and acute symptomatic seizures have been added.

A single chapter has been devoted to pharmacokinetics and addresses the interactive potential of anti-epileptic drugs with other medications as well as the possible influence on vitamin and hormone levels. In particular, therapies for malignant diseases can be critically influenced by interactions.

Schlüsselwörter

Leitlinie - Epilepsie - Anfälle - Antiepileptika - erster Anfall - Epilepsiechirurgie

Key words

guideline - epilepsy - epileptic seizure - antiepileptic drug - first seizure - epilepsy surgery

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