Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona.
Department of Neurology, Franz Tappeiner Hospital, Merano.
Eur J Neurol. 2018 Mar;25(3):451-463. doi: 10.1111/ene.13560. Epub 2018 Jan 24.
Since the 1970s, intravenous (IV) phenytoin (PHT) has traditionally been used as second-stage treatment for convulsive status epilepticus (SE) after failure of benzodiazepines. The aim of this review was to critically assess the evidence supporting the use of IV PHT as treatment of convulsive SE in patients of any age. In particular, we critically appraised the results of randomized controlled trials (RCTs) evaluating IV PHT as treatment of convulsive SE. A systematic search of the literature was carried out to identify RCTs evaluating IV PHT as treatment of convulsive SE in patients of any age. Eight RCTs (544 patients allocated to IV PHT) were included. The included studies differed in almost every single characteristic considered. Six RCTs (472 patients) used IV PHT without demonstrating refractoriness of SE to benzodiazepines. Only two RCTs (72 patients) used IV PHT as second-line treatment for benzodiazepine-resistant convulsive SE. Overall, most evidence from RCTs supports the use of IV PHT immediately after IV diazepam, even if seizures have not recurred. The recommendation derived from RCTs supporting the use of IV PHT as second-line treatment in benzodiazepine-resistant convulsive SE is weak. This is emblematic of the lack of robust evidence from large RCTs to inform clinical practice on how to treat SE after failure of first-line drugs. IV PHT given immediately after first-line benzodiazepines could prolong their short antiepileptic effect and prevent seizure recurrence.
自 20 世纪 70 年代以来，静脉注射苯妥英钠（PHT）一直是苯二氮䓬类药物治疗失败后治疗惊厥性癫痫持续状态（SE）的二线治疗方法。本综述的目的是批判性评估支持将静脉注射 PHT 作为任何年龄段患者治疗惊厥性 SE 的证据。特别是，我们批判性评估了评估静脉注射 PHT 作为惊厥性 SE 治疗的随机对照试验（RCT）的结果。进行了系统的文献搜索，以确定评估任何年龄段患者静脉注射 PHT 作为惊厥性 SE 治疗的 RCT。纳入了 8 项 RCT（544 例患者接受静脉注射 PHT 治疗）。纳入的研究在几乎每个考虑的特征上都存在差异。6 项 RCT（472 例患者）在未证明 SE 对苯二氮䓬类药物耐药的情况下使用了静脉注射 PHT。只有 2 项 RCT（72 例患者）将静脉注射 PHT 作为苯二氮䓬类药物耐药性惊厥性 SE 的二线治疗。总体而言，大多数 RCT 证据支持在静脉注射地西泮后立即使用静脉注射 PHT，即使癫痫未再次发作。支持将静脉注射 PHT 作为苯二氮䓬类药物耐药性惊厥性 SE 的二线治疗的 RCT 得出的建议是薄弱的。这表明缺乏来自大型 RCT 的强有力证据来指导如何治疗一线药物治疗失败后的 SE。在一线苯二氮䓬类药物后立即给予静脉注射 PHT 可能会延长其短暂的抗癫痫作用并预防癫痫发作复发。
