BIOPUNCTURE MEDICATION

What is Biopuncture?

Biopuncture is a therapy whereby specific locations are injected with biological products. Most of these injections are given under the skin or into the muscles.

What kind of products are being injected?

Most ampoules contain low doses of plant extracts. Products commonly used in Biopuncture are, for example, arnica, echinacea, nux vomica and chamomile. Arnica is used for muscle pain, nux vomica is injected for digestive problems, echinacea is used to increase the natural defense system of the body. Biopuncturists always inject cocktails of natural products. Traumeel for example is used for inflammations and sports injuries, Spascupreel is used for muscular cramps and Lymphomyosot for lymphatic drainage. Hundreds of different cocktails are available these days.

Are these products safe for me?

The ampoules do not contain high concentrations of the active substances. As only low doses are injected, toxic side effects are very unlikely. Additionally, the ampoules used in Biopuncture are manufactured by companies that guarantee the production quality of their products. Most of the ampoules used for injection are made in Germany and are submitted to very strict quality control regulations and systems. Clinical studies on thousands of patients have confirmed the safety of ampoules like for example Traumeel.

How can these dilutions actually have an effect on my body?

The fact that most ampoules only contain very low concentrations of plant extracts is often a reason for conventional physicians to criticize the possible effects of these products. But one has to add here that the products used in Biopuncture are not diluted to the extent that an ampoule contains no active products any more (as in “real” homeopathy). That’s why we call them micro-doses. So, it is more than just injecting water.

How does this small dose influence the body then? When you receive a tetanus vaccination, only small amounts of a product are necessary to stimulate the immune system (= your defense system) against lockjaw. A few injections can protect your body for several years against such a serious disease! Biopuncture injections are not real vaccinations, of course, but the idea of the mechanism of action is similar: small doses of the right product can have a huge effect. And Biopuncture produces its clinical effects because it stimulates your immune system to restart its healing capacities.

Has it been proven that Biopuncture works by stimulating my immune system?

Physicians around the world have experienced the effects of these injections for decades. But the problem was to prove to other colleagues how it really worked. Recent research on Biopuncture has given new insights as to how these products seem to do the job. A scientific investigation has illustrated that Traumeel indeed works via the immune system. (Your physician will be surprised to hear that the mechanisms of action of Traumeel include both inhibition of IL-1ß and inhibition of TNF-alpha Secretion.) In June 2004 an article about Traumeel was published in an important medical journal “Clinical & Developmental Immunology” which is a highly respected journal in conventional medicine. If your doctor really wants to know more about this study or is interested in other clinical studies about Biopuncture, he or she can find more information in the textbooks on Biopuncture”.

But how does Biopuncture work then to help me with my pain or inflammations?

In conventional medicine, the actual drug you take suppresses your symptoms immediately. That is why you need to take high doses of chemical substances in order to suppress for example pain. And as soon as the medication stops working, you have to take another pill to kill the pain again. The same goes for anti-inflammatories, medication to control your blood pressure or pills for high cholesterol. That’s how these drugs are designed. However, in Biopuncture small doses of products are injected in order to stimulate the natural healing processes. These micro doses “wake up” mechanisms which are available anyway. So, the healing effect comes from “inside” your body - not from the products themselves. It’s the reaction of your immune system which will produce the proper reactions to regain natural healing. The reaction of the body may vary from better local blood circulation to relaxation of muscles or a local detoxification of tissues.

Will Biopuncture help me as quickly as conventional therapies?

It is obvious that injections of micro-doses are less powerful than for example cortisone injections. The dose used is too small to immediately suppress the inflammation. But that’s not the goal of Biopuncture! We consider an inflammation as an important element of true and lasting healing. The goal of Biopuncture is to stimulate the natural inflammatory processes in order to get complete and natural healing of the injured tissues – not to suppress them. So, we do exactly the opposite of conventional drugs. As a result, the symptomatic relief may take a while, especially for chronic cases. But when dealing with acute injuries, the effects of the injections are apparent almost immediately.

Where are these injections given?

Most people - especially those who are apprehensive about injections because they may have had bad experiences with injections in their childhood - are surprised how easily and quickly these injections are given. In fact, these injections cannot be compared to the ‘usual' injections given in conventional medicine. They are not as painful as an injection in for example a hospital because the needle used is very fine and the quantity injected is very small. Indeed, they look more like little pinpricks. Most of them are given into or just under the skin, others are given into specific muscle points or into your ligaments. Your doctor doesn’t give the injections in the buttock or arm, but they are administered in carefully chosen zones. The place where the doctor injects the product is as important as the product itself. It’s different for each patient. During the Biopuncture course, doctors are instructed what techniques to use and what products to inject.

How many injections will I receive each session?

A lot of these injections are given at more than one spot during each session. For example, if your doctor wants to work on your liver, he or she will give about 7 little injections under the skin on your abdomen. When you have pain in your elbow, your physician will look for several painful spots in your arm muscles or elbow ligaments, and inject each of them in one session. In such a case, you may receive anything from three to ten little injections in your elbow, neck or arm. So in most cases, several injections are given in a specific zone (or in several areas) of the body at each session.

How many sessions of Biopuncture will be necessary?

The fact that your doctor uses small doses of natural products instead of cortisone injections means that you have to be more patient. If you have had problems for several months or even years, your doctor must work on different layers. If it is a complicated case, your health care provider must sometimes also look for deeper causes of your complaints and work on these. Sometimes your hormonal system has to be regulated. Or he or she must do a detoxification first before even starting to work on your symptoms. As a result, you may need five sessions or even more to feel better. When you realize that these products are natural products that do not show any major side effects, you may be motivated to be more patient than usual. In the long run, however, the results of Biopuncture are longer lasting because the healing comes from within and does not depend on the pills you take every day to take away the symptoms.

Is there an element of risk with such injections?

It is clear that the physician who decides to use Biopuncture, will always do so according to the latest technical standards. That is his or her duty as a medical professional. This includes a correct injection technique, and of course the use of sterile disposable material. The latter means that the needle has never been in contact with any other patient and that any transmission of disease (e.g. hepatitis, AIDS) is impossible. This should give you confidence in the safety of the technique. But you may end up with a blue spot at the site of injection the next day.

What is a “detox” treatment?

An important issue in Biopuncture is the detoxification of the body. It literally means “cleaning the body.” All the toxins that have accumulated in your body, for example from the environment (air pollution), from bad nutrition, or from medication (e.g. antibiotics and steroids you’ve taken) can block your immune defense system. They can also disturb the reflex responses of your nervous system. All these toxins in your body are the reason why your body may not be functioning optimally as it did when you were younger. Eliminating all these toxins is an important strategy in Biopuncture, especially when dealing with chronic diseases. Some injections work specifically on the liver and others on the kidneys or on the lymphatic system. Especially, the cleaning up of the lymphatic system with Lymphomyosot is considered very important in Biopuncture.

When should my physician suggest Biopuncture?

Biopuncture cannot heal all your medical problems. This is not a miracle therapy. It is up to your family physician to decide what can be treated, and what can't. The majority of patients choose to be treated with Biopuncture because they are in pain and do not support the use of conventional painkillers. However, it is important to realize that Biopuncture isn’t designed to ‘take away' the pain as with conventional medication. Pain is seen as an important ‘signal' from your body that something is going wrong. It is similar to a red light on the dashboard of your car: the aim is not to just ‘take it away' but to look for the deeper cause. This means that if pain can be alleviated with Biopuncture - without prescribing painkillers - there is good reason to conclude that the deeper cause of that particular pain has been eliminated.

I’ve heard that things can get worse immediately after my first treatment. Is that correct?

It all depends. Every case is different. Sometimes you improve immediately after the injection. It means you really feel better within minutes after the injections. Critics might describe such a phenomenon as a “placebo effect” by saying that you feel better because you believe you’re going to be feeling better. In Biopuncture, such an immediate improvement is rather likely to happen when dealing with a fresh sports injury for example. But as stated before, when dealing with complaints that have persisted for months or years, things need some time to heal. In the beginning the pain may shift from one area to another when the body starts to react to the treatment. This is not a bad sign but the first step of natural healing. It is called the “adaptation phase.” You may even notice that - especially the day after the injection - you feel a little worse, experiencing more pain or discomfort after the first session. This is exactly the opposite of the so-called placebo effect! This temporary worsening of complaints usually means that the healing processes are being activated. The body is working on the problem, and that is exactly what we want. In Biopuncture it is called the “reaction phase”. But when you understand that this means that real healing is on its way, you will be willing to accept these minor reactions in the beginning of the treatment.

When should I consider Biopuncture?

Most physicians use Biopuncture for minor orthopedic problems. Neck pain and back pain are good indications for Biopuncture, but one can also treat sciatica, ankle sprain, pain in the shoulder and Achilles tendonitis using these natural vaccinations. Biopuncture is also very successful in treating sports injuries, tennis elbow, golf elbow, and so on. However, Biopuncture is not just used for pain problems. An area of treatment worth noting is that of allergies and inflammations. For example, one can treat asthma, eczema and hay fever. And even patients with bronchitis, cystitis and sinusitis can be treated with this technique. When a physician is experienced in the technique, he or she can also treat you for migraine, tension headache, Crohn's disease, colitis, Cluster headache, neuralgia, and so on.

Who may benefit from Biopuncture?

The use of biotherapeutic injections can benefit those patients who have tried conventional medicine but have had no success, or for those who have had to stop taking conventional medication because of side effects. It is an interesting healing technique for those patients who want to avoid an operation (for example for sciatica or sinusitis). In some patients it may be advantageous to combine the conventional approach together with Biopuncture. Many people still believe that one has to stop conventional treatments when choosing Biopuncture. This is not true. When you are being treated with Biopuncture, you just continue the medication you were already taking. In case of doubt, always contact your physician first for professional advice. Each case should be taken into account individually, of course.

When is Biopuncture not appropriate?

Let us be clear about it: Biopuncture cannot heal you from cancer, diabetes, a heart attack or AIDS. Nor is it an appropriate treatment for high blood pressure, fibromyalgia, Parkinson, depression or epilepsy. In some cases, the disease is too serious or too aggressive, and can only be stopped through conventional medication or surgery. Your family physician will confirm this. When serious damage has already occurred, Biopuncture will be simply too late to reverse the damage and bring the body back into balance again. For example, a viral hepatitis can be treated with Biopuncture in order to support the healing mechanism of the body, but liver cirrhosis is a phase where cells are damaged beyond repair and healing is impossible. The same goes for chronic problems with the airways. Biopuncture can help a lot here as long as there is no emphysema or lung cancer involved. That is why it is so important to first have a conventional diagnosis before starting with Biopuncture. I advise you to ask your family physician for advice in case of doubt.

Conclusion

Biopuncture is a safe and efficient technique in complementary medicine. It uses biotherapeutic injections to stimulate the natural self-healing capacities of your body. It is worth considering if it can help you with your personal health problems. Consult your medical professional for more information about Biopuncture.

source : www.kersschot.com

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Management of Carpal Tunnel Syndrome

Management of Carpal Tunnel Syndrome

ANTHONY J. VIERA, LCDR, MC, USNR, Naval Hospital, Jacksonville, Florida

Carpal tunnel syndrome affects approximately 3 percent of adults in the United States. Pain and paresthesias in the distribution of the median nerve are the classic symptoms. While Tinel's sign and a positive Phalen's maneuver are classic clinical signs of the syndrome, hypalgesia and weak thumb abduction are more predictive of abnormal nerve conduction studies. Conservative treatment options include splinting the wrist in a neutral position and ultrasound therapy. Orally administered corticosteroids can be effective for short-term management (two to four weeks), but local corticosteroid injections may improve symptoms for a longer period. A recent systematic review demonstrated that nonsteroidal anti-inflammatory drugs, pyridoxine, and diuretics are no more effective than placebo in relieving the symptoms of carpal tunnel syndrome. If symptoms are refractory to conservative measures or if nerve conduction studies show severe entrapment, open or endoscopic carpal tunnel release may be necessary. Carpal tunnel syndrome should be treated conservatively in pregnant women because spontaneous postpartum resolution is common. (Am Fam Physician 2003:68:265-72, 279-80. Copyright© 2003 American Academy of Family Physicians.)

A patient information handout on carpal tunnel syndrome, written by the author of this article, is provided on page 279. A PDF version of this document is available. Download PDF now (8 pages /151 KB). More information on using PDF files.

Carpal tunnel syndrome, the most common focal peripheral neuropathy, results from compression of the median nerve at the wrist.¹ The syndrome affects an estimated 3 percent of adult Americans and is approximately three times more common in women than in men.² High prevalence rates have been reported in persons who perform certain repetitive wrist motions, but the significance of this relationship continues to be challenged. Although 30 percent of frequent computer users complain of hand paresthesias, only 10 percent meet clinical criteria for carpal tunnel syndrome, and nerve conduction studies are abnormal in only 3.5 percent of these persons.³

See page 204 for definitions of strength-of-evidence levels.

Family physicians frequently encounter patients who may have carpal tunnel syndrome. This article reviews the clinical features, diagnosis, and treatment of this relatively common condition.

Clinical Features

The classic symptoms of carpal tunnel syndrome are pain, numbness, and tingling in the distribution of the median nerve (Figure 1), although numbness in all fingers may be a more common presentation.⁴ Symptoms are usually worse at night and can awaken patients from sleep. To relieve the symptoms, patients often "flick" their wrist as if shaking down a thermometer (flick sign).

FIGURE 1. Innervation of the hand (palmar and dorsal views).

In patients with carpal tunnel syndrome, pain and paresthesias may radiate to the forearm, elbow, and shoulder. Decreased grip strength may result in loss of dexterity, and thenar muscle atrophy may develop if the syndrome is severe. Although one hand typically has more severe symptoms, both hands often are affected.

Nonspecific flexor tenosynovitis is the most common cause of carpal tunnel syndrome. However, many conditions, including aberrant anatomy, infections, inflammatory diseases, and metabolic disorders, can cause or exacerbate the syndrome (Table 1).^5,6

Diagnosis

One systematic review⁷ evaluated the effectiveness of findings from the history and physical examination in predicting positive nerve conduction studies. The most highly predictive findings were symptom location (i.e., a classic or probable pattern marked on hand symptom diagrams), hypalgesia (diminished sensitivity to pain along the palmar aspect of the index finger), and weak thumb abduction.

The principal clinical tests for carpal tunnel syndrome are Phalen's maneuver and Tinel's sign. Phalen's maneuver is positive when flexing the wrist to 90 degrees for one minute elicits symptoms in the median nerve distribution. Tinel's sign is positive when tapping over the carpal tunnel elicits symptoms in the distribution of the median nerve. Sensory findings in carpal tunnel syndrome also may be elicited by two-point discrimination, vibration, and monofilament testing.

TABLE 1 Causes and Contributing Factors in Carpal Tunnel Syndrome Aberrant anatomy Anomalous flexor tendons Congenitally small carpal canal Ganglionic cysts Lipoma Proximal lumbrical muscle insertion Thrombosed artery Infections Lyme disease Mycobacterial infection Septic arthritis Inflammatory conditions Connective tissue disease Gout or pseudogout Nonspecific flexor tenosynovitis* Rheumatoid arthritis Metabolic conditions Acromegaly Amyloidosis Diabetes Hypothyroidism or hyperthyroidism Increased canal volume Congestive heart failure Edema Obesity Pregnancy *--Most common cause of carpal tunnel syndrome. Adapted with permission from Von Schroeder HP, Botte MJ. Carpal tunnel syndrome. Hand Clin 1996;12:644, with additional information from Stevens JC, Beard CM, O'Fallon WM, Kurland LT. Conditions associated with carpal tunnel syndrome. Mayo Clin Proc 1992;67:541-8.

Whether carpal tunnel syndrome is a clinical or electrophysiologic diagnosis remains somewhat controversial. In one study of 2,466 persons in a general population,² 354 (14.4 percent) reported pain, numbness, or tingling in the distribution of the median nerve. Nerve conduction studies confirmed the presence of median nerve neuropathy in approximately 45 percent of these symptomatic patients. Interestingly, nerve conduction studies were negative in almost one third of "clinically certain" patients but positive in nearly one third of "clinically uncertain" patients. Of the 125 asymptomatic patients who were examined (control group), 23 (18.4 percent) were found to have median nerve neuropathy on nerve conduction testing.

Consensus committees from the American Academy of Neurology, American Association of Electrodiagnostic Medicine, and American Academy of Physical Medicine and Rehabilitation recognize nerve conduction studies as the diagnostic standard for carpal tunnel syndrome.^7,8

Treatment

GENERAL MEASURES

Patients with carpal tunnel syndrome often have bilateral symptoms, but one hand tends to be more significantly affected.

Patients with carpal tunnel syndrome should avoid repetitive wrist and hand motions that may exacerbate symptoms or make symptom relief difficult to achieve. If possible, they should not use vibratory tools (e.g., jackhammers, floor sanders), because the motion of these tools can make their symptoms worse.⁶

Ergonomic measures to relieve symptoms depend on the motion that needs to be minimized. Patients who work on computers, for example, may benefit from improved wrist positioning or the use of wrist supports, although the latter is controversial. Wrist splints may be helpful for patients in other professions that require repetitive wrist motion.

In addition to wrist splinting, conservative treatments include oral corticosteroid therapy and local corticosteroid injections. Approximately 80 percent of patients with carpal tunnel syndrome initially respond to conservative treatment; however, symptoms recur in 80 percent of these patients after one year.⁹

One group of investigators developed an approach that uses risk factors to predict the likelihood of success for conservative treatment of carpal tunnel syndrome (Figure 2).¹⁰ Surgery should be considered when carpal tunnel syndrome does not respond to conservative measures.

Predicting the Outcome of Conservative Treatment for Carpal Tunnel Syndrome Score 1 point for each "yes" answer and zero for each "no" answer. See the scoring key for the predicted successful outcome of conservative treatment.* 1. Have symptoms been present for more than 10 months? Yes _____ No _____ 2. Does the patient have constant paresthesias? Yes _____ No _____ 3. Does the patient have flexor tenosynovitis ("triggering" of the digits)? Yes _____ No _____ 4. Is Phalen's maneuver positive within less than 30 seconds? Yes _____ No _____ 5. Is the patient older than 50 years? Yes _____ No _____ SCORING KEY: zero points = 65% success rate; 1 point = 41.4% success rate; 2 points = 16.7% success rate; 3 points = 6.8% success rate; 4 or 5 points = 0% success rate. *--Outcome rates are based on the use of wrist splinting and nonsteroidal anti-inflammatory drugs; success rates may be higher with oral corticosteroid therapy or local corticosteroid injection. FIGURE 2. An approach to predicting the outcome of conservative treatment in patients with carpal tunnel syndrome. Adapted with permission from Kaplan SJ, Glickel SZ, Eaton RG. Predictive factors in the non-surgical treatment of carpal tunnel syndrome. J Hand Surg [Br] 1990;15:108.

WRIST SPLINTS

Splinting the wrist at a neutral angle helps to decrease repetitive flexion and rotation, thereby relieving mild soft tissue swelling or tenosynovitis. Splinting is probably most effective when it is applied within three months of the onset of symptoms.¹¹

The optimal splinting regimen depends on the patient's symptoms and preferences. Nightly splint use is recommended to prevent prolonged wrist flexion or extension.¹² When worn at night for four weeks, a specially designed wrist brace was found to be more effective than no treatment in relieving the symptoms of carpal tunnel syndrome (Figure 3).¹³ This brace has not yet been compared with traditional splints.

Some patients choose to wear a wrist splint all of the time. Compared with nighttime-only splint use, full-time use has been shown to provide greater improvement of symptoms and electrophysiologic measures; however, compliance with full-time use is more difficult.¹⁴ [Evidence level B, uncontrolled trial]

FIGURE 3. Manu hand brace for the conservative treatment of carpal tunnel syndrome (palmar and dorsal views). This specially designed brace provides gentle pressure to the heads of the metacarpal bones while stretching the third and fourth fingers.

TABLE 2 Randomized Controlled Trials of Oral Medications in the Treatment of Carpal Tunnel Syndrome The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

ORAL MEDICATIONS

Diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), pyridoxine (vitamin B₆), and orally administered corticosteroids have been used with varying degrees of success in patients with carpal tunnel syndrome. Unfortunately, few high-quality trials have evaluated these treatments.

Nerve conduction studies are the recognized diagnostic standard for carpal tunnel syndrome.

A recent systematic review¹⁵ of conservative treatments for carpal tunnel syndrome found 14 randomized controlled trials (RCTs), including five trials of oral medications (Table 2).^15-20 The authors concluded that NSAIDs, diuretics, and pyridoxine are no more effective than placebo in relieving the symptoms of carpal tunnel syndrome.¹⁵ [Evidence level A, systematic review of RCTs] Nevertheless, some investigators²¹ recommend NSAID therapy as an adjunct to wrist splinting and ergonomic adjustments in patients with mild to moderate carpal tunnel syndrome.

Orally administered corticosteroids have been shown to be more effective than NSAIDs or diuretics in the short-term treatment of carpal tunnel syndrome. The optimal corticosteroid dosage remains to be determined. In one prospective, randomized, double-blind, placebo-controlled trial (73 patients), global symptom scores for carpal tunnel syndrome were significantly improved at two weeks and four weeks in patients randomized to receive prednisolone in a dosage of 20 mg per day for two weeks, followed by 10 mg per day for two weeks.¹⁷ [Evidence level B, lower quality RCT] No major adverse effects were noted. The study also found that NSAIDs and diuretics conferred no greater benefit than placebo.

LOCAL INJECTION

Combined injection of a corticosteroid and a local anesthetic into or proximal to the carpal tunnel can be used in patients with mild to moderate carpal tunnel syndrome. Such injections can be diagnostic as well as therapeutic. While most studies evaluating local injection have been retrospective or uncontrolled, two recent systematic reviews of RCTs concluded that local corticosteroid injection provides greater clinical improvement at one month compared with placebo.^15,22 [References 15 and 22--Evidence level A, systematic reviews of RCTs]

A randomized, double-blind trial²³ compared oral corticosteroid therapy and local corticosteroid injection in 60 patients with electrophysiologically confirmed carpal tunnel syndrome. In this study, 30 patients were treated with local injection of 15 mg of methylprednisolone plus oral placebo; the other 30 patients received 25 mg of orally administered prednisolone for 10 days plus a saline injection. Mean global symptom scores for the two groups did not differ significantly at two weeks. At eight and 12 weeks, however, significant improvement was evident only in the methylprednisolone injection group.

A traditional method for direct injection into the carpal tunnel is shown in Figure 4. Alternatively, injection can be accomplished by advancing the needle through the flexor retinaculum using a perpendicular approach.^24,25

FIGURE 4. Method of injecting directly into the carpal tunnel. After the hand is positioned on a rolled towel, a mixture of 10 to 20 mg of lidocaine (Xylocaine) without epinephrine and 20 to 40 mg of methylprednisolone acetate (Depo-Medrol) or similar corticosteroid preparation is injected with a 25-gauge needle at the distal wrist crease (or 1 cm proximal to it). Injection occurs along the right side of the palmaris longus tendon, which can be identified by having the patient pinch the thumb and fifth fingers together while slightly flexing the wrist. If the palmaris longus tendon cannot be identified, the needle is inserted slightly ulnar to the midline. The needle is angled downward at a 45-degree angle toward the tip of the middle finger and advanced 1 to 2 cm as it traverses the flexor retinaculum. Discomfort in the fingers should prompt repositioning of the needle.

FIGURE 5. Method of injecting proximal to the carpal tunnel. Using a 3-cm-long, 0.7-mm needle introduced at a 10- to 20-degree angle, a mixture of 10 mg of lidocaine (Xylocaine) and 40 mg of methylprednisolone is injected at the distal wrist crease between the tendons of the palmaris longus and flexor carpi radialis muscles. The mixture is introduced as a bolus and massaged toward the carpal tunnel. The needle should be advanced slowly and repositioned if resistance is encountered or the patient reports pain or paresthesias in the fingers.

Direct injection into the carpal tunnel by either method carries the potential for needle injury to the median nerve, intratendinous injection and tendon rupture, or dysesthesias (secondary to intrafascicular injection) that may persist for months.²⁶ An alternative approach is to place the injection proximal to the carpal tunnel, rather than directly in it (Figure 5). This approach lowers the risk of damage to the median nerve and theoretically treats concomitant swelling at the volar side of the forearm. With any method, injection of corticosteroid into the median nerve must be avoided.

Clinical trials in patients with carpal tunnel syndrome have shown that oral corticosteroid therapy, local injection of a corticosteroid plus an anesthetic, and ultrasound therapy provide greater symptom relief than placebo.

In one double-blind, placebo-controlled trial,²⁷ 60 patients older than 18 years with electrophysiologically confirmed carpal tunnel syndrome and symptoms for longer than three months were randomized to receive 10 mg of lignocaine (lidocaine) or 10 mg of lignocaine plus 40 mg of methylprednisolone. In all patients, the injection was administered proximal to the carpal tunnel. Improvement was defined as no symptoms or minor symptoms requiring no further treatment. At
one month, symptoms were improved in 23 (77 percent) of the 30 patients in the corticosteroid-treated group compared with six (20 percent) of the 30 patients in the control group (P <.001); the number needed to treat was 1.8.²⁷ [Evidence level A, RCT] No side effects were reported. Superior symptom relief for corticosteroid injection compared with placebo (lignocaine only) injection was not adequately demonstrated beyond one month of follow-up. All injections in the study were performed by one neurologist, which may limit the reproducibility of the results.

Splinting is generally recommended after local corticosteroid injection.^5,25 If the first injection is successful, a repeat injection can be considered after a few months.⁹ Surgery should be considered if a patient needs more than two injections.⁹ While a poor response to local corticosteroid injection does not predict a poor surgical result, a favorable response has been associated with a satisfactory surgical outcome.⁵

ULTRASOUND THERAPY

Ultrasound therapy may be beneficial in the longer term management of carpal tunnel syndrome. A double-blind, randomized trial²⁸ found that compared with "sham ultrasound" treatment (control), 20 sessions of carpal tunnel ultrasound therapy administered over approximately seven weeks resulted in significantly greater improvement of symptoms at two weeks, seven weeks, and six months. However, a smaller study showed no benefit for this treatment.²⁹ More studies are needed to confirm the usefulness of ultrasound therapy for carpal tunnel syndrome.

Both open and endoscopic carpal tunnel release procedures are effective. Whether endoscopic surgery allows an earlier return to work and activities of daily living remains unclear.

Additional randomized trials comparing conservative therapies for carpal tunnel syndrome would be useful in helping physicians select appropriate treatments for individual patients.

SURGERY

Carpal tunnel release surgery should be considered in patients with symptoms that do not respond to conservative measures and in patients with severe nerve entrapment as evidenced by nerve conduction studies, thenar atrophy, or motor weakness. It is important to note that surgery may be effective even if a patient has normal nerve conduction studies.^30,31

Two thirds of a community-based cohort of patients who underwent carpal tunnel release reported being completely or very satisfied with the outcome at six, 18, and 30 months after surgery.³² A recent study³³ showed that open carpal tunnel release resulted in better outcomes than wrist splinting.

Carpal tunnel release surgery is an outpatient procedure that is performed using regional anesthesia. The traditional surgical approach uses a long palmar curvilinear incision to facilitate division of the transverse carpal ligament and its overlying structures. Endoscopic carpal tunnel release is a newer procedure that allows division of the transverse carpal ligament with the overlying structures left intact. Use of this procedure purportedly lessens scar formation and allows an earlier return to work and activities of daily living. The wrist is generally splinted for three to four weeks after surgery.

One systematic review³⁴ found equal effectiveness for endoscopic and open surgical techniques in relieving the symptoms of carpal tunnel syndrome, but conflicting evidence on whether endoscopic surgery allows an earlier return to work or other activities. Four studies in the review demonstrated earlier return to activity after endoscopic carpal tunnel release, whereas three studies demonstrated no difference between the techniques.

Complications of surgery include injury to the palmar cutaneous or recurrent motor branch of the median nerve, hypertrophic scarring, laceration of the superficial palmar arch, and tendon adhesion.²⁵ Postoperative infection, hematoma, arterial injury, stiffness, and reflex sympathetic dystrophy are other possible complications.²¹ If carpal tunnel release is incomplete, symptoms may recur.

Incorrect or incomplete diagnosis may be a factor in explaining unsuccessful carpal tunnel release surgery. The strongest predictors of an unfavorable surgical outcome are poor scores on patient-reported measures of upper extremity function and mental health status, compensation action connected to carpal tunnel syndrome that involves an attorney, and alcohol use.³²

PREGNANCY

Alterations in fluid balance may predispose some pregnant women to develop carpal tunnel syndrome. Symptoms are typically bilateral and first noted during the third trimester. Conservative measures are appropriate, because symptoms resolve after delivery in most women with pregnancy-related carpal tunnel syndrome.³⁵

The author indicates that he does not have any conflicts of interest. Sources of funding: none reported.

The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the U.S. Naval Medical Department or the U.S. Naval Service at large.

Members of various family practice departments develop articles for "Practical Therapeutics." This article is one in a series coordinated by the Department of Family Medicine at Naval Hospital, Jacksonville, Fla. Guest editor of the series is Anthony J. Viera, LCDR, MC, USNR.

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The Author

ANTHONY J. VIERA, LCDR, MC, USNR, is a staff family physician in the family practice residency program at Naval Hospital, Jacksonville, Fla., and assistant professor of family medicine at the Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine, Bethesda, Md. Dr. Viera received his medical degree from the Medical University of South Carolina College of Medicine, Charleston, and completed a family practice residency at Naval Hospital, Jacksonville.

Address correspondence to Anthony J. Viera, LCDR, MC, USNR, Family Practice Department, Naval Hospital, 2080 Child St., Jacksonville, FL 32214. Reprints are not available from the author.

source : http://www.aafp.org/

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BAYI DAN DIARE

MENDADAK Tidak PUP

Perlukah dikhawatirkan?

Baru-baru ini Mirna mengkhawatirkan bayinya yang baru berusia 4 bulan. Pasalnya, kebiasaan buang air besar (BAB) si kecil mendadak jadi tidak beraturan. Minggu lalu BAB dilakukan setiap 3 hari. Selanjutnya jadi setiap 5 hari. Malah sekarang sudah seminggu belum juga BAB. Aduh, kenapa, ya? Benar enggak sih kalau kata orangtua dulu apa yang dimakan bayi akan jadi 'daging'? Apakah normal dan sampai berapa lama masih bisa ditoleransi? DITUNGGU 10 HARI Kekhawatiran ibu seperti itu memang wajar. Namun, sebetulnya, asalkan si bayi terlihat enjoy (tenang-tenang saja) berat badannya bertambah, menyusunya tetap baik, tidak rewel, tidak kembung, dan tidak sering menangis ibu tak perlu khawatir. Justru asal tahu saja, kegelisahan ibu yang berlebihan dapat menyebabkan BAB bayi terganggu, sebab saat menyusui kondisi psikologis yang dialami ibu dapat dirasakan oleh bayi yang pada akhirnya memengaruhi mekanisme fisiologis BAB-nya. Lagi pula, frekuensi BAB bayi yang mendapat ASI eksklusif masih bisa ditoleransi hingga 10 hari. Frekuensi ini sangat dipengaruhi pergerakan makanan dari mulut ke anus yang semakin ke bawah semakin melambat. Waktu transit makanan di dalam perut sampai kembali keluar, pada bayi usia 1-3 bulan lamanya sekitar 8,5 jam. Lantaran itulah frekuensi BAB bayi usia ini paling lama bisa mencapai 4-6 kali sehari. Sedangkan pada bayi 4-24 bulan, waktu transit makanannya bertambah menjadi 16 jam dan pada usia 3-13 tahun waktunya mencapai 26 jam. Barulah pada saat dewasa menjadi 48 jam. Ini menjawab mengapa frekuensi BAB bayi yang sebelumnya lancar menjadi makin jarang. Dengan adanya waktu transit yang lebih panjang, proses penyerapan zat-zat makanan jadi lebih optimal. Makanan yang masuk ke dalam usus halus setelah diproses dalam bentuk encer kemudian akan masuk ke usus besar. Nah, selama berproses di usus besar sampai ke anus, di situ terjadi kembali penyerapan (reabsorbsi). Pada akhirnya terkumpullah sisa penyerapan makanan dalam bentuk tinja dengan konsistensi agak padat namun tetap lunak dengan warna antara kuning, cokelat atau agak kehijauan. Jadi, kalau orangtua dulu bilang, "Makanannya diserap jadi daging," ya ada benarnya. Namun dalam arti yang tidak berlebihan, lo, karena banyak faktor yang memengaruhi proses penyerapan zat-zat makanan. Sepanjang tak ada keluhan pada bayi, meski belum juga BAB maka ditunggu saja. Ciptakan suasana relaks, bebas dari kekhawatiran. KAPAN DIWASPADAI? BAB yang semakin jarang tak bisa didiamkan bila disertai tanda-tanda ketidaknormalan. Misal, disertai muntah, perut kembung, sering menangis atau rewel, bila diraba perutnya terasa keras, ada darah pada tinjanya, berat badan tidak naik pada bulan berikutnya, atau tanda-tanda lain yang mencurigakan. Perhatikan pula bagaimana frekuensi BAB serta bagaimana bentuk tinjanya. Tinja yang berbentuk bulat-bulat kecil menandakan ada timbunan tinja di dalam usus besarnya. Hal ini sebagian besar disebabkan oleh gangguan fungsional, misalnya bayi menahan keinginan BAB karena pernah punya pengalaman sakit akibat feses atau tinja yang keras. Sebagian kecil lainnya bisa disebabkan kelainan organik, seperti penyempitan rektum (penyakit Hirschsprung) atau lubang dubur terlalu ke depan. Keadaan ini sering diselingi dengan keluarnya tinja encer sedikit-sedikit. Dengan demikian, gangguan sembelit yang sifatnya fungsional dapat dipengaruhi oleh faktor asupan seperti komposisi makanan dan jumlah cairan yang masuk, dan faktor psikologis. Namun begitu, terlambat BAB pun bisa diawali oleh masalah teknis. Jika bayi tidak menguasai teknik mengedan yang benar, ia tidak akan menghasilkan dorongan yang dapat mengeluarkan tinjanya. Pada kasus seperti ini, orangtua tidak perlu kawatir, karena bayi akan belajar sendiri bagaimana mengedan yang benar HINDARI PENCAHAR Tanpa gejala sakit yang mencurigakan, bayi tidak dianjurkan diberi obat pencahar karena dikhawatirkan justru akan mengganggu mekanisme fisiologis normal BAB-nya. Bayi juga berisiko mengalami ketergantungan pada perangsang BAB ini. Jadi tak perlu menginterupsinya dengan obat-obatan kecuali dokter memberikan dengan pertimbangan tertentu. Itu pun dengan catatan tidak terlalu sering dan lama. Untuk bayi yang usianya sudah melewati 6 bulan, tinjanya yang keras dapat dilunakkan dengan mempersering pemberian buah pepaya lumat. Pepaya membantu melunakkan tinja. Buah yang tidak dianjurkan adalah pisang karena dapat memperkeras tinja. Selain buah, berikan juga makanan berserat lainnya seperti sayuran dan serealia. Minyak nabati dari jagung dan kacang pun dapat membantu melancarkan buang air besar. Penggunaan minyak sumber asam lemak tak jenuh ini dapat menambah gurih makanannya. Campurkan dengan bubur atau timnya, antara 1/2 sampai 1 sendok teh. BAB BERDARAH Tinja bayi berdarah? Jangan panik. Cobalah lihat kembali, karena bisa saja itu bukan darah. Makanan seperti tomat atau wortel yang tidak tercerna dengan baik membuat tinja keluar dengan warna merah-merah menyerupai bercak darah. Kalaupun memang benar darah, perhatikan bagaimana lokasi darah tersebut. Ada bermacam kemungkinan penyebab BAB berdarah, antara lain: * Darah segar dan tampak berada di bagian luar tinja. Biasanya dikarenakan ada luka di anus (fissura ani). Tinja keras akan menimbulkan gesekan keras dengan permukaan anus. Darah pada luka tersebut kemudian terbawa oleh tinja. * Darah segar yang keluar menetes. Jika darah menetes dari dalam anus setelah tinja keluar, kemungkinan terdapat luka pada anus atau ada polip di usus besar yang tergesek dan mengalami perdarahan. Lihatlah bagian anus bayi untuk memastikan ada tidaknya luka. Jika tidak ada, kemungkinan terdapat polip yang letaknya lebih dalam lagi. Tentu saja BAB berdarah ini perlu dikonsultasikan pada dokter. * Darah bercampur lendir yang ada pada tinja. Berbeda dengan kedua gangguan BAB berdarah tadi, perdarahan yang disertai lendir ini disertai rasa mulas. Tandanya, yaitu bayi rewel saat BAB. Setelah feses keluar biasanya rasa mulas akan hilang. Kemungkinan bayi terkena disentri amuba atau baksiler. Namun, pada bayi yang mendapat ASI, kemungkinan terjadi disentri sangatlah kecil. Penyakit ini umumnya berjangkit di lingkungan yang kurang bersih atau karena peralatan makan dan makanannya tidak higienis. Bila dipastikan karena disentri, biasanya dilakukan pemberian antibotik untuk 7-10 hari. TINJA CAIR Tak SELALU DIARE Konsistensi tinja "bayi ASI" sering kali berbentuk cair dibandingkan bayi susu formula yang konsistensi tinjanya agak lebih padat. Artinya, tinja bayi yang cair tak selalu merupakan diare. Tinja pada kasus diare bentuknya memang cair tetapi biasanya disertai busa karena adanya gas. Dubur bayi tampak kemerahan karena teriritasi cairan tinja berzat asam tadi. Frekuensi BAB pun jadi semakin sering. Diare sebagian besar disebabkan oleh infeksi virus (rotavirus). Virus menyebabkan lesi/kerusakan pada jonjot-jonjot usus halus bayi. Akibatnya enzim laktase akan berkurang dan proses pencernaan serta penyerapan laktosa terganggu. Inilah yang menimbulkan diare. Pemberian ASI pada bayi diare tetap harus diteruskan. Dalam ASI terkandung zat-zat yang dapat memperbaiki kerusakan pada usus. Sedangkan bayi yang mendapatkan susu formula sebaiknya menghindari kandungan laktosa selama diare. Dedeh Kurniasih. Ilustrator Pugoeh Konsultan Ahli: dr. Hadjat S. Digdowirogo, Sp.A dari RS Medika Permata Hijau, Jakarta

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TERAPI EPILEPSI DAN DIET KETOGENIK

• Kejang grand mal , yaitu jenis epilepsi yang paling banyak terjadi. Pasien yang megalami serangan tiba-tiba jatuh, kejang, napas terengah-engah, dan keluar air liur. Beberapa pasien umumnya ngompol atau menggigit lidah. Serangan terjadi beberapa menit kemudian diikuti lemah, bingung, sakit lepala, atau tertidur.
• Kejang petit mal, umumnya terjadi pada anak-anak atau awal remaja. Pasien tiba-tiba melotot atau mata berkedip-kedip dengan kepala terkulai. Serangan hanya terjadi beberapa detik dan bahkan sering tidak disadari.
• Kejang myoclonic, biasanya terjadi pagi hari setelah bangun tidur berupa sentakan sesaat secara tiba-tiba. Kejang ini dapat dialami oleh penderita epilepsi maupun orang normal/sehat.
• Kejang atonic, merupakan jenis serangan yang paling jarang terjadi. Pasien tiba-tiba jatuh, dan pulih kembali beberapa saat kemudian.

Diet ketogenik adalah diet dengan kandungan tinggi lemak dan rendah karbohidrat dan protein sehingga memicu keadaan ketosis.

Diet ini mengandung 2-4 gram lemak untuk setiap kombinasi 1 gram karbohidrat dan protein. Diet ketogenik biasanya digunakan sebagai terapi dari epilepsi. Melalui diet ketogenik, lemak menjadi sumber energi dan keton terakumulasi di dalam otak sehingga menjadi tinggi kadarnya (ketosis).

Keadaan ketosis ini dipercaya dapat menghasilkan efek antikonvulsi, yang dapat mengurangi simptom epilepsi dengan mengurangi frekuensi dan derajat kejang, meskipun bagaimana mekanisme biokimia peristiwa ini belum diketahui dengan pasti. Pada anak-anak diet ini dirasakan lebih efektif dibandingkan orang dewasa, khususnya pada saat obat antikolvusan tidak bekerja secara efektif atau menjadi kontraindikasi.

Makanan yang digunakan dalam diet ini memanfaatkan produk trigliserida dengan kandungan tinggi (mentega, krim, mayonais) dan kacang. Kandungan karbohidrat yang terdapat dalam makanan dan minuman dikurangi untuk menambah efek akumulasi keton. Diet ketogenik sebenarnya telah lama ditemukan yaitu pada sekitar tahun 1930-an; tetapi sejak diketemukannya phenytoin pada tahun 1938, diet ini semakin jarang digunakan. Pada tahun 1990-an diet ini dikembangkan dan diimplementasikan kembali pada klinik Mayo dan Fakultas Kedoketran John Hopkins.

Diet ketogenik merupakan alternatif terapi khususnya pada anak-anak dengan gangguan kejang yang tidak terkendali. Diet harus dilakukan dengan hati-hati dan dibawah pengawasan ahli gizi. Pada diet ketogenik ini hingga 90% sumber kalori dapat diberikan dalam bentuk lemak, dengan asupan protein tidak lebih dari 1g /kg berat badan dan minimal karbohidrat. Rasio standar dari kalori lemak berbanding karbohidrat dan protein adalah 4:1, pada anak-anak yang usianya lebih muda dan remaja rasio bisa menjadi 3:1 hal ini dikarenakan karena mereka dalam usia pertumbuhan sehingga diperlukan asupan protein lebih banyak. Cairan yang masuk dibatasi hingga 80% dari asupan biasa dan vitamin dan mineral harus diberikan dalam bentuk suplemen.

Berdasarkan studi yang telah dilakukan oleh Fakultas Kedokteran John Hopkins yang melibatkan 150 pasien anak-anak dengan gangguan kejang tidak terkontrol dilaporkan terjadi penurunan serangan setelah pasien menjalani diet ketogenik ini.

Yang banyak menjadi pertanyaan adalah: Apakah diet ini tidak akan mengganggu pertumbuhan dan berat badan anak (anak menjadi obese karena makan tinggi lemak)?

Hasil menunjukkan bahwa anak-anak tetap tumbuh dalam batas-batas yang normal. Efek samping yang mungkin muncul akibat diet ketogenik jangka panjang adalah konstipasi, batu ginjal (6-7%); biasanya dalam bentuk kalsium sitrat atau asam urat, turunnya berat badan, dehidrasi, hipekolesterolnemia dan penipisan tulang (oleh karenanya pada diet ini bisanya ditambahkan preparat vitamin D dan kalsium).

Kesuksesan dari diet ini memungkinkan penurunan dosis antikonvulsi yang berarti dapat menurunkan risiko efek samping dari pemakaian obat tersebut, sehingga diet ketogenik dapat dipertimbangkan sebagai terapi alternatif dalam mengontrol serangan kejang khususnya pada anak-anak dengan epilepsi karena selain efektif juga dengan baik dapat ditoleransi (www.padusi.com ).

Problems on epilepsy do not only depend on itself but also on management and drug regimens. Optimal therapy selection is very important to yield optimal therapy effect and to prevent side effect due to longterm therapy. Phenytoin, carbamazepine and valproic are the first line drugs for general tonic clonic and parsial epilepsy. The aim of this study is to determine whether there are any different effects of monotherapy of phenytoin, carbamazepine, and valproic in pediatric general tonic clonic and partial epilepsy. A historical cohort study is conducted on children who were between one month until 18 years old and have been diagnosed general tonic clonic or parsial epilepsy and have been given phenytoin, carbamazepine or valproic therapy routinely
for more than two years in Sardjito hospital. The sample size are 41. The main outcome is time of 12 month remission and the secondary outcome are withdrawal from treatment, time to remission, side effects and cured. We found 175 medical records between January 2000 and May 2007 that agree to inclusion criteria , 21 were excluded. Thus, 154 of medical records role in the study, 65 to phenitoin group, 47 to carbamazepin group and 42 to valproat group. Valproat increased the possibility of 12 month remission (RR 2.66 95%CI 1.06-6.65) when compared to phenitoin, but carbamazepin did not (RR 1.47 95%CI 0.66-3.28). Survival analysis of valproat was better than carbamazepin (p=0.042) and phenitoin (p=0.007). There are not significant difference among groups in the result of withdrawal from treatment, time to remission and cured variables. The side effects of valproat seem less than others. Valproat increased the possibility of 12 month remission when compared to carbamazepin and phenitoin as monotherapy in pediatric general tonic clonic and partial epilepsy without increasing side effects. Carbamazepin have similar effects of therapy to phenitoin .

PERBANDINGAN EFEK TERAPI FENITOIN, KARBAMAZEPIN DAN

VALPROAT SEBAGAI MONOTERAPI PADA ANAK DENGAN EPILEPSI

GENERAL TONIK KLONIK DAN EPILEPSI PARSIAL

Permasalahan pada epilepsi tidak hanya tergantung dari faktor penyakit

epilepsinya itu sendiri, tetapi juga akibat dari terapi yang diberikan. Pemilihan obat

yang tepat sangat penting untuk mendapatkan efek terapi yang optimal dan

menghindari efek samping yang tidak diinginkan. Fenitoin, karbamazepin maupun

valproat adalah anti epilepsi pilihan pertama untuk epilepsi general tonik klonik dan

epilepsi parsial. Pemilihan obat pertama sebagai terapi epilepsi masih beragam.

Tujuan penelitian ini untuk mengetahui apakah ada perbedaan efek terapi

fenitoin, karbamazepin, dan valproat sebagai monoterapi pada anak dengan epilepsi

general tonik-klonik maupun epilepsi parsial.

Penelitian ini adalah suatu penelitian kohort retrospektif yang dilakukan pada

data rekam medis anak umur 1 bulan sampai 18 tahun dengan diagnosis epilepsi

general tonik klonik atau epilepsi parsial yang mendapatkan terapi fenitoin,

karbamazepin atau valproat lebih dari 2 tahun di RSUP dr Sardjito. Sampel yang

diperlukan 41. Luaran utama yang dinilai adalah lamanya bebas kejang 12 bulan, dan

luaran sekunder yaitu gagal pengobatan, lamanya kejang terakhir setelah terapi,

timbulnya efek samping dan kesembuhan.

Didapatkan 175 rekam medis dengan data lengkap, 21 dieksklusi dan 154

diikutsertakan dalam penelitian. Terdiri dari 65 dari kelompok terapi fenitoin, 47

karbamazepin dan 42 valproat. Valproat meningkatkan kemungkinan tercapainya

bebas kejang 12 bulan dengan RR 2.66 95%CI 1.06-6.65 dibandingkan dengan

fenitoin, tetapi karbamazepin tidak (RR 1.47 95%CI 0.66-3.28). Dengan analisis

kesintasan bebas kejang 12 bulan didapatkan valproat lebih baik dibanding

karbamazepin (p=0.042) maupun fenitoin (p=0.007). Tidak ada perbedaan bermakna

diantara ketiganya pada kegagalan pengobatan dan kesembuhan dengan efek samping

hampir sama.

Kesimpulannya adalah valproat meningkatkan kemungkinan tercapainya

bebas kejang 12 bulan dibandingkan dengan fenitoin dan karbamazepin sebagai

monoterapi pada anak dengan epilepsi general tonik klonik maupun epilepsi parsial

tanpa peningkatan efek samping, sedangkan karbamazepin mempunyai efek yang

tidak berbeda bila dibanding dengan fenitoin. (dr.Muchamad Budi Nugroho )

Isnatin Miladiyah

Dep. Farmakologi FK UII

ANTIKONVULSAN

Blok Sistem Saraf

Kejang (konvulsi)

• Suatu episode disfungsi neurologik karena aktivitas sel-sel saraf yang abnormal
• Manifestasi umum : perubahan kesadaran dan aktivitas motorik abnormal
• Epilepsi (kejang berulang tanpa pemicu jelas) : 1% populasi
• Terapi farmakologik: sangat bermanfaat à catatan: diagnosis akurat dan sesuai klasifikasi kejang

Klasifikasi kejang epilepsi
(International League against Epilepsy)

III. Kejang epileptik tak terdefinisikan

A. 1. Kejang absence

2. Kejang atypical absence

B. Kejang mioklonik

C. Kejang klonik

D. Kejang tonik

E. Kejang tonik-klonik

F. Kejang atonik

II. Kejang umum

A. Kejang parsial sederhana

1. Dengan gejala motorik

2. Dengan gejala somatosensorik atau sensori khusus

3. Dengan gejala otonomik

4. Dengan gejala psikis

B. Kejang parsial kompleks

1. Dimulai dengan kejang parsial sederhana kemudian berkembang ke gangguan kesadaran

2. Dengan gangguan kesadaran sejak pertama kali serangan

I. Kejang parsial (fokal, lokal)

Strategi terapi

• Menghambat aktivitas repetitif – misalnya dengan memblok kanal Na⁺
• Meningkatkan input inhibitorik – misalnya memperkuat GABA
• Menurunkan input eksitatorik – misalnya antagonis glutamat

Klasifikasi Obat
(Berdasarkan Struktur)

1967

Karbamazepin

Antikonvulsan lain

1965

Diazepam, Lorazepam, Klonazepam, Klorazepat

Benzodiazepin

1953

Etosuksimid

Suksinat

1938

Fenitoin

Hidantoin

1914

Fenobarbital, Primidon

Barbiturat

Klasifikasi Obat
(Berdasarkan Mekanisme Kerja)

Levetiracetam

Modulasi protein sinaptik

Etosuksimid, Zonisamide

Modifikasi kanal kalsium

Felbamat, Lamotrigine, Topiramate

Mereduksi glutamat

Karbamazepin, Oxcarbazepine, Fenitoin

Menghambat kanal natrium

Clonazepam, Clorazepat, Lorazepam, Diazepam, Divalproat, Gabapentin, Fenobarbital, Primidon, Tiagabin, Asam valproat

Memperkuat GABA

Contoh

Klas Obat

Obat untuk

Partial Seizures atau Generalized Tonic-Clonic

Fenitoin

• Obat generasi lama, digunakan luas
• Mekanisme tidak pasti, diduga mempengaruhi kanal Na⁺
• Dalam bentuk oral dan i.v.
• Farmakokinetikanya kompleks :
• Absorpsi oral cukup baik, bervariasi
• Ikatan protein tinggi
• Metabolisme terutama hepatal

• 
  
• T1/2 22 jam, variasi luas à 2x sehari
• Induktor enzim metabolisme hepar antikonvulsan lain, juga antikoagulan
• Toksisitas oral : nistagmus, ataksia, diplopia, sedasi
• Pemberian lama: hirsutisme, hiperplasia gusi, disfungsi serebelar, neuropati perifer
• Hipersensitivitas: demam, ruam (bisa berlanjut sindroma Steven-Johnson) à hentikan obat

Karbamazepin

• Struktur dan mekanisme aksi: serupa fenitoin
• Hanya bentuk oral
• Farmakokinetika:
• Ikatan protein <>
• Metabolisme hepatal
• T1/2 10-20 jam à 3x/hari, kadang 4x/hr

• 
  
• Toksisitas: ataksia, diplopia, sedasi, hiponatremia, anemia aplastik (jarang)
• Derivat: Oxcarbazepine à efek samping lebih rendah

Barbiturat

• Juga digunakan untuk hipnotik dan anestetik
• Mekanisme aksi: meningkatkan GABA
• Fenobarbital:
• Bentuk oral, i.m., i.v.
• T1/2 panjang (100 jam), metabolisme hepatal, induktor kuat enzim metabolisme hepar
• Sering digunakan pada bayi (jarang pada dewasa karena efek sedasi kuat)
• Primidon:
• Toksisitas sebanding dengan fenobarbital

Asam valproat

• Struktur mengandung gugus karboksilat
• Mekanisme belum jelas
• Bentuk: oral, i.v.
• Metabolisme hepatal, T1/2 8-12 jam, menginduksi enzim hepar
• Efek samping: tremor, kegemukan, nausea
• Hepatotoksik: fatal, terutama pada bayi <>

Obat untuk

Primary Generalized Epilepsy

• 
  
• Etosuksimid
• Drug of choice untuk tipe absence
• Asam valproat
• Efektif untuk kejang umum, selain untuk kejang fokal
• Terutama apabila muncul kejang dengan berbagai tipe

Status Epileptikus

• Benzodiazepin
• Yang sering digunakan: Diazepam dan Lorazepam (karena stabil dan aksi cepat, secara i.v)
• T1/2 biologik panjang, namun durasi aksi pendek karena segera diterminasi (redistribusi)
• Bentuk oral jarang digunakan secara tunggal untuk terapi epilepsi (kadang sebagai terapi tambahan baik fokal maupun generalized)

Panduan Terapi Antikonvulsan

• Perhatikan : tipe kejang dan faktor pencetusnya, usia saat onset kejang pertama, riwayat keluarga, dan adanya abnormalitas pola EEG intraiktal. (Cao dkk, 2001).
• Berikan setelah kejang ke-2. Pemberian pada kejang pertama :
• pasien dengan riwayat keluarga epilepsi
• perubahan epileptiform pada EEG
• adanya cidera pada otak (Kwan, 2001; Simon, 2004).

Panduan Terapi Antikonvulsan
(cont’d)

• Penggunaan awal : monoterapi (terapi tunggal), pilihan pertama adalah fenitoin, karbamazepin, dan asam valproat (Kwan, 2001; Simon, 2004).
• Mulai dengan dosis rendah. Naikkan perlahan-lahan sampai kejang terkontrol atau timbul efek samping (Simon, 2004).
• Gagal satu jenis obat: ganti dengan obat lain sebelum memutuskan untuk memberikan kombinasi dua obat atau lebih (Muggleton, 2001). Pertimbangkan usia pasien, tipe kejang, frekuensi, dan penyebab kejang (Simon, 2004; Muggleton, 2001).

Panduan Terapi Antikonvulsan
(cont’d)

• Pantau kadar obat dalam darah (1-2 kali). Lakukan monitoring: efek samping, interaksi antar obat atau antara antikonvulsan dengan obat lain, dan komplikasi yang mungkin timbul (Simon, 2004).
• Pemberian sampai dua tahun bebas kejang (dua tahun setelah kejang terakhir), terutama pada kasus kejang parsial dan EEG abnormal (Simon, 2004) à antikonvulsan jangka lama : risiko gangguan kognitif dan kejiwaan (Bouma dkk, 2002).

Panduan Terapi Antikonvulsan
(cont’d)

• Tetap tidak berespon terhadap OAE yang telah diberikan (4 atau 5 jenis obat) à pembedahan (juga dilakukan pada pasien epilepsi pada lobus temporalis, di mana sebagian besar tipe kejangnya adalah parsial kompleks) (Simon, 2004).

Referensi

• Bouma, P.A.D., Peters, A.B.C., Brouwer, O.F. 2002. Long-term course of childhood epilepsy following relapse after antiepileptic drug withdrawl. J Neurol Neurosurg Psychiatry 72: 507-510
• Cao, A., Steinberg, I., Gill, M.A. Adult Seizure Disorders : New Antiepileptic Drug Treatments. Jurnal CE, April 2001 : 14-22
• Kwan, P. 2001. Management of Patients with Newly Diagnosed Epilepsy. Epilepsy Quarterly, vol 9 (issue no 2) : 1-18
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