目的:促肾上腺皮质激素(ACTH)治疗婴儿痉挛(ISs)的局限性,比如高成本,可用性有限,和不良反应(AE),有必要探讨皮质类固醇是否是最佳替代品。由于激素治疗的效果欠佳,许多其他令人信服的治疗方法已经通过了试验。进行了系统评价和荟萃分析,以评估激素治疗对ISs患者的有效性和安全性。
方法:EMBASE,OvidMEDLINE,Cochrane中央对照试验登记册(中央),并在2021年4月之前搜索了在线注册的随机对照试验(RCT).
结果:共纳入19项随机对照试验(N=1,279)。口服皮质类固醇和ACTH在电临床反应中的有效性没有显着差异(风险比[RR]=0.85,95%CI0.41-1.76)。与常规剂量组相比,低剂量ACTH在电临床反应中的有效性相似(RR=0.94,95%CI0.60-1.47),但AE的风险较低(RR=1.71,95%CI1.08-2.71)。对于没有结节性硬化症(TSC)的患者,ACTH在控制痉挛方面比维卡特林(VGB)更有益(RR=1.31,95%CI1.05-1.64)。所有RCT通过网络荟萃分析连接,我们发现生酮饮食(KD),唑尼沙胺,甲基强的松龙,与常规剂量ACTH相比,托吡酯(TPM)或吡哆醇的激素治疗或联合治疗在临床电反应方面没有差异。
结论:我们的分析表明,当ACTH不适用时,口服皮质类固醇可能是可选的替代药物,ACTH对没有TSC的患者更有益。此外,由于比较有效,但AE的风险较低,因此建议使用低剂量ACTH.然而,由于纳入患者和治疗方案的高度异质性,这些结果必须谨慎解释。对于其他替代治疗的可靠评估,需要具有多中心参与和较大样本量的RCT。
OBJECTIVE: The limitations of adrenocorticotrophic hormone (
ACTH) treatment for infantile spasms (ISs), such as high costs, limited availability, and adverse effects (AEs), make it necessary to explore whether corticosteroids are optimal alternatives. Many other compelling treatments have gone through trials due to the suboptimal effectiveness of hormonal therapy. A systematic
review and meta-analysis were performed to evaluate the effectiveness and safety of hormonal therapy for patients with ISs.
METHODS: EMBASE, Ovid MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and online registers were searched through April 2021 for randomized controlled trials (RCTs).
RESULTS: A total of 19 RCTs (N = 1,279) were included. There was no significant difference in the effectiveness of oral corticosteroids and ACTH in electro-clinical response (risk ratio [RR] = 0.85, 95% CI 0.41-1.76). Low-dose
ACTH had similar effectiveness in electro-clinical response compared to usual-dose group (RR = 0.94, 95% CI 0.60-1.47) but conferred a lower risk of AEs (RR = 1.71, 95% CI 1.08-2.71). ACTH was more beneficial in controlling spasms than vigabatrin (VGB) (RR = 1.31, 95% CI 1.05-1.64) for patients without tuberous sclerosis complex (TSC). All RCTs were connected through network meta-analysis, and we found that ketogenic diet (KD), zonisamide, methylprednisolone, or combined treatment of hormonal therapy with topiramate (TPM) or pyridoxine was not different in electro-clinical response compared to usual-dose ACTH.
CONCLUSIONS: Our analysis showed that oral corticosteroids could be optional alternatives when ACTH is not applicable, and
ACTH is more beneficial for patients without TSC. Moreover, low-dose
ACTH is recommended due to comparative effectiveness but lower risk of AEs. However, due to the high heterogeneity of included patients and treatment protocols, these results must be interpreted with caution. RCTs with multicentric involvement and larger sample size are needed for solid evaluation of other alternative treatments.