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Botulinum-Neurotoxin in der Behandlung der Spastizität im Erwachsenenalter

Ein interdisziplinärer deutscher 10-Punkte-Konsensus 2010

Botulinum toxin in the treatment of adult spasticity

An interdisciplinary german 10-point consensus 2010

  • Aktuelles aus Diagnostik und Therapie
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Zusammenfassung

Spastizität ist neben Paresen und sensiblen sowie neuropsychologischen Störungen eine wichtige Ursache für funktionell relevante Behinderungen bei Erwachsenen mit Schäden des zentralen Nervensystems. So zeigen bis zu 30% der Patienten nach Schlaganfall im frühen Verlauf bereits eine Spastizität in leichter bis mittlerer Ausprägung, die bei schweren Verläufen mit konsekutiven Beeinträchtigungen des betroffenen Muskel- und Bindegewebes einhergehen kann. Zahlreiche Studien und Metaanalysen belegen, dass lokale Injektionen von Botulinum-Neurotoxin Typ A (BoNT-A) durch eine dosisabhängige Verminderung des Muskeltonus und Verbesserung der passiven Beweglichkeit auch passive Funktionsverbesserungen (z. B. Erleichterung der Pflege und Hygiene) erreichen, gerade auch bei wiederholten Behandlungen. Länderspezifische Unterschiede bei der Zulassung in Europa sowie die oft patientenferne Administration im deutschen Gesundheitswesen erschweren jedoch die Bereitstellung dieser Therapie, sodass eine Aktualisierung von bereits existierenden Positionspapieren erforderlich erscheint. In dieser Stellungnahme wird in Anlehnung an kürzlich erschienene englischsprachige Publikationen eine deutschsprachige interdisziplinäre Aktualisierung in Form eines 10-Punkte-Konsensus zur Verfügung gestellt. Durch Aufarbeitung und Bewertung der existierenden Literatur und Abstimmung mit betroffenen Fachgesellschaften soll die Kommunikation mit Entscheidungs- und Kostenträgern erleichtert werden.

Vor Einleitung einer BoNT-A-Behandlung bei Spastizität sollte auf der Basis einer klinischen Evaluation ein realistisches patientenindividuelles Behandlungsziel vorzugsweise in einem multiprofessionellen Behandlungskontext formuliert werden. Zur lokalen Spastikbehandlung bei Schlaganfallpatienten sind in Deutschland derzeit drei Präparate zugelassen: Botox® (Pharm Allergan, Ettlingen, BRD), Dysport® (Ipsen Pharma, Ettlingen, BRD) und Xeomin® (Merz Pharm., Frankfurt/Main, BRD). Generell konnte die Sicherheit der BoNT-A-Behandlung in einer Metaanalyse nachgewiesen werden. Die Dosierung und Muskelauswahl sollte sich jeweils an den individuellen Symptomen orientieren. Die BoNT-A-Injektion sollte zielgenau, kontrolliert und mit begleitenden Therapien koordiniert erfolgen. Kontrollierte Studien belegen in ausgesuchten Patienten auch funktionell relevante Verbesserungen aktiver Funktionen (Hand- und Armfunktion, Gehen). Kombinationen von BoNT-A mit zeitlich abgestimmten weiteren Maßnahmen wie Redressionen und modernen neurorehabilitativen Therapien zeigen zusätzlich verbesserte Ergebnisse im Vergleich zur alleinigen BoNT-A-Behandlung.

Summary

Spasticity is one of the major causes of functional impairment in adults with lesions of the central nervous system. For instance, approximately 30% of post-stroke patients suffer from different degrees of spasticity with possible consecutive impairments. Numerous studies or meta-analyses showed that local injections of botulinum toxin in spastic muscles lead to dose-dependent reduction in muscle tone and improvement of passive movements (e. g. facilitated care), especially following repeated injections.

However, country-specific regulations and patient-remote administration in German health care often do not allow adequate provision of this therapy. Thus, the present consensus statement based on the EBM analyses of the published international literature tries to highlight recent advances and the standard in the field of local spasticity treatment, aiming to facilitate communication between the decision makers and German reimbursement institutions in health care. Prior to initiation of BoNT-A injections, patient-oriented goals should be identified in a multiprofessional context to assure realistic goals for this specific treatment and patient expectations. In Germany for the treatment of focal spasticity following stroke three products have been approved: Botox® (Pharm Allergan, Ettlingen), Dysport® (Ipsen Pharma, Ettlingen) and Xeomin® (Merz Pharma, Frankfurt/Main). For all preparations safety has been repeatedly shown. Functional improvements have also been illustrated for selected patients concerning hand/arm function and gait. The dose per muscle and the selection of muscles to be injected have to be individualized according to the patient’s symptoms and should be accompanied by modern neurorehabilitative therapies such as redression or repetitive activation of the injected and antagonistic muscles.

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Danksagung

Wir bedanken uns bei Herrn Prof. Dr. Thomas Meyer, Charité-Universitätsmedizin Berlin, Dr. med. Peter Koßmehl, wissenschaftlicher Mitarbeiter in der Arbeitsgruppe von Professor Dr. med. Jörg Wissel, Kliniken Beelitz GmbH sowie Dr. med. Julius Hübl, wissenschaftlicher Mitarbeiter in der Arbeitsgruppe von Prof. Dr. med. Andreas Kupsch, Charité-Universitätsmedizin Berlin.

Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehung hin: Diese Arbeit wurde durch eine nicht zweckgebundene Förderung („unrestricted grant“) von Pharm Allergan Deutschland unterstützt. Die Autoren geben bekannt, dass keine Interessenkonflikte zum Inhalt dieses Konsensuspapiers bestehen.

Alle Autoren dieses Artikels waren als Referenten für die Firmen Ipsen Pharma GmbH, Pharm Allergan GmbH und Merz Pharmaceuticals GmbH tätig.

Darüber hinaus waren Prof. Jörg Wissel, Dr. Mathias auf dem Brinke, Dr. Christoph Herrmann, Dr. Martin Huber und Prof. Dr. Andreas Kupsch als Referenten für die Firma Medtronic GmbH tätig.

Prof. Dr. Jörg Wissel war zusätzlich als Referent und Berater für die Firma Eisai GmbH tätig. Zusätzlich erhielt er eine Förderung für die Durchführung von klinischen Studien und Forschungsprojekten von Ipsen Pharma GmbH, Pharm Allergan GmbH und Merz Pharmaceuticals GmbH sowie von der Stiftung Deutsche Schlaganfallhilfe und dem Bundesministerium für Bildung und Forschung.

Privatdozent Dr. Martin Hecht erhielt weiterhin eine finanzielle Unterstützung für klinische Studien von den Firmen Pharm Allergan GmbH und Merz Pharmaceuticals GmbH.

Dr. Christoph Herrmann erhielt zusätzlich eine finanzielle Unterstützung für die Durchführung von klinischen Studien von den Firmen Ipsen Pharma GmbH, Pharm Allergan GmbH, Merz Pharmaceuticals GmbH und Medtronic GmbH.

Dr. Martin Huber erhielt weiterhin eine finanzielle Förderung für wissenschaftliche Projekte von der Pharm Allergan GmbH.

Dr. Sabine Mehnert erhielt eine finanzielle Förderung für die Durchführung von klinischen Studien von der Pharm Allergan GmbH und der Merz Pharmaceuticals GmbH.

Privatdozentin Dr. Iris Reuter war zusätzlich als Referentin für die Firma GlaxoSmithKline GmbH & Co. KG tätig. Sie erhielt zusätzlich eine finanzielle Förderung für die Durchführung von klinischen Studien von der Pharm Allergan GmbH.

Dr. Axel Schramm ist Referent und erhielt zusätzlich von der Ipsen Pharma GmbH sowie der Pharm Allergan GmbH eine finanzielle Förderung für wissenschaftliche Projekte.

Prof. Dr. Andreas Kupsch war weiterhin als Referent für die Firmen Boehringer Ingelheim Pharma GmbH & Co. KG, GlaxoSmithKline GmbH & Co. KG, Lundbeck GmbH, Merck KGaA, Orion Pharma GmbH und der UCB Pharma GmbH tätig. Von der Firma Pharm Allergan GmbH erhielt er eine finanzielle Förderung für wissenschaftliche Projekte, darüber hinaus wird er von der Deutschen Forschungsgemeinschaft und dem Bundesministerium für Bildung und Forschung unterstützt.

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Authors and Affiliations

  1. Kliniken Beelitz GmbH, Paracelsusring 6 A, 14547, Beelitz-Heilstätten, Deutschland

    J. Wissel

  2. Klinik für Neurologie, Charité-Universitätsmedizin Berlin, Campus Virchow, Berlin, Deutschland

    A. Kupsch

  3. Asklepios Klinken, Bad Wildungen, Deutschland

    M. auf dem Brinke

  4. Neurologische Klinik BKH, Kaufbeuren, Deutschland

    M. Hecht

  5. Asklepios Kliniken Schildautal, Seesen, Deutschland

    C. Herrmann

  6. Therapiezentrum Burgau, Burgau, Deutschland

    M. Huber

  7. Neurologische Klinik, Universitätsklinikum Gießen und Marburg, Gießen und Marburg, Deutschland

    S. Mehnert & I. Reuter

  8. Neurologische Klinik, Universitätsklinikum, Erlangen, Deutschland

    A. Schramm

  9. MVZ – Paracelsusklinik Zwickau, Zwickau, Deutschland

    A. Stenner

  10. Neurologisches Rehabilitationszentrum „Godeshöhe“, Bonn-Bad Godesberg, Deutschland

    C. van der Ven

  11. Krankenhaus Rummelsberg, Rummelsberg, Deutschland

    M. Winterholler

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  1. J. Wissel
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Correspondence to J. Wissel.

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Wissel, J., auf dem Brinke, M., Hecht, M. et al. Botulinum-Neurotoxin in der Behandlung der Spastizität im Erwachsenenalter. Nervenarzt 82, 481–495 (2011). https://doi.org/10.1007/s00115-010-3172-8

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