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Li Q, Chen X, He L, Zhou D
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2009, Issue 3
http://www.thecochranelibrary.com
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACKNOWLEDGEMENTS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 One formula of TCMH versus single Western medication, Outcome 1 Xiaxingci granule versus
phenytoin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.2. Comparison 1 One formula of TCMH versus single Western medication, Outcome 2 Dianxianning pill
versus valproate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.3. Comparison 1 One formula of TCMH versus single Western medication, Outcome 3 Tianmadingxian
capsule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.4. Comparison 1 One formula of TCMH versus single Western medication, Outcome 4 Zhixian I versus
phenytoin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.5. Comparison 1 One formula of TCMH versus single Western medication, Outcome 5 Antiepilepsy capsule
versus phenobarbital. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.6. Comparison 1 One formula of TCMH versus single Western medication, Outcome 6 Incidence of adverse or
harmful effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
1
2
2
3
3
5
8
9
9
10
11
20
21
22
23
24
25
26
26
27
28
28
28
29
29
[Intervention Review]
Contact address: Dong Zhou, Department of Neurology, West China Hospital, Sichuan University, Guo xue xiang No.37, Chengdu,
Sichuan, 610041, China. zhoudong66@yahoo.de.
Editorial group: Cochrane Epilepsy Group.
Publication status and date: New, published in Issue 3, 2009.
Review content assessed as up-to-date: 23 November 2007.
Citation: Li Q, Chen X, He L, Zhou D. Traditional Chinese medicine for epilepsy. Cochrane Database of Systematic Reviews 2009,
Issue 3. Art. No.: CD006454. DOI: 10.1002/14651858.CD006454.pub2.
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ABSTRACT
Background
Seizures are poorly controlled in many people with epilepsy, despite current antiepileptic treatments. Some turn to alternative or
complementary therapy to treat their condition and the use of traditional Chinese medicinal herbs (TCMH) is increasingly popular.
However, it remains unclear whether the existing evidence is rigorous enough to support its use.
Objectives
To determine the effectiveness and safety of traditional Chinese medicine in people with epilepsy.
Search methods
Our search included the Cochrane Epilepsy Groups Specialised Register and the Cochrane Central Register of Controlled Trials
(CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1950 to 2007) and EMBASE (1974 to 2007).
Selection criteria
Randomised controlled trials evaluating traditional Chinese medicine in people of any age with any type of epilepsy, and comparing
one formula of TCM with no intervention, placebo or single Western medicine (monotherapy).
Data collection and analysis
Two review authors independently extracted trial data and assessed quality. We assessed the following outcomes: (a) seizure freedom
for at least one year; (b) 50% or greater reduction in seizure frequency; (c) percentage reduction in seizure frequency and duration; and
(d) adverse events.
Main results
Five short-term studies involving 1125 participants met the inclusion criteria. All the studies were of poor methodological quality and
had a high probability of selection, detection and performance bias.
Two studies assessed seizure freedom for one year. One found no difference between Xiaxingci granule and phenytoin for primary
generalized tonic-clonic seizures (RR 1.00; 95% CI 0.07 to 14.90).The other study found no difference between Dianxianning pill
and valproate (RR 13.00; 95% CI 0.74 to 227.72) for different types of epilepsy.
Traditional Chinese medicine for epilepsy (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Three studies assessed a 50% or greater reduction in seizure frequency. One found an advantage for Tianmadingxian capsule when
compared to phenytoin (RR 1.37; 95% CI 1.23 to 1.53) in different types of epilepsy, the second an advantage for Zhixian I pill when
compared to phenytoin (RR 1.31; 95% CI 1.16 to 1.48) in primary generalized tonic-clonic seizure, and the third an advantage for
an Antiepilepsy capsule when compared to phenobarbital (RR 1.21; 95% CI 1.02 to 1.43) for primary and secondary generalized
tonic-clonic seizure. One study reported the incidence of adverse effects and the Peto odds ratio was 0.04 (99% CI 0.01 to 0.12, P <
0.00001) favouring TCMH compared to phenobarbital.
Authors conclusions
The current evidence is insufficient to support the use of traditional Chinese medicine as a treatment for epilepsy. Much larger, high
quality randomised clinical trials are needed to evaluate the effectiveness and safety of traditional Chinese medicinal herbs for treating
epilepsy.
BACKGROUND
Epilepsy is an important neurological condition, with an estimated
annual incidence of 50 per 100,000 and prevalence of 5 to 10 per
1000 in the developed world (Sander 1996). Approximately 3% of
the population will suffer from epilepsy at some point in their lives
(Hauser 1993). Although the majority of people with epilepsy will
go into remission, up to 30% will become drug-resistant despite
treatment with adequate doses of appropriate antiepileptic drugs
(AEDs) (Cockerell 1995). Their continuing attacks will result in
reduced quality of life, and may also lead to injuries, social isolation and depression (Villeneuve 2004). Hence, there is a constant
search for newer modes of treatment. Many people are turning
to alternative or complementary therapy to treat their condition
and the use of traditional Chinese medicinal herbs is becoming
increasingly popular.
Traditional Chinese medicine (TCM) is a 3000-year old theoretical and methodological holistic system for both the treatment
and prevention of disease (Fulder 1996). TCM has unique theories regarding aetiology, systems of diagnosis and treatment, which
are vital to its practice. TCM herb treatment consists typically of
complex prescriptions of a combination of several components.
The combination is based on Chinese diagnostic patterns (i.e.
inspection, listening, smelling, inquiry and palpation) and has a
completely different rationale compared to many Western drug
treatments (Liu 2000). Historically the Chinese have used traditional Chinese medicinal herbs (TCMH) to treat epilepsy. The first
known document on epilepsy in China appeared in The Huang
Di Nei Ching, written by a group of TCM physicians between
770 and 221 B.C. The description of epilepsy in this book, and
in many others published later, was confined to generalized convulsive seizures. No documentation of absence or simple partial
seizures was noted. The first classification of epilepsy, probably by
Cao Yuan Fang in A.D. 610, listed five types of epilepsy: Yang
Dian, Yin Dian, Feng (Wind) Dian, Shih (Wet) Dian and Ma
(Horse) Dian. The treatment of epilepsy, based on principles of
OBJECTIVES
METHODS
Types of studies
Randomised studies using adequate or quasi (i.e. day of the week)
methods of randomisation. Studies may be single blinded, double
blind or unblinded.
Types of participants
People of any age, either gender and of any ethnic origin with
epilepsy of any type and syndrome(ILAE 1981; ILEA 1989), at
any stage of diagnosis.
Types of interventions
Traditional Chinese medicinal herbs (TCMHs) are defined as
preparations derived from plants, or parts of plants, including single herbs or mixtures of different herbs. We included any types
of preparation, such as decoction, oral liquid, tablet, capsule or
powder. We also included single chemicals extracted from a plant,
or synthetic chemicals based on plant constituents.
We considered the following comparisons:
1. one formula of TCMH versus no interventions;
2. one formula of TCMH versus placebo;
3. one formula of TCMH versus single Western medication
(monotherapy).
We excluded studies of TCMH in combination with antiepileptic
drugs (AEDs) versus AEDs alone. We will include these studies in
the update of this review.
Types of outcome measures
Primary outcomes
Secondary outcomes
Selection of studies
To determine the studies to be assessed further, two authors (QL
and DZ) independently scanned the titles, abstract sections and
keywords of every record. The two authors retrieved full articles
for further assessment if the information given suggested that the
study:
1. included participants with epilepsy;
2. compared Chinese herbal medicine with any other active or
placebo intervention;
3. used random or quasi-random allocation to the comparison
groups.
If there was any doubt regarding these criteria from the information given in the title and abstract, we retrieved the full article for
clarification. Two authors (QL and DZ) independently assessed
each of these studies for inclusion and there were no recorded disagreements. We excluded studies that did not meet the inclusion
criteria and have stated the reasons in Characteristics of excluded
studies.
We also divided studies into the following three categories according to the simple approach set out in The Cochrane Handbook for
Systematic Reviews of Interventions (Handbook 2008). The quality
criteria include blinding and losses to follow up as well as allocation concealment.
A - all quality criteria met: low risk of bias.
B - one or more of the quality criteria only partly met: moderate
risk of bias.
C - one or more criteria not met: high risk of bias.
The description of the quality of each study was given based on
these components. Two review authors (QL and DZ) independently assessed each trial selected for inclusion in the review. There
were no recorded disagreements.
Data synthesis
We analysed data using Review Manager 5.0 (RevMan 2008). We
used relative risks with 95% confidence intervals (CI) for binary
outcomes. We used standardised mean differences with 95% CI
for continuous outcomes. Where possible all analyses included all
participants in the treatment groups to which they had been allocated. For the efficacy outcome (50% or greater reduction in
seizure frequency), we planned to undertake three analyses: (1)
primary (intention-to-treat) analysis; (2) worst case; (3) best case,
to address the potential problem of missing outcome data. However, not all included studies reported loss to follow up data, so we
were unable to perform these analyses.
We assessed clinical heterogeneity by comparing the distribution of
important participant factors between studies (age, gender, seizure
type, duration of epilepsy, number of AEDs taken at time of randomisation) and study factors (randomisation concealment, blinding, losses to follow up). We assessed statistical heterogeneity with
the I2 statistic; a value greater than 50% was considered to indicate
significant heterogeneity. However, the preparation and composition of herbal medicines in each study varied and there was clear
heterogeneity of intervention, so meta-analysis was not attempted.
We planned to assess the impact of important patient characteristics including seizure type, duration and aetiology of epilepsy, and
presence of neurological signs upon outcome, assuming sufficient
data were available. We also planned to undertake sensitivity analyses including: (i) all studies; (ii) only those using adequate methods of allocation concealment, such as sealed opaque envelopes
or telephone randomisation. For the analysis of adverse events, as
stated above, we calculated Peto odds ratios (ORs) with 99% CIs
for the comparison between randomised groups.
RESULTS
Description of studies
Health. All studies except one (Xin 1999) reported the time between first seizure and randomisation, and this ranged from three
months to more than 30 years. None of the studies mentioned
whether the included participants were newly diagnosed. Only
one study (Tian 2006) mentioned that most of the participants
had antiepileptic drug monotherapy or biotherapy history before
entering the studies, but did not give details. The baseline seizure
frequency was reported in three studies (Tian 2006; Xiang 1998;
Xin 1999), and all the three studies included the patients who
had a seizure at least once a month. Although none of the studies
reported the aetiologies of epilepsy, three (Liu 1994a; Tian 2006;
Xiang 1998) excluded secondary or symptomatic epilepsy caused
by stroke, trauma or tumour. Neurological signs were not mentioned in any of the studies.
Randomisation
Although all the studies mentioned that the patients were randomly allocated to the intervention and control groups, none of
them described the allocation sequence in detail. None of the
included studies mentioned allocation concealment. We tried to
contact the authors of studies by telephone in order to obtain more
detailed information, however we were unable to reach them. We
also wrote to the authors but did not receive any replies.
Interventions
The preparation and composition of herbal medicines in each
study varied and each trial compared one formulation of TCMH
with a single antiepileptic drug (see Table 1). Several herbs, such as
changpu (Acorus calamus), dannanxing (Arisaema cum bile), banxia
(Rhizoma pinelliae), fu ling (Poria), yuanzhi (Polygala) and tianma
(Gastrodia rhizome) were tested. TCMH was given in the form
of patient prescription in four studies (Liu 1994a; Song 2001;
Tian 2006; Xin 1999 ). Two studies (Tian 2006; Xin 1999) used
capsules, one granule (Liu 1994a) and one pill (Song 2001). All the
tested herbs were prepared by the trial authors hospital, except the
antiepilepsy capsule, which was produced by a pharmaceutical
company.
The different intervention and comparators are listed below.
Liu 1994a compared Xiaxingci granule with phenytoin.
Song 2001 compared Dianxianning pill with valproate.
Tian 2006 compared Tianmadingxian capsule with phenytoin.
Xiang 1998 compared Zhixian I with phenytoin.
Xin 1999 compared Antiepilepsy capsule with phenobarbital.
The duration of treatment was two months (Xiang 1998), 12
weeks (Liu 1994a) and three months (Song 2001; Tian 2006; Xin
1999).
Outcomes measures
Two studies (Liu 1994a; Song 2001) used seizure freedom as an
outcome measure. All studies reported the number of participants
with percentage reduction in seizure frequency (such as 50% or
greater, 75% or greater) as one of the major outcomes. All studies
except one (Tian 2006) also reported the electroencephalogram
(EEG) results before and after treatment. One study (Xin 1999)
reported the number of participants with good (75% or greater)
or moderate (50% to 74%) reduction in seizure duration. None of
the studies mentioned health-related quality of life as outcomes.
All studies except one (Tian 2006) assessed adverse events and
reported the incidence in detail. None of the studies reported
withdrawal due to side effects or due to lack of efficacy.
Blinding
None of the studies mentioned blinding.
Effects of interventions
The five studies tested five different traditional Chinese medicines
compared with antiepileptic drugs (AEDs), and the reported outcomes included seizure freedom, 50% or greater reduction in
seizure frequency, percentage reduction in seizure frequency and
duration, improvement in EEG and adverse effects. We did not
perform a meta-analysis due to heterogeneity in interventions and
controls.
We found one study (Tian 2006) comparing Tianmadingxian capsule with phenytoin, which recruited 334 participants. All participants were diagnosed with epilepsy according to the classifications
of ILEA 1989.
The study used Zhixian I versus phenytoin and a statistically significant difference was found favouring Zhixian I (RR 1.31; 95%
CI 1.16 to 1.48, P < 0.0001).
Since none of the studies reported loss to follow up, we could not
analyse the withdrawals due to side effects or due to lack of efficacy.
DISCUSSION
Summary
In this review we have included data from 1125 patients from five
studies in which participants were randomised to either traditional
Chinese medicine (TCM) or antiepileptic drugs (AEDs). All the
studies were of low methodological quality. No studies were conducted using adequate methods of randomisation, allocation concealment or blinding of both investigators and patients. They provide only limited descriptions of baseline and follow up data. All
studies stated that random assignment was used, but there was insufficient information to judge whether or not this was conducted
properly. All the included studies therefore had a high probability
of selection, detection and performance bias. Although the studies
did report some benefit (in terms of patients becoming seizure free
or having a 50% or greater reduction in seizure frequency), we
are unable to draw a reliable conclusion on the effect of TCM for
epilepsy. No adverse effects were found in two studies and only
slight gastrointestinal discomfort was reported in the two other
studies reporting this.
All studies except one (Tian 2006) mentioned adverse events (see
Characteristics of included studies) and two studies (Liu 1994a;
Song 2001) showed no obvious adverse effect in the TCM group.
The other two studies (Xiang 1998; Xin 1999) reported only slight
gastrointestinal discomfort after TCM. Xin 1999 reported the
incidence of adverse effects both in the Antiepilepsy capsule and
phenobarbital group and the Peto odds ratio was 0.04 (99% CI
0.01 to 0.12, P < 0.00001), favouring the Antiepilepsy capsule.
None of the studies reported any cognitive side effects, allergic
reaction skin rashes or Steven Johnson syndrome.
ualised treatment by stratification of practitioners or by the pattern of the syndromes. However, most of the constituents of the
pharmacological preparations cannot be specified precisely. There
may be variation between different formulations and batches of
treatment, although the variation is an inevitable consequence of
the nature of TCM and the Chinese government does specify the
limits of variation that are acceptable. This variation is a factor
that may contribute to any heterogeneity between different study
results, making meta-analysis difficult.
AUTHORS CONCLUSIONS
Implications for practice
The current evidence is insufficient to support traditional Chinese medicine (TCM) as a treatment for epilepsy. Much larger,
high quality randomised clinical trials are needed to evaluate the
effectiveness and safety of traditional Chinese medicinal herbs for
treating epilepsy.
ACKNOWLEDGEMENTS
We would like to acknowledge the Cochrane Epilepsy Group for
their technical support. We thank Professor Tony Marson and
Rachael Kelly (Cochrane Epilepsy Group), Dr Sridharan Ramaratnam (Department of Neurology, Apollo Hospitals, India), Professor Paula Williamson (University of Liverpool) and Professor
Taixiang Wu (Chinese Cochrane Center, China) for their kind
advice and encouragement in the preparation of this review.
REFERENCES
Additional references
Cockerell 1995
Cockerell OC, Johnson L, Sander JWAS, Hart YM,
Shorvon SD. Remission of epilepsy: results from the
National General Practice Study of Epilepsy. Lancet 1995;
346:1404.
Fulder 1996
Fulder S. The Handbook of Alternative and Complementary
Medicine. Oxford: Oxford University Press, 1996.
Glauser 2006
Glauser T, Ben-Menachem E, Bourgeois B, Cnaan A,
Chadwick D, Guerreiro C, et al.ILAE treatment guidelines:
evidence-based analysis of antiepileptic drug efficacy and
effectiveness as initial monotherapy for epileptic seizures
and syndromes. Epilepsia 2006;47(7):1094120.
Guo 1993
Guo Q, Kuang P. Effect of qingyangshen on hippocampal
alpha- and beta-tubulin gene expression during kainic acid
induced epileptogenesis. Journal of Traditional Chinese
Medicine 1993;13(4):2816.
Handbook 2008
Higgins JPT, Green S, editors. Cochrane Handbook
for Systematic Reviews of Interventions 5.0.0 [updated
10
Lai 1991
Lai C W, Lai Y H. History of epilepsy in Chinese traditional
medicine. Epilepsia 1991;32(3):299302.
Liu 2000
Liu JP, McIntosh H, Lin H. Chinese medicinal herbs for
chronic hepatitis B. Cochrane Database of Systematic Reviews
2000, Issue 4. [Art. No.: CD001940. DOI: 10.1002/
14651858.CD001940]
Minami 1999
Minami E, Shibata H, Nunoura Y, Nomoto M, Fukuda
T. Efficacy of shitei-to, a traditional Chinese medicine
formulation, against convulsions in mice. American Journal
of Chinese Medicine 1999;27(1):10715.
Moher 2001
Moher D, Schulz KF, Altman D. The CONSORT
statement: revised recommendations for improving the
quality of reports of parallel-group randomized trials. JAMA
2001;285(15):198791.
RevMan 2008
The Nordic Cochrane Centre. The Cochrane Collaboration.
Review Manager. 5.0. Copenhagen: The Nordic Cochrane
Centre. The Cochrane Collaboration, 2008.
Sander 1996
Sander JW, Shorvon SD. Epidemiology of the epilepsies.
Journal of Neurology, Neurosurgery, and Psychiatry 1996;61
(5):43343.
Villeneuve 2004
Villeneuve N. Quality-of-life scales for patients with drugresistant partial epilepsy. Reviews of Neurology (Paris) 2004;
160:37693.
Wang 1996
Wang Q. Advances in treatment of epilepsy with traditional
Chinese medicine. Journal of Traditional Chinese Medicine
1996;16(3):2307.
11
CHARACTERISTICS OF STUDIES
Participants
Interventions
Outcomes
Notes
(1) There was potential conflict of interest in the use of Xiaxingci granules made by the authors hospital
(2) The course and therapy was irregular
Risk of bias
Item
Authors judgement
Description
Allocation concealment?
Unclear
B - Unclear
12
Song 2001
Methods
Participants
Interventions
Outcomes
SEIZURE FREEDOM: treatment group seizure free (6), control group (0)
SEIZURE FREQUENCY (number of patients): treatment: 80% or greater reduction (82), 60% to 79%
reduction (12); control: 80% or greater reduction (30), 60% to 79% reduction (66)
IMPROVEMENT IN EEG: treatment: 100 (100%) obviously improved; control: 20 (40%) obviously
improved, 18 (36%) improved and 12 (24%) unchanged
ADVERSE EVENTS: treatment group had no obvious adverse events; control: 5 had gastrointestinal
reaction and 2 had fatigue and drowsiness
Notes
There was potential conflict of interest in the use of Dianxianning pill made by the authors hospital
Risk of bias
Item
Authors judgement
Description
Allocation concealment?
Unclear
B - Unclear
Tian 2006
Methods
Participants
13
Tian 2006
(Continued)
Treatment group: 4 to 10 years (39), 11 to 20 years (67), 21 to 30 years (51), 31 to 40 years (13), > 40
years (8). Control: 4 to 10 years (32), 11 to 20 years (54), 21 to 30 years (46), 31 to 40 years (19), > 40
years (5)
SEIZURE TYPES (number of patients): GTCS: treatment (91), control (82); absence: treatment (31),
control (40); simple partial seizure: treatment (34), control (23); complex partial seizure treatment (22),
control (11). Verified diagnosis of xian zheng in TCM, wind phlegm obstacle orifice types: treatment
(81), control (76); pyrophlegm intervene mind types: treatment (54), control (47); stagnant blood block
brain types: treatment (28), control (23); collateral and hepatic and renal yin deficiency types: treatment
(15), control (10)
NEWLY DIAGNOSED: unclear
BASELINE SEIZURE FREQUENCY: at least once a month and in total more than 3 times
TIME BETWEEN FIRST SEIZURE AND RANDOMISATION (number of patients): treatment: 0.3
to 5 years (85), 6 to 10 years (52), 11 to 20 years (30), 21 to 30 years (6), > 30 years (5); Control: 0.3 to
5 years (67), 6 to 10 years (46), 11 to 20 years (31), 21 to 30 years (9), > 30 years (3)
NUMBER AND TYPES OF AEDs TAKEN: most had monotherapy or biotherapy history including
VAL, CBZ, TPM etc
Interventions
Outcomes
Notes
(1) There was potential conflict of interest in the use of Tianmadingxian capsule made by the authors
hospital
Risk of bias
Item
Authors judgement
Description
Allocation concealment?
Unclear
B - Unclear
Xiang 1998
Methods
Participants
14
Xiang 1998
(Continued)
Outcomes
Notes
(1) There was potential conflict of interest in the use of Zhixian I made by the authors hospital
(2) The baseline seizure frequency was not mentioned
Risk of bias
Item
Authors judgement
Description
Allocation concealment?
Unclear
B - Unclear
Xin 1999
Methods
Participants
15
Xin 1999
(Continued)
Outcomes
Notes
Risk of bias
Item
Authors judgement
Description
Allocation concealment?
Unclear
B - Unclear
16
Study
Chen 1998
Chen 2000
Li 1997
Lin 1999
Liu 1994b
TCM (alkaline extract of Euphorbia fisheriana) combined with AEDs compared with AEDs
Cross-over design
Wang 2001
The participants did not accord with the diagnosis criteria of ILAE
Wu 2002
Xu 2005
Yin 2001
TCM (Ginkgo biloba extract) combined with AEDs compared with AEDs
DESIGN: unclear
BLINDING: not used
DURATION OF FOLLOW UP: 180 day
Participants
17
Ma 2003a
(Continued)
TREATMENT GROUP:
Xifeng capsule to be taken 3 times daily at age-dependent dosage: < 1 year 1 (1 capsule), 1 to 3 years (2 capsules), 3
to 7 years (5 capsules) and > 7 years (8 capsules)
Antiepilepsy capsule to be taken 3 times daily at age-dependent dosage: < 1 year 1 (1 capsule), 1 to 3 years (2
capsules), 3 to 7 years (5 capsules) and > 7 years (8 capsules)
Phenobarbital group: phenobarbital: 2 mg/kg 3 times daily for 180 days
Outcomes
Notes
Ma 2003b
Methods
Participants
Interventions
TREATMENT GROUP: Antiepilepsy capsule to be taken 3 times daily at age-dependent dosage: 1 to 5 years (1
to 5 capsules), 6 to 10 years (7 capsules) and 11 to 14 years (8 capsules). If the participants had ever taken AEDs for
more than 1 month, antiepilepsy capsule was taken with AEDs for 1 month, then AEDs were gradually decreased
from the second month, then stopped taking AEDs and took separate antiepilepsy capsule for 180 days
Control group: phenobarbital 1.5 to 2 mg/kg 3 times daily for 180 days
Outcomes
REDUCTION IN SEIZURE FREQUENCY (number of patients): 75% or greater reduction treatment (534),
control (64); 51% to 75% reduction treatment (241), control (19); 25% to 50% reduction treatment (96), control
(38); no reduction or aggravated treatment (13), control group (10)
18
Ma 2003b
(Continued)
Notes
19
No. of
studies
No. of
participants
Statistical method
Effect size
Subtotals only
1
1
40
40
40
Subtotals only
1
1
1
200
200
200
1
1
334
Subtotals only
1.37 [1.23, 1.53]
334
334
1
1
200
Subtotals only
1.31 [1.16, 1.48]
200
200
Subtotals only
1
1
401
401
401
401
Subtotals only
1
1
401
20
Analysis 1.1. Comparison 1 One formula of TCMH versus single Western medication, Outcome 1 Xiaxingci
granule versus phenytoin.
Review:
Study or subgroup
Treatment
Control
n/N
n/N
Risk Ratio
Weight
1/20
1/20
100.0 %
20
20
100.0 %
3/20
2/20
100.0 %
20
20
100.0 %
18/20
18/20
100.0 %
20
20
100.0 %
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
1 Seizure freedom
Liu 1994a
0.01
0.1
Favours experimental
10
100
Favours control
21
Analysis 1.2. Comparison 1 One formula of TCMH versus single Western medication, Outcome 2
Dianxianning pill versus valproate.
Review:
Study or subgroup
Treatment
Control
n/N
n/N
Risk Ratio
Weight
6/100
0/100
100.0 %
100
100
100.0 %
82/100
30/100
100.0 %
100
100
100.0 %
94/100
96/100
100.0 %
100
100
100.0 %
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
1 Seizure freedom
Song 2001
0.01
0.1
Favours experimental
10
100
Favours control
22
Analysis 1.3. Comparison 1 One formula of TCMH versus single Western medication, Outcome 3
Tianmadingxian capsule.
Review:
Study or subgroup
Treatment
Control
n/N
n/N
Risk Ratio
Weight
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
169/178
108/156
100.0 %
178
156
100.0 %
125/178
46/156
100.0 %
178
156
100.0 %
175/178
129/156
100.0 %
178
156
100.0 %
0.01
0.1
Favours experimental
10
100
Favours control
23
Analysis 1.4. Comparison 1 One formula of TCMH versus single Western medication, Outcome 4 Zhixian I
versus phenytoin.
Review:
Study or subgroup
Treatment
Control
n/N
n/N
Risk Ratio
Weight
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
97/100
74/100
100.0 %
100
100
100.0 %
88/100
62/100
100.0 %
100
100
100.0 %
99/100
90/100
100.0 %
100
100
100.0 %
0.01
0.1
Favours experimental
10
100
Favours control
24
Analysis 1.5. Comparison 1 One formula of TCMH versus single Western medication, Outcome 5
Antiepilepsy capsule versus phenobarbital.
Review:
Study or subgroup
Treatment
Control
n/N
n/N
Risk Ratio
Weight
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
222/301
61/100
100.0 %
301
100
100.0 %
180/301
41/100
100.0 %
301
100
100.0 %
147/301
38/100
100.0 %
301
100
100.0 %
225/301
60/100
100.0 %
301
100
100.0 %
0.01
0.1
Favours experimental
10
100
Favours control
25
Analysis 1.6. Comparison 1 One formula of TCMH versus single Western medication, Outcome 6 Incidence
of adverse or harmful effects.
Review:
Study or subgroup
Treatment
Control
Odds Ratio
n/N
n/N
Peto,Fixed,99% CI
Weight
Odds Ratio
Peto,Fixed,99% CI
7/301
37/100
100.0 %
301
100
100.0 %
0.01
0.1
Favours experimental
10
100
Favours control
ADDITIONAL TABLES
Table 1. The preparation and composition of the herbal medicines in the included trials
Preparation
Composition
Xiaxingci granule
Granule
Dianxianning pill
Pill
Study ID
26
Table 1. The preparation and composition of the herbal medicines in the included trials
(Continued)
Tianmadingxian capsule
Capsule
Zhixian I
Decotion
Antiepilepsy capsule
Capsule
A
formula
composed
of
dan- Xin 1999
naxing (Arisaema cum bile), tianma (Gastrodia rhizome), banxia (Rhizoma pinelliae)
, changpu (Acori graminei, rhizome), fuling
(Poria), taizishen (heterophylly falsestarwort
root), chuanxiong (Ligustici rhizome), etc.
APPENDICES
Appendix 1. MEDLINE search strategy
The following search was used in MEDLINE and adapted for use in other databases:
1. exp Epilepsy/
2. epilep$.tw.
3. exp Seizures/
4. seizure$.tw.
5. convuls$.tw.
6. Lennox Gastaut.tw.
7. West$ syndrome.tw.
8. infant$ spasm.tw.
9. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8
10. exp Medicine, Herbal/
11. exp Plants, Medicinal/
12. exp Medicine, Traditional/
13. exp Drugs, Chinese Herbal/
14. herb$.tw.
15. (plant or plants).tw.
16. exp Medicine, Oriental Traditional/
17. (Chinese adj medicine).tw.
Traditional Chinese medicine for epilepsy (Review)
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
27
HISTORY
Protocol first published: Issue 2, 2007
Review first published: Issue 3, 2009
Date
Event
Description
23 May 2008
Amended
CONTRIBUTIONS OF AUTHORS
Dr Qifu Li performed the bibliographic searches, identified the studies, assessed their methodological quality, extracted the data, and
produced the first draft of the review. Dr Xiaoyan Chen and Dr Li He performed the bibliographic searches, identified the studies and
extracted the data. Dr Dong Zhou assessed the methodological quality of the studies, checked the extracted data, and commented on
all the draft manuscripts.
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DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
Internal sources
Department of Neurology, West China Hospital, China.
Chinese Cochrane Center, China.
External sources
No sources of support supplied
INDEX TERMS
Medical Subject Headings (MeSH)
Anticonvulsants [therapeutic use]; Drugs, Chinese Herbal [ therapeutic use]; Epilepsy [ drug therapy]; Epilepsy, Tonic-Clonic [drug
therapy]; Medicine, Chinese Traditional [methods]; Phenobarbital [therapeutic use]; Phenytoin [therapeutic use]; Randomized Controlled Trials as Topic; Valproic Acid [therapeutic use]
29