Epilepsy is a chronic disease. With the in-depth understanding of the pharmacokinetics of antiepileptic drugs, the implementation of antiepileptic drug blood concentration monitoring, the introduction of new antiepileptic drugs, and the progress of non-pharmacological treatment, the treatment of epilepsy has made great progress, but in clinical practice, there are still many noteworthy misconceptions, which are listed below.
1. Treatment without clinical diagnosis of epilepsy
Many non-epileptic seizure disorders such as migraine and pseudo-seizures are misdiagnosed as epilepsy and given anti-epileptic treatment.
① Misdiagnosis as epilepsy leads to great mental stress for the patient and family members due to deep-rooted social prejudice and public discrimination;
(ii) unwarranted risk of adverse reactions due to antiepileptic drugs, some of which, such as exfoliative dermatitis, necrotizing hepatitis, and suppression of the hematopoietic system, are lethal; and (iii) increased unnecessary financial burden. In particular, it should be noted that epilepsy is a clinical diagnosis, and merely having abnormal EEG, even if disease-like waves appear without clinical seizures, cannot be diagnosed as epilepsy and given antiepileptic treatment.
2. Failure to select drugs according to seizure type
There are many types of seizures, and the determination of seizure type involves both drug selection and etiological examination. It is common to misjudge the seizure type and wrongly select drugs, for example, failing to correctly recognize aphasic seizures as transient partial seizures, and wrongly treating with carbamazepine or phenytoin is not uncommon.
For example, myoclonic seizures in juvenile myoclonic epilepsy often appear on one side, so they are mistaken for clonic seizures of focal origin and are treated with carbamazepine and phenytoin sodium. Some partial seizures in frontal lobe epilepsy are misdiagnosed as non-epileptic psychotic seizures, thus delaying treatment. Bilateral frontal spikes are common and are mistaken for bilaterally synchronized full-blown seizures.
Recommendations.
①A detailed history is essential to determine the type of seizure;
(2) video (video) EEG can be used to determine the type of seizure for more frequent seizures; video EEG is also extremely useful in confirming the diagnosis of epilepsy; (3) in cases where it is difficult to identify partial seizures or akathisia seizures, myoclonic seizures can be preceded by broad-spectrum sodium valproate, clobazam (oxyisotonic) lamotrigine or topiramate
3. Failure to ensure maximum tolerated dose in poorly controlled seizures
Failure to apply the maximum tolerated dose in poorly controlled seizures is a very common error in epilepsy drug therapy due to experience alone. The standard first-line antiepileptic drugs plus valproic acid, carbamazepine, and newer drugs such as oxcarbazepine, topiramate, and gabapentin are all dose-response related, and if the patient is not given the so-called “conventional dose” on an individualized basis, the patient will be in a “subtherapeutic state” The patient will be in a “subtherapeutic state” resulting in poor control.
Recommendations.
①Some drugs such as carbamazepine, phenobarbital, etc. can be monitored therapeutically and the dose can be adjusted to achieve effective blood levels;
②The dose can be gradually increased until the initial clinical adverse effects appear;
③Some patients reduce the dose on their own for fear of adverse reactions at high doses, so it is important to understand whether there are compliance problems;
If there is no satisfactory response with the maximum tolerated dose, the dose should be reduced to avoid chronic toxicity, and the second antiepileptic drug should be used instead.
4. Failure to diagnose epilepsy syndrome
Epilepsy syndromes can provide additional information such as age of onset, etiology, seizure type, contributing factors, severity, circadian pattern, chronicity, prognosis and treatment options. Many epilepsy syndromes are age-related, and the age of seizure onset can provide clues to the correct diagnosis of the syndrome, which in turn can guide the appropriate pharmacological treatment;
For example, myoclonic epilepsy in adolescence is an idiopathic generalized epilepsy with bilateral synchronous generalized spike and slow wave discharges starting in adolescents.
Recommendations.
① Familiarize yourself with the classification of epilepsy and epilepsy syndromes;
②Supplement with EEG, especially video EEG;
③Avoid the precipitating factors as much as possible.
5. Inappropriate application of new antiepileptic drugs
Many new antiepileptic drugs have been developed internationally, nine of which have been approved by the U.S. Food and Drug Administration (FDA), including felbamate, lamotrigine, gabapentin, topiramate, aminoglutethimide, levetiracetam, tiagabine, oxcarbazepine, and zonisaguan, which raises the question of how to apply them rationally. For example, the selective GABAergic compounds gabapentin, tiagabine and aminoglutethimide cannot be used for the treatment of akathisia or myoclonic seizures and can exacerbate them;
Since sodium valproate obviously inhibits the metabolism of lamotrigine, the latter is slow to add; however, some new drugs also have their advantages, such as lennox Gastaut syndrome, West syndrome, these refractory epilepsy, the new anti-epileptic drugs topiramate, lamotrigine, etc. have a better control effect; another example is that gabapentin and lamotrigine have no drowsy effect, which is beneficial to the application of elderly patients, they rarely interact with each other and are also welcomed by patients with medical conditions or with other drugs due to contraception.
Recommendations.
① New antiepileptic drugs should be considered for any patient whose seizures cannot be controlled with standard antiepileptic drugs or who develops severe side effects;
② Indications should be mastered;
③ Pay attention to new adverse reactions.
6. Premature withdrawal of antiepileptic drugs
After seizures are controlled, premature withdrawal of drugs may lead to recurrent seizures, and sudden withdrawal may also promote persistent status epilepticus.
Recommendations.
(1) Consider the time to stop medication according to the risk factors for possible recurrence (e.g. frequent seizures, long duration of disease, EEG still abnormal, previous multidrug therapy, etc.);
②Electroencephalography (EEG) should be done for many years after the clinical seizures have disappeared to understand the presence of seizure-like waves, ideally 24h dynamic EEG;
③When withdrawing medication, it should be done slowly, not less than 1 year for generalized tonic clonic seizures and not less than 6 months for disoriented seizures;
④If there is a relapse, the original treatment plan should be resumed immediately.