Epilepsy is a common and frequent disease in neurology, with the second highest incidence after cerebrovascular disease. The treatment of epilepsy in China is seriously confusing, and attention should be paid to formal treatment.
1. Treatment goals of epilepsy
The goals of epilepsy treatment include.
(1) Complete control of seizures ;
(2) Reduction of malignant seizures ;
(3) Avoidance of drug side effects;
(4) Reduction of adverse drug interactions;
(5) Suppression of subclinical epileptiform discharges;
(6) Reduction of morbidity and mortality;
(7) To avoid hindering the normal life of the patient;
(8) To stop the source of epilepsy from occurring.
The goal of epilepsy treatment is not only to completely control seizures, but also to enable the patient to achieve a high quality of life or return to society. Formal treatment is the most important means to make epilepsy cure or control epileptic seizures and reduce adverse drug reactions.
If formal treatment is not taken seriously, not only can seizures not be controlled, but even “medically intractable epilepsy” can be caused, so that patients with seizures that can be controlled can prolong their lives and form chronic epileptic encephalopathy, which affects the quality of life of patients. The current status of domestic epilepsy treatment is unsatisfactory, and there are many problems that need to be corrected.
2, the principles of epilepsy treatment
First determine whether to use medication There are 5% of people who will have one to several occasional seizures in their lifetime, but the occurrence of one seizure is not the same as having epilepsy, which means that not every patient who has had an epileptic seizure needs antiepileptic treatment. For example, some patients with hypoglycemia will have seizures, but when the hypoglycemia is corrected, the seizures will naturally end, so this group of patients does not need antiepileptic treatment.
Medication may be withheld in the following cases.
(1) Patients with their first seizure should not usually be medicated until the cause is identified, and the decision to use medication will be made at the time of the next seizure;
(2) The medication may be withheld in cases where the interval between seizures is longer than one year;
(3) Those who have obvious triggering factors can withhold medication;
(4) Those who cannot adhere to regular medication can withhold medication;
(5) Some children with benign epilepsy have a tendency to heal themselves with age, and if the seizures are not frequent, they can be withheld.
Indications for epilepsy medication.
(1) Patients with two or more seizures in a year may be treated with monotherapy as appropriate.
(2) Symptomatic epilepsy caused by progressive brain disease requires antiepileptic treatment;
(3) Regular antiepileptic treatment is required for those with significant epileptic discharges on EEG.
In 2006, the International League Against Epilepsy proposed the timing of drug treatment for epilepsy based on evidence-based medicine: as long as there is a persistent susceptibility to seizures in the brain, drug treatment should be started after a single seizure.
The susceptibility to epilepsy is demonstrated by.
(1) A clear family history of epilepsy;
(2) Significant epileptiform discharges on the EEG during the interictal period;
(3) A clear and non-eradicable etiology, such as head trauma, late-onset epilepsy after cerebrovascular disease, and seizures caused by chronic tumors.
The selection of antiepileptic drugs according to the type of seizure is the first principle of epilepsy treatment. The prerequisite for the correct selection of antiepileptic drugs is the correct diagnosis, and the diagnosis of epilepsy alone is only the first step. The type of seizure should be determined by a professional clinician, and effective, safe, inexpensive and guaranteed source drugs should be selected according to the type of seizure.
Internationally recognized principles of drug selection.
(1) Valproic acid is preferred for generalized seizures, myoclonic seizures;
(2) Ethosuximide or valproic acid is preferred for anhedonic seizures;
(3) Carbamazepine is preferred for partial seizures;
(4) In infantile spasms, adrenocorticotropic hormone, valproic acid or aminolevulinic acid should be preferred;
(5) Lennox-Gastaut syndrome drugs of choice are topiramate, fexamate and lamotrigine.
Generalized seizures
(1) Primary generalized tonic-clonic seizures: valproate (VPA) is preferred; carbamazepine, phenytoin sodium, phenobarbital, and paroxetine are second choices.
(2) Aphasic seizures: valproate is preferred; ethosuximide is the second choice; for aphasic seizures with unsatisfactory effect of monotherapy, valproate and ethosuximide can be combined. If the above two drugs are not effective, clonidine and Valium can be considered.
(3) Idiopathic tonic-clonic seizures with typical akathisia: valproate is preferred.
(4) Myoclonic seizures: valproate is preferred; ethosuximide, clonidine, acetazolamide are the second choices.
(5) Infantile spasms: ACTH or prednisone first; valproate second, gabapentin (GBP), lamotrigine (LTG), tolterodine (TPM).
(6) Lennox-Gastaut syndrome and dystonic seizures: valproate is preferred; clonidine, Tolterol, felbamate, lamotrigine are second choices.
Contraindications for systemic seizures: Phenobarbital, phenytoin sodium, carbamazepine can aggravate akathisia, myoclonic and atonic seizures and should be avoided for these types.