The primary medical treatment for epilepsy is the use of antiepileptic drugs to control seizures. There are no antiepileptic drugs that are effective for all seizure types and can completely control seizures. Antiepileptic drugs only have the symptomatic effect of seizure control, but not the radical effect of eliminating the cause and source of epilepsy, so they need to be used for a long time. The regular application of antiepileptic drugs can improve the efficacy and reduce the adverse effects.
(A) General principles
1. Before epilepsy is diagnosed or only 1 seizure, observation can be continued and antiepileptic drugs should not be started.
2. The diagnosis and treatment of epilepsy should be carried out under the guidance of a specialist.
3, antiepileptic drugs should be used according to the seizure type. Different antiepileptic drugs have different anti-seizure mechanisms, so a certain antiepileptic drug is only effective for a certain type or types of seizures.
The first thing you need to do is to take a look at the actual product. Its advantages are.
①Avoid drug interactions;
(2) Few adverse effects and easy to identify;
③Good compliance;
④Low cost;
⑤ can improve the quality of life.
5. First-line drugs should be used as the first choice of antiepileptic drugs. First-line drugs include sodium valproate, carbamazepine, phenytoin sodium and phenobarbital. When monotherapy with first-line drugs fails, a combination of two or even three first-line drugs can be used. The number of patients who are not satisfactorily controlled with first-line drug combinations is very small, about 5%, and these few patients are mostly patients with encephalopathies such as Lennox-Gastaut syndrome and West syndrome. For these few patients with what is called drug-resistant epilepsy or intractable epilepsy or refractory epilepsy, second-line drugs may be used in combination with or instead of first-line drugs alone.
In order to maintain the steady-state effective blood concentration and to bring out the best efficacy, long-term regular medication should be used. The failure of antiepileptic drug therapy is mostly caused by unreasonable and irregular drug use.
The application of antiepileptic drugs should start with small doses and gradually increase, generally taking about 1 week to reach effective plasma drug concentrations.
The most basic pharmacokinetic characteristics of antiepileptic drugs should be understood, including half-life, effective concentration range, peak concentration time, etc., which are closely related to the efficacy and adverse effects. The interval between each dose should be shorter than its half-life, otherwise it is difficult to reach the steady-state effective concentration. Only when the drug is administered for more than 5 half-lives can the steady-state concentration be reached, and then the maximum efficacy can be achieved. To determine whether an antiepileptic drug is effective, it is necessary to observe 5 times the average interval of past seizures, e.g., the patient has an average of 2 seizures per month, and should be observed for at least 2.5 months.
9, Children, the elderly and pregnant women, as well as patients with chronic diseases who are on other medications for a long time, should be determined on a case-by-case basis when choosing antiepileptic drugs and using doses.
10. Observe and regularly test patients’ tolerance and adverse reactions to drugs at all times and deal with them accordingly.
(II) Anti-epileptic drugs
1. First-line antiepileptic drugs are available according to different seizure types and patient’s specific conditions.
(1) Generalized tonic clonic seizures, limited seizures with or without secondary generalized seizures: sodium valproate, carbamazepine, phenytoin sodium are available.
(2) Akathisia seizures, myoclonic and atonic seizures: sodium valproate.
(3) Mixed seizures: a broad-spectrum antiepileptic drug sodium valproate is appropriate for those with mixed multiple seizure types.
(4) phenobarbital: WHo clinical trials of phenobarbital in China and other developing countries have confirmed that the application of phenobarbital can increase the percentage of epileptic patients receiving treatment in areas with lagging medical conditions, economic and cultural development, and is a drug worth promoting. Phenobarbital is also a broad-spectrum antiepileptic drug, and its adverse effects include affecting the learning ability of children and increasing hyperactivity.
2. Second-line antiepileptic drugs
(1) Newly developed second-line antiepileptic drugs include: vigabatrin, lamotrigine, gabapentin, topiramate, tiagabine, oxcarbazepine. oxcarbazepine, zonisamide, stiripentol (stiri-pento1) and levetiracetam. Older drugs used as second-line agents include: oxyisotretinoin (clobazam), acetazolamide (acetazolamide) and flunarizine (flunarizine). Since the new second-line antiepileptic drugs still have not been proven to have better efficacy and adverse effects than the first-line drugs, etc., the second-line drugs are still classified as adjunctive antiepileptic drugs (adjunctivetherapy) to the first-line drugs. Second-line drugs that are effective as monotherapy can be used as replacement drugs for those that fail or are not tolerated by first-line drugs. Second-line drugs are also effective in controlling seizure reduction and are not beneficial for non-seizure symptoms such as progressive mental decline in patients with encephalopathies such as Lennox-Gastaut syndrome and West syndrome. Among the new second-line antiepileptic drugs, lamotrigine, tolpiride and levetiracetam are broad-spectrum antiepileptic drugs along with sodium valproate; aminoglutethimide should be the second-line antiepileptic drug of last choice because of its centripetal visual field deficit. Lamotrigine and oxcarbazepine are more effective for myoclonic seizures. The older second-line antiepileptic drugs oxycodone and acetazolamide are sometimes effective for generalized and limited seizures when other medications have failed, and flunarizine has also been used to treat childhood-acquired epileptic aphasia (LandauKleffner syndrome).
(2) Indications for second-line antiepileptic drugs: The indications for second-line antiepileptic drugs are drug-resistant seizures (drug-resistentepilepticseizures).
(C) Monitoring in antiepileptic drug therapy
1.Electroencephalography, routine blood and liver and kidney function tests should be performed before starting medication as basic records.
2. Regular follow-up visits should be made during the course of treatment, every 2 weeks for frequent seizures and once a month for general patients. Ask about the increase or decrease of seizure frequency, whether there is any change in the type of seizure, whether there is any adverse reaction and whether the medication is taken according to medical prescription.
3. Liver function should be measured once every 3 months. Sodium valproate has the potential to cause fatal hepatotoxicity, so liver function should be measured once a month.
4.Blood routine should be measured once every 3 months. The rate of occasional aplastic anemia in carbamazepine users is 2/57.5 thousand, and the whole blood cells should be measured regularly.
5.Electroencephalography can be checked once every 6 months. EEG should be done promptly when the number of seizures increases.
6.Blood concentration can be measured in the following cases in hospitals where conditions exist.
① When the steady-state blood concentration is estimated at the beginning of treatment, it is used as the basis;
②To determine compliance;
③ Determine the dose-related adverse effects;
④When one antiepileptic drug is added or discontinued for multidrug therapy;
(⑤) If seizures are not controlled or increase during treatment;
(6) When the patient has conditions that may alter the drug concentration, such as hypoproteinemia, pregnancy, renal insufficiency, hepatic insufficiency, gastrointestinal disorders, etc.
(iv) Start and termination of medication
Only the first seizure of tonic clonic seizure needs to be considered to start medication, and the general principles are
① Prior history of myoclonus, akathisia or limited seizures;
②Electroencephalogram with epileptiform waves;
(iii) The presence of congenital neurological defects;
④The patient does not want to have further seizures and can exclude episodic seizures due to alcohol and drug (such as benzodiazepines) withdrawal and other factors.
2. There is no accepted standard for discontinuing antiepileptic drugs, and the decision should depend on the patient’s specific condition. The medication should be discontinued gradually, and the process of discontinuation is 0.5 to 1 year. The recurrence rate after drug discontinuation is 20% to 40%, mostly occurring within 2 years after drug discontinuation.
(E) Surgical treatment of epilepsy
In 20% of patients with epilepsy where drug therapy is ineffective, surgical treatment can be considered.
1. Indications
(1) Those who have been treated with regular and adequate antiepileptic drugs for more than 2 years in combination with multiple drugs and have proven to be ineffective;
(2) Structural intracranial lesions on imaging can be surgically treated in areas that do not have a serious impact on the patient’s brain function.
2. Contraindications
①Primary epilepsy;
② lesions located in important functional brain areas such as motor cortex, language center;
③IQ below 70;
④Progressive medical or neurological lesions;
(⑤) Dysfunction of the hemisphere contralateral to the lesion, including memory, cognitive function and psychological function.
(vi) Treatment of persistent status epilepticus
In 80% of persistent status epilepticus)9 convulsive persistence, if it lasts more than 30 minutes, it will cause systemic and neurological damage, and the morbidity and mortality rate is 10%-12%. Therefore, seizures should be controlled in as short a time as possible.
1, general treatment of patients with persistent status epilepticus should do emergency treatment. First, determine whether the airway is open, circulatory function and other vital signs are stable, and make routine blood and biochemical examination, if there are abnormalities, do the corresponding treatment.
2. Rapid seizure control Select appropriate antiepileptic drugs, the principles are.
① Intravenous medication;
②It can quickly enter the brain through the blood-brain barrier;
③Long maintenance time in the brain. Intramuscular injections are generally not used because of unstable absorption and difficulty in maintaining effective blood concentrations. Infants can be administered rectally. Adequate doses should be used at one time to achieve complete seizure control, and repeated doses in small amounts should not be used. Benzodiazepines are preferred. Valium 10mg intravenously (no more than 2mg per minute) can control seizures within 5 minutes in 85% of patients and 0.1-1.0mg/kg in children. If it is not effective, the same dose can be used again after 20 minutes. Valium 40rng dissolved in 250ml saline can be used as a slow drip. It should be noted that Valium can become cloudy when added quickly to saline, so Valium should be diluted with 10ml of water for injection first, and then the diluted Valium injection should be added slowly while shaking the infusion bottle. Phenytoin sodium can also be used, the dosage is 20mg/kg, intravenous injection, the speed should not be too fast, should be less than 50mg/min, can make 41% to 90% of patients control seizures within 10-30 minutes. Blood pressure and electrocardiogram should be monitored at the same time.
3. Finding and dealing with triggers and causes The active search for triggers or causes should be started at the same time as the seizure is dealt with, and corresponding treatment should be done in time. After complete seizure control, a regular antiepileptic drug regimen should be established to avoid recurrence.