I. With or without medication.
The chance of having one to several epileptic seizures occasionally in a person’s life is 5%, and 30% of epilepsy patients have a tendency to spontaneous remission. Not every epilepsy patient needs medication. Wang Aihua, Department of Neurology, Shandong Province Qianfo Mountain Hospital
1, generally more than two seizures within six months, once the diagnosis is confirmed, you need to use drugs.
The first seizure or more than one seizure in a six-month interval can be treated with or without medication at the discretion of the patient’s family, after informing them of the adverse effects of antiepileptic drugs and the possible consequences of not being treated. The mean recurrence rate was 42%, and 60%-70% of patients had a recurrence within 6 months of the initial seizure.
3. However, if the first seizure, abnormal neurological examination, abnormal EEG, Todd’s palsy, or imaging examination with clear lesions cause the first seizure, medication is still recommended, although the first seizure occurs.
Second, what drugs to choose
1, according to the type of seizure, the type of epilepsy syndrome reasonable selection of drugs: such as children’s aphasic seizures, myoclonic seizures, generalized tonic clonic seizures preferred valproate, partial seizures, partial seizures secondary to generalized tonic clonic seizures preferred carbamazepine or oxcarbazepine.
2, the selection of drugs should also pay attention to the side effects of drugs, such as allergic patients, caution or not to use carbamazepine, oxcarbazepine and Lipitor; kidney stones patients are prohibited Toutai; liver damage patients are cautiously used or prohibited valproate sodium, hyponatremia, severe atrioventricular block patients cautiously use carbamazepine. For women of childbearing age or women preparing to have children, use valproate, carbamazepine and phenytoin sodium with caution to avoid causing polycystic ovaries or increasing the possibility of fetal malformations.
3, pay attention to drug interactions: many drugs, such as carbamazepine, sodium phenytoin, phenobarbital and other liver enzyme-inducing drugs, often cause the metabolism of antiviral drugs, anticancer drugs, contraceptives, anti-heart failure drugs digoxin, anti-transplant rejection drugs cyclosporine A, anticoagulant warfarin, and glucocorticoid drugs, if the patient applies the above drugs, try to avoid taking liver enzyme-inducing effects of antiepileptic drugs, so as to avoid reduced efficacy .
4, the choice of antiepileptic drugs, should also pay attention to co-morbidity issues
(1) Patients with hepatitis B carriers and idiopathic generalized seizures, regardless of whether the liver function is normal or not, it is recommended that Toltea and levetiracetam (Keplar) are preferred. In patients with secondary partial seizures, oxcarbazepine is preferred for those with normal liver function, and first-line drugs such as Toltea, levetiracetam and lamotrigine are available.
(2) For idiopathic generalized seizures with renal insufficiency and dialysis treatment, sodium valproate is preferred, and first-line drugs such as Lipitor and levetiracetam are also preferred; for symptomatic partial seizures, lamotrigine is preferred.
(3) Children and elderly with cognitive impairment: Lamotrigine and levetiracetam and sodium valproate are preferred for generalized seizures, and lamotrigine or oxcarbazepine are preferred for symptomatic partial seizures, and levetiracetam is the first-line drug.
(4) Valproate and lamotrigine are preferred for idiopathic full-blown episodes with combined depressive disorder or behavioral problems; lamotrigine, oxcarbazepine, carbamazepine are preferred for symptomatic partial episodes, and valproate is also available as first-line drugs.
III. Dosage of drugs.
Start with a small dose and gradually increase the dose to reach the minimum dose to control no seizures. Prevent adverse reactions such as rash, dizziness, nausea and ataxia from occurring if the dose is increased too quickly. It is best to monitor the drug concentration and adjust the drug dose according to the concentration.
Fourth, as far as possible monotherapy
Monotherapy is the principle of antiepileptic drug therapy, because 70-80% of epilepsy can be controlled without seizures by monotherapy.
V. Reasonable combination of drugs
The majority of seizures cannot be controlled by monotherapy and require combination of drugs. This is to minimize the increase in adverse reactions and maximize seizure control. Consider combination medication in the following cases.
1. Multiple types of seizures
2. To reduce the adverse effects of the present drug: PHT disorientation plus clonidine
3.Ineffective monotherapy: high effective concentration limit, failure to control for more than six months
4.Special population: menstrual epilepsy
5. Precautions: drugs with the same chemical structure should not be combined: clonidine and Valium, paracetamol and PB; drugs with the same side effects and interactions should not be combined: e.g. CBZ and PHT: CBZ makes PHT metabolism ↑, CBZ and PB: CBZ concentration ↓ PB concentration ↑.
Sixth, increase or decrease drugs, discontinue and change the principle of drugs
1, increase or decrease drugs: increase drugs quickly, reduce drugs must be slow, must be decreasing one by one, in order to facilitate the exact assessment of efficacy and toxic side effects; antiepileptic drugs to control seizures must be adhered to, unless serious adverse reactions, should not arbitrarily reduce or stop drugs, so as not to cause persistent status epilepticus. Long-term use
2. Change of medication: If a drug reaches the maximum tolerated amount and cannot control seizures, another first-line or second-line drug can be added, and after seizures are controlled, switch to monotherapy for 5-7 days during the change of medication.
3.Discontinuation of medication: use the principle of slow and gradual dose reduction: seizures are completely controlled for 4-5 years, atonic seizures are controlled for more than half a year, EEG is recorded several times without epileptiform emission, normal background waves and no organic brain lesions, the dose can be gradually reduced. The dose reduction process is generally not less than 1-1.5 years without seizures before the drug is discontinued.