Drug treatment strategies and dosage optimization for epilepsy, mastered in one article

*Only for medical professionals to read for reference.
Pure dry goods sharing, bookmarked! Epilepsy (epilepsy), commonly known as "saw horn wind" or "sheep epilepsy", is a chronic disease in which the sudden abnormal discharge of brain neurons leads to transient brain dysfunction.

The following are related concepts of epilepsy: (1) Epileptic seizure refers to the transient clinical manifestations caused by abnormal excessive and synchronized discharge of brain neurons, which can be divided into induced seizures and non-evoked seizures.

(2) Epilepsy (epilepsy) is a brain disease characterized by a persistent tendency to cause epilepsy.

The diagnosis of epilepsy requires at least two seizures, or one seizure with a clear tendency to seizure.

(3) Epilepsy syndrome (epileptic syndrome) refers to a group of epileptic disorders composed of specific clinical manifestations and electroencephalogram changes, emphasizing the combination of EEG and clinical syndromes, such as temporal lobe epilepsy, frontal lobe epilepsy, and benign children Epilepsy with central temporal spikes, juvenile myoclonic epilepsy, etc.

It is worth noting that not all patients can be clearly diagnosed with a certain epilepsy syndrome.

(4) Epileptic encephalopathy refers to the progressive neuropsychiatric dysfunction or degeneration caused by frequent epileptic seizures and/or epileptiform discharges.
In the past 10 years, with the deepening of the understanding of the nature of the disease, international resistance Institutions or organizations such as the Epilepsy Alliance (ILAE), the American Academy of Neurology (AAN) and the National Institute of Health and Clinical Optimization (NICE) have issued relevant clinical diagnosis and treatment guidelines, and have proposed more significant adjustments or supplements to the clinical diagnosis and treatment strategies of epilepsy.
.The International Anti-Epilepsy Alliance expanded the definition of epilepsy in 2014.
The 2005 version of the definition of epilepsy only includes Article 1: At least two unevoked (or reflex) seizures, with an interval of more than 24 hours between the two seizures; while the 2014 definition broadened The scope of epilepsy has been increased, and the following two items have been added (1) The probability of recurrence within the next ten years after an uninduced (or reflex) seizure is equivalent to the risk of recurrence after two uninduced seizures (at least 60%); ( 2) Epilepsy syndrome.

Epilepsy can be diagnosed when one of the above conditions is met.

When to start epilepsy treatment? (1) Indications for starting medication: If a single or single cluster of epileptic seizures is difficult to confirm and confirm that there is a chronic dysfunction in the brain, the diagnosis must be cautious.
Therefore, it is generally believed that the anti-epileptic seizures can be started after two seizures without trigger Epilepsy medications (AEDs) treatment.

In the following special cases, AEDs treatment can be considered after the first attack: a.
It is not a true first attack.
Before a general tonic-clonic seizure, the patient has a neglected absence or myoclonus seizure form, such The patient is likely to have a seizure again; b.
Partial seizures, a clear cause, focal abnormalities in imaging, seizures during sleep, definite epileptiform discharges on EEG, and abnormal signs of the nervous system, etc.
, These factors indicate an increased risk of reoccurrence; c.
Although it is the first seizure, its typical clinical manifestations and EEG characteristics are consistent with the diagnosis of epilepsy syndrome, such as Lennox-Gastaut syndrome, infantile spasm, etc.
; d.
The patient himself and The guardian thinks that the recurrence is unacceptable, and can explain the risks and benefits of treatment to him, and start AEDs treatment after consultation with him.

(2) The dose and timing of epilepsy treatment recommended by Chinese and foreign guidelines should start from a smaller dose and slowly increase until the seizure can be controlled or the maximum tolerable dose; usually, the use of AEDs is recommended after the second seizure; Circumstances, treatment is started after the first uncaused seizure: a) The patient has brain dysfunction; b) EEG indicates a clear epileptiform discharge; c) The patient or guardian thinks that he cannot bear the risk of another attack; d) Head imaging Show brain structure damage.

The choice of anti-epileptic drugs? What are the anti-epileptic drugs recommended by the Chinese guidelines in 2015 and the adjustment of the dose selection drugs? Should I change the dressing OR add the treatment after the initial treatment of epilepsy fails? When the initial anti-epileptic treatment is not effective, or AED1 (the first anti-epileptic drug) has a significant dose-effect relationship, the dose should be gradually increased until the epilepsy is controlled or no obvious adverse reactions occur.

If the epilepsy is not adequately controlled, adverse reactions occur, and a different drug (replacement drug) or additional drug (combination therapy) should be used: if AED1 is completely ineffective, AED2 (the second antiepileptic drug) should be used immediately to replace AED1 single drug treatment.

If AED1 can partially control epilepsy, AED1 can be added without withdrawal.

If AED1+AED2 can completely control epilepsy for 2-3 months, AED1 can be considered to be withdrawn.

The selection criteria of AED2 are the same as those of AED1, and the potential interaction between AED2 and AED1 should also be considered.

The principle of withdrawal? No epilepsy clinical seizures for 3 years; video electroencephalogram (VEEG) is normal; no predisposing factors for epilepsy recurrence.

In 2014, ILAE proposed the concept of resolved epilepsy.

Those who have exceeded the prevalence of a certain age-dependent epilepsy syndrome, have no seizures for 10 years, and have stopped AEDs for the past 5 years can be considered to be relieved of the diagnosis of epilepsy.

The overall treatment strategy for epilepsy These drug adjustment programs usually take several months to several years; if the drug treatment is not effective, surgery can be considered.

If MRI shows clear lesions and corresponding clinical manifestations, you can switch to surgery after trying 2-3 optimal doses of AED treatment, but it usually takes 2-3 years.

Surgical treatment of epilepsy.
Surgical treatment of epilepsy is the most important treatment option besides drugs.
The surgical indications include: drug-refractory epilepsy; disease-related epilepsy, such as focal cerebral cortical dysplasia and hippocampal sclerosis.

For those undergoing surgery, the precise location of the epileptic area and the distribution of important functional areas in the surrounding cerebral cortex must be strictly evaluated before the operation, and it must be completed in an experienced epilepsy center.

Including: resection surgery; surgery to block the passage of electrical discharge; destructive surgery: X-knife, γ-knife; neuromodulation: transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), vagus nerve stimulation ( VNS), percutaneous vagus nerve stimulation (tVNS).

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