The goal of treating epilepsy is to completely stop seizures without neuropsychiatric, somatic side effects, as well as to ensure the pedagogical, professional and social adaptation of the patient.
Since all antiepileptic drugs are potentially toxic, and treatment in almost all cases should be long and intensive, the decision on treatment is based on the prediction of positive results in relation to possible side effects.
The question of the need for therapy is decided strictly individually, taking into account the patient’s age, the form of epilepsy, neurological and mental status, comorbidities, and social factors. You can refrain from anticonvulsant therapy in cases of a single epileptic seizure, with established benign forms of idiopathic epilepsy (rolandic), the patient’s unwillingness to take anticonvulsants.
If a decision is made to start anti-epileptic therapy, then certain principles of medical therapy for epilepsy should be followed.
General principles for the selection of antiepilegic drugs
Monotherapy (!) With the 1st row drug.
Preparations of the 1st row for partial seizures – valproates and carbamazepines. When generalized seizures – tonic-clonic, absences (in combination with generalized tonic-clonic seizures), myoclonic, etc. 1st row drugs are valproates. With simple absences, valproate and ethosuximide. With insufficient efficiency, lamotrigine is used.
After consecutive attempts to use several drugs in monotherapy with its ineffectiveness, polytherapy is possible. In these cases, with the continuation of seizures on the background of monotherapy, it is advisable to attach the 2nd drug.
It is necessary to take into account the possible adverse interaction of drugs. The abolition of the drug – a gradual, with the obligatory account of the form of epilepsy and its prognosis.
Consideration of the interests of the patient (balance of effectiveness, side effects, cost of drugs). In the selection of drugs, first of all, take into account the type of attacks. So, with partial
seizures with or without secondary generalization of the drugs of choice are valproates and carbamazepines. Phenobarbital and phenytoin are effective, but they are not the drugs of choice because of their high toxicity. New drugs (lamotrigine, topamax) are used for treatment-resistant choice of epilepsy, as a rule, as an additional therapy (in some cases monotherapy is possible).
For generalized tonic-clonic seizures, valproates and carbamazepines are the drugs of choice. With absences combined with tonic-clonic seizures, valproate, with simple absences, valproate and ethosuximide. Also, with generalized seizures, lamotrigine is effective (in cases of poor tolerability, lack of efficacy of the drugs of choice). In myoclonic seizures, valproate is the drug of choice. Clonazepam, lamotrigine is also used. For undifferentiated seizures, valproatum should be prescribed.
Since epilepsy is a disease that requires long-term, long-term (at least 2 years after the cessation of seizures) therapy, the anticonvulsant drug must meet a number of requirements:
To be effective for different types of seizures.
Do not have side effects, teratogenic and mutagenic effects. This is especially important in the treatment of patients with epilepsy, since among patients there are a significant number of children and the elderly, as well as potentially able-bodied young people. Modern AED should not have a negative impact on cognitive functions (memory, attention, speed of thinking), as well as physical, mental and sexual activity.
Do not interact with other drugs.
Have a linear pharmacokinetics that does not require constant determination of serum concentrations.
Have a convenient form and convenient mode of administration, which reduces the patient’s psychological dependence on the medication.
The standards of the International League include the following antiepileptic drugs:
Traditional: valproatol, carbamazepines, phenytoin, phenobarbital, primidone, ethosuximide, clonazepam, clobazam, acetazolamide, ACTH, pyridoxine, diazepam.
New: lamotrigine, tiagabin, vigabatrin, gabapentin, topiramate, oxcarbazepine, felbamate. Experimental drugs: zonisamide, levetiracetam, rematsemid, styripetol.