Beth Israel Deaconess Medical Center, Boston, MA, USA,
Curr Treat Options Neurol. 2013 Aug;15(4):529-43. doi: 10.1007/s11940-013-0237-6.
HIV(+) patients are at increased risk for developing seizures due to the vulnerability of the central nervous system to HIV-associated diseases, immune dysfunction, and metabolic disturbances. In patients with acute seizures, standard protocols still apply with urgent seizure cessation being the priority. Management of the person with established epilepsy who contracts HIV is challenging, but the decision to initiate chronic antiepileptic drug (AED) therapy in an HIV(+) patient is also difficult. Chronic treatment guidelines emphasize the interactions between AEDs and antiretroviral (ARV) medications, but provide no explicit advice regarding when to initiate an AED, what medication to select, and/or the duration of treatment. Epidemiologic data regarding seizure recurrence risk in HIV(+) individuals is not available. The risk of further seizures likely depends upon the underlying etiology for the seizure(s) and patients' immune status and may be increased by the use of efavirenz (an ARV). The issues for consideration include AED-ARV interactions, organ dysfunction, seizure type, and drug side effects, which may worsen or be confused with symptoms of HIV and/or epilepsy. Co-administration of enzyme inducing (EI)-AEDs and ARVs can result in virological failure, breakthrough seizure activity, AED toxicity, and/or ARV toxicity. Where available, the AED of choice in HIV(+) patients is levetiracetam due to its broad spectrum activity, ease of use, minimal drug interactions, and favorable side effect profile. Lacosamide, gabapentin, and pregabalin are also favored choices in patients with partial onset seizures and/or those failing levetiracetam. Where newer AEDs are not available, valproic acid may be the treatment of choice in terms of an AED, which will not cause enzyme induction-associated ARV failure, but its side effect profile causes other obvious problems. In resource-limited settings (RLS) where only EI-AEDs are available, there are no good treatment options and further pressure needs to be placed upon policymakers to address this care gap and public health threat.
HIV(+) 患者由于中枢神经系统易受 HIV 相关疾病、免疫功能障碍和代谢紊乱的影响，发生癫痫发作的风险增加。对于急性癫痫发作的患者，仍需遵循标准方案，紧急终止癫痫发作是首要任务。对于患有癫痫且感染 HIV 的患者，管理起来具有挑战性，但决定对 HIV(+) 患者启动慢性抗癫痫药物 (AED) 治疗也颇具难度。慢性治疗指南强调了 AED 与抗逆转录病毒 (ARV) 药物之间的相互作用，但并未就何时启动 AED、选择何种药物以及/或治疗持续时间提供明确建议。有关 HIV(+) 个体癫痫复发风险的流行病学数据尚不可用。再次发生癫痫的风险可能取决于癫痫发作的潜在病因以及患者的免疫状况，并且可能因使用依非韦伦（一种 ARV）而增加。需要考虑的问题包括 AED-ARV 相互作用、器官功能障碍、癫痫发作类型和药物副作用，这些可能会加重或与 HIV 和/或癫痫的症状混淆。酶诱导 (EI)-AED 和 ARV 的联合使用可能导致病毒学失败、突破性癫痫活动、AED 毒性和/或 ARV 毒性。在有条件的情况下，HIV(+) 患者的首选 AED 是左乙拉西坦，因为它具有广谱活性、使用方便、药物相互作用少以及良好的副作用特征。拉科酰胺、加巴喷丁和普瑞巴林也是部分发作性癫痫和/或左乙拉西坦治疗失败患者的首选药物。在没有新型 AED 的情况下，丙戊酸可能是一种治疗选择，因为它不会引起与酶诱导相关的 ARV 失败，但它的副作用特征会带来其他明显的问题。在资源有限的环境 (RLS) 中，仅提供 EI-AED，因此没有良好的治疗选择，需要进一步向决策者施压，以解决这一护理差距和公共卫生威胁。
