Unidad Epilepsia Refractaria, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
Unidad de Epilepsia, Hospital Vithas la Salud, Granada, Spain.
Epilepsy Behav. 2021 Jan;114(Pt A):107540. doi: 10.1016/j.yebeh.2020.107540. Epub 2020 Nov 24.
Following publication in 2014 of the International League Against Epilepsy (ILAE) official report changing the definition of epilepsy, a number of questions remain unresolved in regard to deciding when to start treatment and to the choice of a particular antiseizure medication (ASM). This study uses a Delphi method to update consensus among a panel of experts on the initiation of epilepsy treatment in order to provide insight regarding those questions. The study was undertaken in four phases. Firstly, a multi-center steering committee met to review relevant bibliography and to draft a questionnaire. Secondly, a panel of neurologists specialized in epilepsy was selected and convened. Thirdly, an online survey was carried out in two rounds. Fourthly, the final results were discussed at a face-to-face meeting of the steering committee to draw conclusions. The final questionnaire focused on three independent sections: the decision to commence ASM in different clinical situations, the choice of initial monotherapy depending on the type of epilepsy and the patient's age/sex (including childbearing potential), and the choice of initial monotherapy depending on comorbidity. In these two latter sections, fourteen ASMs approved for monotherapy use by the EMA and available in Spain were considered. Regarding the decision as to when to commence treatment, the results show agreement exists to initiate treatment following a first generalized tonic-clonic seizure or a focal seizure if the electroencephalography (EEG) reveals epileptiform activity, if the MRI reveals a lesion, or when it occurs in elderly patients. With respect to the choice of initial monotherapy depending on the type of epilepsy and the patient's age/sex profile, it is agreed to avoid valproic acid (VPA) in women with childbearing potential, with levetiracetam (LEV) and lamotrigine (LTG) being the preferable options in generalized epilepsy. In focal epilepsy, the options are broader, particularly in men, and include the most recent ASMs approved for monotherapy. In the elderly, LEV, lacosamide (LCM), eslicarbazepine acetate (ESL) and LTG are considered the most suitable drugs for initiating treatment. With regard to comorbidities, the recommendation is to avoid enzyme inducing ASMs, with LEV, the most recent ASMs approved for monotherapy and LTG being the preferred options. In conclusion, as the ILAE definition states, there are different situations that lead to treatment initiation after a first seizure. When choosing the first ASM, the type of epilepsy, childbearing potential and drug-drug interaction are key factors.
继 2014 年国际抗癫痫联盟（ILAE）发布官方报告修改癫痫定义后，关于何时开始治疗以及选择特定抗癫痫药物（ASM）的问题仍未得到解决。本研究采用德尔菲法，更新了一组专家对癫痫治疗启动的共识，以期深入了解这些问题。研究分四个阶段进行。首先，一个多中心指导委员会开会审查了相关文献，并起草了一份问卷。其次，选择并召集了一组专门研究癫痫的神经病学家组成专家组。然后，进行了两轮在线调查。最后，在指导委员会的一次面对面会议上讨论了最终结果以得出结论。最终的问卷集中在三个独立的部分：在不同的临床情况下开始使用 ASM 的决定、根据癫痫类型和患者的年龄/性别（包括生育潜力）选择初始单药治疗，以及根据合并症选择初始单药治疗。在后两个部分中，考虑了欧洲药品管理局批准用于单药治疗且在西班牙可用的 14 种 ASM。关于何时开始治疗的决定，结果表明，在首次全面强直阵挛发作或局灶性发作后，如果脑电图（EEG）显示癫痫样活动、MRI 显示病变或发生在老年患者中，可开始治疗。关于根据癫痫类型和患者的年龄/性别选择初始单药治疗的问题，专家组一致认为，在有生育潜力的女性中避免使用丙戊酸（VPA），在全面性癫痫中，左乙拉西坦（LEV）和拉莫三嗪（LTG）是首选药物。在局灶性癫痫中，选择范围更广，特别是在男性中，包括最近批准用于单药治疗的 ASM。在老年患者中，LEV、拉科酰胺（LCM）、依佐加滨（ESL）和 LTG 被认为是启动治疗的最合适药物。关于合并症，建议避免使用酶诱导型 ASM，LEV、最近批准用于单药治疗的 ASM 和 LTG 是首选药物。总之，正如 ILAE 定义所述，首次发作后有不同的情况会导致开始治疗。在选择第一种 ASM 时，癫痫类型、生育潜力和药物相互作用是关键因素。
