Department of Neurology, University of Utah Clinical Neuroscience Center, George E. Wahlen VA Medical Center, 175 North Medical Drive East, 5th Floor, Salt Lake City, UT 84132, USA.
Epilepsy Behav. 2021 Sep;122:108065. doi: 10.1016/j.yebeh.2021.108065. Epub 2021 Jul 7.
Failure to control epileptic seizures with two medications, adequately chosen and dosed, indicates drug-resistant epilepsy (DRE). The chance of pharmacologically controlling seizures is low for patients with DRE and uncontrolled seizures who are not candidates for surgery, who have already undergone surgery, or who already had a vagus nerve stimulator (VNS) placed. Patients experiencing these conditions must instead rely on medical management of their seizures, and there is no breakthrough solution on the horizon. Medical care of DRE might be optimized by systematically considering factors that promote and inhibit breakthrough seizures. For example, seizure control could be enhanced through measures such as increasing the frequency of follow-up visits, tracking treatment plan compliance, treating sleep disorders, rational polypharmacy, adjusting drug administration to achieve higher levels when seizures are more likely and educating patients on seizure triggers. A systematic and simultaneous implementation of all of these measures is likely to yield a sizable, clinically relevant, improvement. This paper presents an exploratory study on the effects of implementing such an approach, specifically evaluating this method's impact on seizure frequency.
I performed a retrospective chart review of 659 consecutive adult patients with epilepsy followed up at the University of Utah and at the Salt Lake City VA Medical center using the multimodal approach described above. I identified 27 patients who had DRE and uncontrolled seizures and in whom a medical management optimization protocol was implemented. I measured these patients' seizure frequency at the beginning and the end of the study period and compared the results with those of a matching control group of 48 patients.
The optimization protocol did not increase the number of seizure-free patients with DRE; however, it was effective in minimizing seizure frequency in patients whose seizures remained uncontrolled. Among these patients, the median seizure frequency dropped by 64% in the optimization group but did not change in the control group.
Despite the high occurrence of DRE, there is no accepted protocol for the related medical management. This paper describes an effective approach that can be implemented in a clinically relevant and readily achievable manner.
如果两种药物（经过充分选择和剂量调整）仍无法控制癫痫发作，则表明存在药物难治性癫痫（DRE）。对于那些药物治疗无法控制发作、不符合手术条件、已接受手术或已植入迷走神经刺激器（VNS）的 DRE 患者和发作未控制的患者，控制癫痫发作的机会很低。这些患者必须依靠癫痫发作的医疗管理，目前尚无突破性解决方案。通过系统地考虑促进和抑制突破性发作的因素，可能会优化 DRE 的医疗护理。例如，通过增加随访频率、跟踪治疗计划依从性、治疗睡眠障碍、合理联合用药、调整药物管理以在更有可能发作时达到更高水平以及教育患者了解发作诱因等措施，可能会增强癫痫控制。系统地同时实施所有这些措施可能会产生相当大的、具有临床意义的改善。本文介绍了一项关于实施这种方法效果的探索性研究，特别是评估了该方法对癫痫发作频率的影响。
我对在犹他大学和盐湖城退伍军人事务医疗中心接受治疗的 659 例连续成人癫痫患者进行了回顾性图表审查，使用了上述多模式方法。我确定了 27 例 DRE 且癫痫发作未得到控制的患者，并对他们实施了医疗管理优化方案。我在研究开始和结束时测量了这些患者的癫痫发作频率，并将结果与 48 例匹配的对照组患者进行了比较。
该优化方案并未增加 DRE 无发作患者的数量，但确实有效降低了癫痫发作仍未得到控制的患者的癫痫发作频率。在这些患者中，优化组的中位癫痫发作频率下降了 64%，而对照组没有变化。
尽管 DRE 发生率很高，但目前尚无针对相关医疗管理的既定方案。本文描述了一种有效且可在临床相关和易于实现的方式实施的方法。
