Wieser H G
Abteilung Epileptologie und Elektroenzephalographie, Universitätsspital, Zürich.
Praxis (Bern 1994). 1996 Jan 23;85(4):74-9.
The modern treatment of epilepsy has improved considerably in all three pillars. More than a century has passed, however, since Sir Charles Locock introduced the bromides in 1857 and Sir Victor Horsely pioneered epilepsy surgery in 1886 (18). In drug therapy, the 'classic AED' of the last decades, i.e. phenobarbital (Hauptmann, 1912) and phenytoin (Putnam and Merrit, 1938) are being largely displaced by valproate (Meunir, 1963) and carbamazepine (Lorge, 1963). Only ethosuximide (Zimmermann, 1951) has continued to maintain its position in 3/s spikewave-absence epilepsy, in particular in the USA (28, 29). Although it is an excellent drug against absences, it has the unpleasant property that it may induce GM seizures and should therefore be combined with a so-called 'GM protector' (mostly phenobarbital). For this reason ethosuximide has been relegated to second place in Europe by valproate. Thus, the decision as to which AED should be employed at the outset has been simplified considerably: actually, with valproate as the drug of first choice, which displays a very broad spectrum of action, we are on the right track for virtually all forms of epilepsy, perhaps with the exception of focal epilepsy (11). Especially in the event of focal epilepsy of temporal origin we employ carbamazepine as the preparation of first choice. In some countries (Denmark), because of the less severe side effects, oxcarbazepine is already preferred (Mogens Dam, personal communication). Considerable experience and knowledge are still required, however, when resistance has developed to traditionally applied classic monotherapy. Here, the range of further treatment can also be greatly extended by the availability of the 'new AED'. A generally accepted protocol for the replacement of one preparation with another first- or second-choice drug and, above all, for the 'right' combination with third-choice preparations can as yet not be compiled. What we need here is the expert epileptologist who has experience with 'theoretically useful' combinations and has an insight into the interactions occurring with such combinations. For several specific epileptic syndromes the 'Königsteiner Working Group of German-Speaking Epileptologists' has given clear and binding recommendations for AED therapy (e.g. for benign juvenile myoclonic epilepsy--Janz syndrome). This working group has also made recommendations for the necessary clinical and laboratory controls in AED therapy with potentially severe side effects (e.g. valproate therapy in high-risk children), which were published and/or are being published and discussed in the 'Epilepsie-Blätter' of the German League against Epilepsy (4). Despite all advances in drug therapy, the number of epilepsy patients not satisfactorily treatable with drug therapy has not been dramatically reduced statistically, so that the other two pillars of epilepsy therapy, i.e. epileptic surgery and behavioural therapy, continue to be very important.
癫痫的现代治疗在所有三个支柱方面都有了显著改善。然而，自1857年查尔斯·洛科克爵士引入溴化物以及1886年维克多·霍斯利爵士开创癫痫手术以来，一个多世纪已经过去了。在药物治疗方面，过去几十年的“经典抗癫痫药物”，即苯巴比妥（豪普特曼，1912年）和苯妥英（普特南和梅里特，1938年），在很大程度上已被丙戊酸盐（默尼尔，1963年）和卡马西平（洛热，1963年）所取代。只有乙琥胺（齐默尔曼，1951年）在3/秒棘慢波失神性癫痫中继续保持其地位，尤其是在美国（28,29）。尽管它是治疗失神发作的优秀药物，但它有一个令人不快的特性，即可能诱发全身强直阵挛发作，因此应与所谓的“全身强直阵挛保护剂”（大多是苯巴比妥）联合使用。出于这个原因，在欧洲乙琥胺已被丙戊酸盐取代而退居第二位。因此，一开始选择哪种抗癫痫药物的决定已大大简化：实际上，以丙戊酸盐作为首选药物，其作用谱非常广泛，对于几乎所有形式的癫痫我们都选对了方向，可能局灶性癫痫除外（11）。特别是对于颞叶起源的局灶性癫痫，我们首选卡马西平作为治疗药物。在一些国家（丹麦），由于副作用较轻，奥卡西平已更受青睐（莫根斯·达姆，个人交流）。然而，当对传统应用的经典单一疗法产生耐药性时，仍需要相当多的经验和知识。在这里，“新型抗癫痫药物”的可用性也可以大大扩展进一步治疗的范围。目前还无法编制出一个普遍接受的方案，用于用另一种首选或次选药物替代一种制剂，最重要的是，用于与第三选择制剂进行“正确”组合。我们这里需要的是有“理论上有用”组合经验并且能够洞察此类组合中发生的相互作用的癫痫专家。对于几种特定的癫痫综合征，“德语区癫痫专家科尼希施泰因工作组”已经给出了关于抗癫痫药物治疗的明确且有约束力的建议（例如对于良性青少年肌阵挛癫痫——扬茨综合征）。该工作组还就具有潜在严重副作用的抗癫痫药物治疗（例如高危儿童的丙戊酸盐治疗）所需的临床和实验室检查提出了建议，这些建议已在德国癫痫联盟的《癫痫学报》上发表和/或正在发表并讨论（4）。尽管药物治疗取得了所有进展，但从统计学上看，药物治疗不能令人满意的癫痫患者数量并没有显著减少，因此癫痫治疗的另外两个支柱，即癫痫手术和行为治疗，仍然非常重要。
