抗癫痫药物应用专家共识

Expert consensus opinion in treatment of epilepsy Electroencephalogram and Epilepsy Chapter, Chinese Society of Neurology

目的编制我国抗癫痫药物应用专家共识。方法采用无记名问卷调查形式，收集我国三级医院中成人神经科专科医生有关抗癫痫药物的应用经验与评价。调查内容为特发性全面性癫痫与症状性部分性癫痫的药物治疗，以及特殊人群与伴有共患病患者的抗癫痫药物应用。药物评价标准采用九级分级制。药物治疗策略评价根据专家评分所得均数、标准差与95％可信区间（95％CI），分为首选药物、一线、二线与三线药物。结果发出问卷50份，回收49份（98％）。49名专家中，男性38名（77．6％），女性11名（22．4％），年龄（53．9±10．8）岁（35～81岁），平均从业时间（17．9±10．2）年（3～45年），所有专家每月诊治癫痫患者20～800例（中位数100例）。总体治疗策略中，有关特发性全面性癫痫与症状性部分性癫痫的首选治疗，100％的专家选择单药。丙戊酸是新诊断特发性全面性癫痫的一线药物且惟一的首选药物。症状性部分性癫痫的初始药物首选均为卡马西平和奥卡西平。在特发性全面性癫痫药物治疗中，丙戊酸是与其他药物联合治疗的首选药物。症状性部分性癫痫的药物治疗中，卡马西平（奥卡西平）＋托吡酯、卡马西平（奥卡西平）＋左乙拉西坦、卡马西平（奥卡西平）＋丙戊酸、丙戊酸＋拉莫三嗪等是常用配伍。拉莫三嗪为健康育龄期妇女特发性全面性癫痫与症状性部分性癫痫的首选用药；伴抑郁的癫痫患者，特发性全面性发作的首选用药为丙戊酸与拉莫三嗪，继发性部分性发作的首选用药为拉莫三嗪、奥卡西平与卡马西平；伴有乙肝的癫痫患者，无论肝功能是否正常，特发性全面性发作的首选用药为托吡酯与左乙拉西坦，肝功能正常的继发性部分性患者，首选用药为奥卡西平，肝功能指标异常时，首选用药为托吡酯与左乙拉西坦；急诊室中的癫痫患者（不确定类型）首选丙戊酸与左乙拉西坦。结论本共识归纳专家的临床经验，将对癫痫的药物治疗有帮助。

Objective To prepare expert consensus opinion in treatment of epilepsy in China. Methods To sent an anonymous questionnaire on the treatment of adolescent and adult epilepsy syndromes to a group of hospital neurologists in the field of epilepsy. The questions were formatted to simulate real-world clinical situations in the treatment of symptomatic localization related epilepsy （SLRE）, idiopathic generalized epilepsy （IGE） , and treatment in special patient populations and patients with comorbidity. The experts were asked to rate treatment options based on a modified RAND 9-point scale （with ＂9＂ most appropriate and ＂1＂ least appropriate）. Statistical analysis of data was performed as defined by the expert consensus method. The results were used to develop user-friendly recommendations concerning overall treatment strategies and choice of specific medications. Results Of the 50 experts to whom the survey was sent, 49 （98%） responded. Of the respondents, 11 （22.4%） were female and 38 （77. 6% ） male. Theirmean age was 53.9 years, with a mean of 17.9 years in practice. The median number of patients seen per month was 100 （ range, 20 to 800 ）. For initial monotherapy of IGE （ generalized tonic-clonic （ GTC ）, absence, and myoclonic seizures） , valproate was rated as treatment of choice. Treatment options were rated for 3 types of SLRE ： simple partial seizures （ SPS ） , complex partial seizures （ CPS ） , and secondarily generalized tonic-clonic seizures （SGTC）. In SLRE-SPS and SLRE-CPS, carbamazepine and oxcarbazepine were treatments of choice, with lamotrigine, topiramate and levetiracetam as second line agents. In SLRE- SGTC, carbamazepine, lamotrigine and oxcarbazepine were treatments of choice, while lamotrigine, topiramate, levetiracetam and valproate were also usually appropriate. Valproate was selected as treatment of choice when combined with other AEDs in IGE. For SLRE, combination/add-on therapy of carbamazepine （ oxcarbazepine ） ＋ topiramate, carbamazepine （ oxcarbazepine ） ＋ levetiracetam, carbamazepine （oxcarbazepine） ＋ valproate, valproate ＋ lamotrigine were considered as treatment of choice. For women who are pregnant or trying to conceive, lamotrigine was treatment of choice for both idiopathic generalized epilepsy （IGE） and symptomatic localization related epilepsy （SLRE）. For patients with school-age, lamotrlgine was treatment of choice for IGE, with oxcarbazepine and lamotrigine for SLRE. In people with both epilepsy syndromes who have depression, valproate and lamotrigine were treatment of choice for IGE ; in SLRE, lamotrigine, oxcarbazepine and carbamazepine were treatment of choice. In persons with epilepsy and hepatitis B, whether liver function was normal or not, topiramate and levetiracetam were treatment of choice for IGE; in SLRE with normal liver function, oxcarbazepine was treatment of choice, while topiramate and levetiracetam were selected for SLRE with liver function impairment. Valproate and levetiracetam were treatment of choice for seizures in the emergency department. Conclusions The expert consensus method concisely summarizes expert opinion, and this opinion may be helpful in situations in which the medical literature is scant or lacking.