抗癫痫药物的选择.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,文章内容来源于网络，如果侵权或者不当的地方，请联系我删除或者改正。文章内容仅可参考，不能作为科学依据。谢谢！,The content of this article comes from the Internet.If there is any infringement or improper place,please contact me to delete or correct it.The content of the article can only be referred to,not as a scientific basis.thank you!,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,文章内容来源于网络，如果侵权或者不当的地方，请联系我删除或者改正。文章内容仅可参考，不能作为科学依据。谢谢！,The content of this article comes from the Internet.If there is any infringement or improper place,please contact me to delete or correct it.The content of the article can only be referred to,not as a scientific basis.thank you!,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,文章内容来源于网络，如果侵权或者不当的地方，请联系我删除或者改正。文章内容仅可参考，不能作为科学依据。谢谢！,The content of this article comes from the Internet.If there is any infringement or improper place,please contact me to delete or correct it.The content of the article can only be referred to,not as a scientific basis.thank you!,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,文章内容来源于网络，如果侵权或者不当的地方，请联系我删除或者改正。文章内容仅可参考，不能作为科学依据。谢谢！,The content of this article comes from the Internet.If there is any infringement or improper place,please contact me to delete or correct it.The content of the article can only be referred to,not as a scientific basis.thank you!,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,文章内容来源于网络，如果侵权或者不当的地方，请联系我删除或者改正。文章内容仅可参考，不能作为科学依据。谢谢！,The content of this article comes from the Internet.If there is any infringement or improper place,please contact me to delete or correct it.The content of the article can only be referred to,not as a scientific basis.thank you!,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,文章内容来源于网络，如果侵权或者不当的地方，请联系我删除或者改正。文章内容仅可参考，不能作为科学依据。谢谢！,The content of this article comes from the Internet.If there is any infringement or improper place,please contact me to delete or correct it.The content of the article can only be referred to,not as a scientific basis.thank you!,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,文章内容来源于网络，如果侵权或者不当的地方，请联系我删除或者改正。文章内容仅可参考，不能作为科学依据。谢谢！,The content of this article comes from the Internet.If there is any infringement or improper place,please contact me to delete or correct it.The content of the article can only be referred to,not as a scientific basis.thank you!,Although AEDs are called“,antiepileptic,”,they do not,cure,epilepsy,but just suppress seizures while the medications are in the body,Primary,Types of,s,(focal),seizure,seizure,癫痫发作带来的意外事件：躯体伤害等,认知功能障碍,社会功能障碍,学习,/,就业,/,婚姻,心理和精神障碍、抑郁,/,焦虑,/,精神病,/,羞耻感,医源性损伤。,生活质量降低,生育功能。,不容乐观的的现状,全球有,5,千万癫痫患者，,40%,没有得到有效治疗,1,中国有,800-900,万癫痫患者，约有,2/3,没有得到正确治疗,2,癫痫给社会造成沉重的经济负担，但即使发达国家也很少,有一个针对癫痫病人的完整的防治计划,许多病人对他们自身的疾病缺乏正确的认识,1,特殊癫痫人群在治疗时没有得到相应的考虑,1,儿童,妇女,老年患者,1,Martin J.Brodie,Hanneke M.de Boer,Svein IJohannessenEruopean,European White Paper on Epilepsy.Epilepsia Volume 44.supplement 6.2003,2,，,Natl Med J China,April 10,2002,Vol 82,No.7,1840,1860,1880,1900,1920,1940,1960,1980,2000,0,5,10,15,20,Bromide,Phenobarbital,Phenytoin,Primidone,Ethosuximide,Sodium,v,alproate,Benzodiazepines,Carbamazepine,Vigabatrin,Zonisamide,Lamotrigine,Felbamate,Gabapentin,Topiramate,Fosphenytoin,Oxcarbazepine,Tiagabine,Levetiracetam,More,Year,AEDs,AEDs,的发展,AEDs,分类,窄谱,AEDs,广谱,AEDs,-phenytoin(Dilantin),-valproic acid(Depakote),-phenobarbital,-topiramate(Topamax),-carbamazepine(Tegretol),-levetiracetam(Keppra),-oxcarbazepine(Trileptal),-lamotrigine(Lamictal),-gabapentin(Neurontin),-clonazepam(Klonopin),-pregabalin(Lyrica),-rufinamide(Banzel),-lacosamide(Vimpat),-,zonisamide(Zonegran),-vigabatrin(Sabril),癫痫发作类型,失神,肌阵挛,全面强,直阵挛,复杂部分,性发作,简单部分性发作,PB,PHT,CBZ,VPA,BZ,ESM,VGB,FBM,GBP,LTG,TGB,TPM,广谱的药物有三个药物可以选择,在疗效相当的情况下，需要考虑其他综合因素,Carbamazepine(Tegretol),机制 钠通道,.,成人剂量：,400 mg tid,起始量,200 mg bid,，一周后加量，每次加量,200mg/,日，直到,400 mg tid,药代动力学,口服吸收良好,80%,蛋白结合率,强的肝药酶诱导剂（包括自身诱导），减低药物疗效：华法令、避孕药,肝脏代谢,半衰期,30h,血药浓度：,6-12 g/ml,副作用,胃肠道不适,头晕、头痛、共济失调、复视等,过敏反应,肝炎,发育畸形,低钠血症,/,水中毒,白细胞减少或再障,体重增加,严重的皮疹,called Stevens-Johnson syndrome.,Asian descent with HLA-B*1502 antigen,药物相互作用,肝药酶诱导剂降低其血药浓度,e.g.,苯妥英，苯妥英，利福平,肝药酶抑制剂升高其血药浓度,e.g.,红霉素，异烟肼，维拉帕米,il,，西咪替丁,oxcarbazepine(Trileptal),与卡马西平相似（不产生环氧化物），疗效相当但副作用轻微,（低钠血症除外）,对部分肝药酶代谢有影响,成人剂量,600 mg bid,起始量,150 mg bid,每周增加一次，每次,150mg/d,，最大量,2400mg/d,可以与卡马西平快速调换（,300,200,）,Phenytoin,(Dilantin),机制：钠通道,.,成人剂量,300-400 mg/d,起始量常为,100mg/d,。急诊可以静脉或口服加大剂量。小量调整剂量即可引起血药波动可以较大,口服吸收良好,80-90%,蛋白结合率,肝脏代谢失活,肝药酶诱导剂,饱和型代谢曲线,血浆半衰期,20h,血药浓度：,10-20ug/ml,副作用,:,剂量相关性,:,胃肠道不适,神经系统如头痛、眩晕、共济失调、复视、眼震,镇静,副作用,非剂量相关性,:,牙龈增生,毛发增生,巨幼红细胞性贫血,过敏反应,(,主要是皮肤及口腔粘膜损伤，,Stevens-Johnson syndrome.,),肝炎,少见,致死性发育畸形,出血性疾病,(,幼儿,),骨质疏松,药物相互作用,肝药酶抑制剂增加其血药浓度：氯霉素、异烟肼等,肝药酶诱导剂降低其血药浓度：卡马西平、利福平等,lamotrigine(Lamictal):,广谱,(,肌阵挛除外,),，,多种机制：钠通道，谷氨酸释放,副作用,头昏与疲倦,轻度认知障碍,(thinking),皮疹,特别是加量较快时,其它：头痛、复视、震颤、胃肠不适、共济失调、流感样症状等,对肝药酶无影响,成人剂量,200 mg bid,起始量,25 mg/d,一周后加量，直到,200 mg bid,合并应用丙戊酸时一定缓慢加量。,可用于情绪稳定剂,clonazepam(Klonopin),机制：,GABA,对肌阵挛和皮层下肌阵挛发作、全面性发作有效，部分性癫痫发作部分有效,副作用,镇静（类似安定）,记忆障碍,心境改变,成瘾，药效减低,减药困难,成人剂量,0.5-1.0 mg tid,起始量,0.5 mg qn,如无嗜睡，第二天加至,0.5 mg bid.,一周后仍发作可加量至,0.5 mg tid,phenobarbital(Luminal),机制：,GABA,较强的肝药酶诱导剂，多种癫痫类型，便宜,副作用：,镇静,思考,/,记忆障碍,抑郁、行为异常,长期骨质异常,需要缓慢加量缓慢减量,.During pregnancy,there is a significant rate of birth defects,成人剂量约,100 mg/d,，最大量,240mg/d.,起始量,30 mg,睡前。,需缓慢减药,valproic acid(Depakote),标准的广谱,AEDs,机制,GABA(at least in very high doses),neurotransmitter called NPY to block seizures,maybe also on calcium channels.,成人剂量,250 mg-500 mg tid,but dose can be higher.,起始量,250mg qd,，通常用到,500-1500mg/d,肝脏代谢,口服吸收好,肝药酶抑制剂，降低药物代谢：卡马西平、苯妥英、苯巴比妥、妥泰,半衰期：,15h,对失神、肌阵挛发作有效,对全面性强直阵挛发作有效,对部分性癫痫较卡马西平差,与卡马西平一样可用作情绪稳定剂,副作用：,胃肠道不适（可缓慢加量）,增加食欲和体重,脱发（暂时）,肝毒性,血小板减少,神经管发育畸形（孕妇禁用）,多囊卵巢,gabapentin(Neurontin),安全但疗效差,机制：,GABA,和钙通道,与其它药物无相互作用，不经肝脏代谢，蛋白结合率低，原形肾脏排出,副作用有 动作不稳,体重增加,疲倦,头昏,成人剂量,300-600 mg tid,最大量,1200 mg tid,起始量,300 mg/d,分,3,次或顿服，,1,2,月的时间加量至治疗量。,还可用于慢性疼痛,levetiracetam(Keppra),广谱、认知的副作用较小，起始量可为治疗量,500 mg bid,不与其它药物作用，不与蛋白结合，经肾代谢，无肝药酶作用（,YP450 isoenzymes,epoxide hydrolase,or UDP-glucuronidation,）,副作用,头晕、头昏,疲倦,失眠,易激惹或心境改变,上呼吸道感染,成人,500-1500 mg bid,起始量,250 mg bid,一周后加量,500 mg bid,直到,1000 mg bid,，可达,3000mg/d.,topiramate(Topamax),机制：增加局部酸性环境，从而抑制癫痫发作,.,口服吸收好，食物无影响，蛋白结合率,9-17%,副作用：,思考与记忆障碍（,about 1/3rd,）,肾结石（,1-2%,）,少数可致青光眼,(increased eye pressure),体重减轻,感觉异常,致畸,成人剂量,150-200 mg bid.,起始量,25 mg qd,每周加量一次,25mg,，,bid,，直到,100 mg bid.,或增加至,200 mg bid,也可用于偏头痛,AEDS,的副作用,生活质量,不仅与癫痫的控制有关,还与药物的以下影响有关,认知,心境,(,如 抑郁,焦虑,and,易激惹,),精神运动障碍,性功能障碍,外观改变骨胳,体重等,.,需要停药的副作用,:,Clobazam:,行为异常,易激惹,Topiramate:,语言障碍,青光眼,Levitiracetum:,心境和行为改变,Lamotrigine:,药诊,&SJ syndrome,Zonisamide:,反应迟钝,少汗,Vigabatrin:,视野缺损,肝酶诱导剂,苯妥英钠,卡马西平（自身诱导）,苯巴比妥,奥卡西平,托吡酯（轻微）,经肾代谢药物,加巴喷丁,左乙拉西坦,托吡酯,导致体重减轻,托吡酯,唑胒沙胺,非氨酯,导致体重增加,丙戊酸,卡马西平,加巴喷丁,普瑞巴林,治疗头痛,丙戊酸钠,加巴喷丁,托吡酯,癫痫临床诊治的过程,The Process of Clinical Inference,试验证据,Experimental Evidence,专家意见,Expert Opinion,行动,Action,个人经验,Personal Experience,在某些临床领域缺乏试验数据时专家意见是一个很好的补充,Expert opinion considered a reasonable supplement when data on a topic is incomplete or lacking,癫痫治疗指导意见的优缺点,优点：,治疗选择的推荐建立在大量的随机临床试验（,RCTs),结果的基础上，符合循证医学的原则，具有科学的严谨性，客观性,不足：,滞后性,试验设计不能完全代表临床实际情况,主要指南的最新趋势,NICE(,发表日期,:March 2004),主要趋势（一）,下列情况开始新药治疗,不能从传统抗癫痫治疗中获益,由于以下情况不适合传统抗癫痫药治疗,属于禁忌症范围,与患者正在服用的药物有相互作用（特别是避孕药等）,明显能判断该患者不能耐受传统抗癫痫的治疗,患者处于准备生育期,主要指南的最新趋势,NICE(Issue Date:March 2004),主要趋势（二）,尽量单药治疗,第一次单药治疗失败，换一种药物仍然采取单药治疗（换药过程应谨慎进行）,在下列情况下才可考虑联合治疗,先后应用两种药物单药治疗仍没有达到发作消失,权衡疗效与安全性后，认为患者所受到的利益大于带给他的不利（例如副作用）,主要指南的最新趋势,NICE,主要趋势（三）,药物治疗应取得疗效与安全性的最佳平衡,Get the balance between effectiveness in reducing seizure frequency and tolerability of side effects,主要指南的最新趋势,NICE(Issue Date:March 2004),主要趋势（四）,个性化治疗,儿童：认知功能，语言能力,处于生育年龄的妇女：,尽量选择新药治疗，考虑,与口服避孕药的相互作用（目前的证据显示拉莫三嗪不影响口服避孕药的代谢致畸性,尽量避免使用丙戊酸,老年人：,药物的相互作用,对认知功能的损害,单药,第二次单药,合并两个,AEDs,继续换用其他,AED,单药治疗,专家对特发性全面性癫痫的诊治意见,Karceski S,et al.,Epilepsy Behav,.2001;2:A1-A50.,专家对部分性癫痫的诊治意见,单药,第二次单药,2 AEDs,继续换用其他,AED,单药治疗,开始手术的评估,Karceski S,et al.,Epilepsy Behav,.2001;2:A1-A50.,癫痫的药物治疗,治疗是否恰当,?,何时开始治疗,?,如何开始药物治疗,?,何种药物,?,剂量,?,何时联合治疗,?,药物治疗的风险,?,疗程的长短,?,癫痫的药物治疗,治疗是否适当,?,何时开始治疗,?,如何开始药物治疗,?,何种药物,?,剂量,?,何时联合治疗,?,药物治疗的风险,?,疗程的长短,?,AEDs,的选择因素,痫性发作的类型,癫痫综合症的类型,AEDs,的副作用,年龄与性别,应用的方便性,(,剂量调节的方便性,),经济性,Best first AED,没有统一的用药定式,药物的选择依据,:,疗效,Efficacy,耐受性,Tolerability,方便性,Affordability,Best first AED,疗效,:,主要与发作类型有关,Step.1,明确癫痫综合症的诊断,Step 2,如果诊断不明,尽量明确是否为,JME or,失神,卡马西平,&,苯妥英加重,JME,CBZ,phenytoin,噻加宾,Tiagabine,&vigabatrin:(,氨乙烯酸,),加重失神,Step.3,Valproate,lamotrigine or topiramate,Levitiracetum,癫痫综合征,临床表现,发作期及间期,EEG,表现,发病年龄,病情演变及进展特点,.,家族史,为何要明确癫痫综合征的类型？,有利于明确是否进一步检查病因,有利于药物选择,判断预后,癫痫综合征的用药,癫痫综合征,药物选择,Febrile seizure,Rectal diazepam,Wests syndrome,ACTH,Vigabatrin,Lennox-Gestaut,Valproate,lamotrigine,topiramate,clobazam,BECTS,Carbamazepine,Valproate,Early onset Benign Occipital seizures,Intermittent rectal diazepam,Late onset childhood occipital seizure,carbamazepine,Absence epilepsy,Valproate,Ethosuximide,lamotrigine,Juvenile myoclonic epilepsy,Valproate,Lamotrigine,Best first AED,疗效,:,Step.2:,如果癫痫综合征分不清,尽量排除 青少年肌阵挛,or,失神,CBZ&phenytoin will aggravate JME,CBZ,phenytoin,tiagabine&vigabatrin will aggravate Absences,Step.3;,If the seziure can not be typed,Valproate,lamotrigine or topiramate,Levitiracetum,Best first AED,疗效,:,Step.3:,如果不明，则分清痫性发作类型,部分性,/,原发性全面性发作,Choice of AED,部分性,/,继发全面性强直阵挛,Carbamazepine,phenytoin,valproic acid(sodium valproate),phenobarbital and primidone are all effective,CBZ drug of choice,所有的全面性发作,:,Valproate;drug of choice,失神发作,:,Valproate,Ethosuximide,Best first AED,婴儿癫痫有时不可能区分是否为部分性或全面性,Eg,:,Dravets,syndrome(severe,myoclonic,epilespy,of,chiildhood,),usually presents with,hemiconvulsion,.,Infantile spasm:,Pattern can change from,generalised,to partial seizures,Best first AED,疗效,:,如果痫性发作无法分型或分类,Valproate,lamotrigine or topiramate,Levitiracetum,Best first AED,耐受性,:,Valproate&Carbamazepine are better tolerated,than Pheno or phenytoin,方便性,;,Newer AEDs are costly compared older ones,Newer AEDS,新药的真正优势,?,是否可以替代传统药物,?,新药的高价格是否提示具有高疗效,?,我们如何应用新药,?,Newer drugs,No,疗效,主要区别在于副作用,另一区别是药物的相互作用,Drug choice should be,tailored to the patient,可用于部分性癫痫的新型,AEDs,Lamotrigine,拉莫三嗪,Oxcarbazepine,奥卡西平,Clobazam,氯巴占,Gabapentin,加巴喷丁,and Topiramate,妥泰,疗效与卡马西平或苯妥英相当,新药的耐受性,Gabapentin,Levetiracetum,Lamotrigine,Oxcarbamazepine,Tiagabine,Topiramate,Vigabatrin,耐受性好,治疗中止率高,对认知的影响,Levetiracetum,Lamotrigine,Tiagabine,无显著差异,药物起效时间,?,稳态时间,AEDs,达稳态的时间,药物,半衰期,稳态时间,Phenytoin,15-30 hrs,5-15 days,Carbamazepine,11-17 hrs,3-5 days,Valproate,6-18 hrs,2-4 days,Oxcarbamazepine,8-10 hrs,3-4 days,Lamotrigine,10-15 hrs,5-15 days,Topiramate,20-24 hrs,5 days,Levetiracetum,7-8 hrs,2-3 days,Gabapentin,5-7 days,1-2 days,不恰当的药物选择与癫痫发作,Wrong selection of drugs can worsen seizure,药物,综合征,Carbamazepine,Absence epilepsy,Juvenile myoclonic epilepsy,Progressive Myoclonus E.,Phenytoin,Absence epilepsy,Progressive Myoclonus E,Phenobarbitone,Absence epilepsy,Benzodiazepines,Lennox-Gastaut syndrome,AEDs,可导致加重的癫痫综合征,药物,综合征,Vigabatrin,Absence epilepsy,Epilepsies with myoclonus,Gabapentin,Absence epilepsy,Epilepsies with myoclonus,Lamotrigine,Severe myoclonic epilepsy,Juvenile myoclonic epilepsy,AEDs,可导致加重的癫痫综合征,单药治疗的初始选择,特发性全面性癫痫,（,expert committee,）,CLINICAL SITUATION,GTCS,ABSENCE S,MYOCLONIC EPILEPSY,Initial monotherapy,Valproate,Lamotrigine,Topiramate,Valproate,Ethosuximide,Lamotrigine,Valproate,Second monotherapy,(Valproate failure),Lamotrigine,Topiramate,Levitirecetum,Ethosuximide,Lamotrigine,Zonisamide,Levitiracetum,Topiramate,Second monotherapy,(lamotrigine failure),Valproate,Topiramate,Levitiracetum,Zonisamide,Valproate,Ethosuximide,Valproate,zonisamide,Second monotherapy,(Topiramte failure),Valproate,Lamotrigine,Valproate,Ethosuximde,Lamotrigine,Valproate,如丙戊酸无效,丙戊酸单药治疗无效,拉莫三嗪单药治疗可能也无效,(Nicolson,et al.2004,),选择妥泰或左乙拉西坦可能更好,.,如仅为,GTCS,发作,选择广泛,可添加卡马西平或奥卡西平,部分性癫痫,(expert committee),SIMPLE PARTIAL SEIZURE,COMPLEX PARTIAL SEIZURE,SECONDARILY GENERALISED SEIZURE,Carbamazepine,Carbamazepine,Carbamazepine,Oxcarbamazepine,Lamotrigine,Oxcarbamazepine,Lamotrigine,Oxcarbamazepine,Lamotrigine,Levitiracetum,levitiracetum,Levitiracetum,ILAE/AES Guidelines,According ILAE treatment guidelines,一代,AEDs,：,carbamazepine,phenytoin,对部分性发作单药治疗有效，丙戊酸可能同样有效,According to AAN/AES subcommittees,新型,AEDS,中,lamotrigine,oxcarbazepine,and topiramate,但要治疗有效,ILAE,已把,gabapentin,和,vigabatrin,作为单药治疗选择,.,部分性癫痫药物的选择,如卡马西平有效但耐受性差,可选,oxcarbazepine or lamotrigine.,如,carbamazepine,无效,Levetiracetam or topiramate,可能比,gabapentin or lamotrigine,更有效,valproate,可试用,育龄妇女，没有生育并且不打算受孕,癫痫的类型,一线用药,特发性全面强直阵挛发作,拉莫三嗪,症状性部分性发作,卡马西平,拉莫三嗪,奥卡西平,Steven Karceski,Martha Morrell,Daniel Carpenter.The Expert Consensus Guideline Series Treatment of Epilepsy.Epilepsy Behavior 2,A1-A50(2001).,妊娠或哺乳期妇女,癫痫的类型,一线用药,特发性全面强直阵挛发作,拉莫三嗪,症状性部分性发作,拉莫三嗪,卡马西平,奥卡西平,Steven Karceski,Martha Morrell,Daniel Carpenter.The Expert Consensus Guideline Series Treatment of Epilepsy.Epilepsy Behavior 2,A1-A50(2001).,不伴有严重内科疾患的老年病人,癫痫的类型,一线用药,特发性全面强直阵挛发作,拉莫三嗪,丙戊酸,症状性部分性发作,拉莫三嗪,加巴喷丁,卡马西平,奥卡西平,左乙拉西坦,Steven Karceski,Martha Morrell,Daniel Carpenter.The Expert Consensus Guideline Series Treatment of Epilepsy.Epilepsy Behavior 2,A1-A50(2001).,伴有抑郁症的患者,癫痫的类型,一线用药,特发性全面强直阵挛发作,丙戊酸,拉莫三嗪,症状性部分性发作,卡马西平,奥卡西平,拉莫三嗪,症状性全面强直阵挛发作,丙戊酸,拉莫三嗪,Steven Karceski,Martha Morrell,Daniel Carpenter.The Expert Consensus Guideline Series Treatment of Epilepsy.Epilepsy Behavior 2,A1-A50(2001).,癫痫药物的联合应用,Is treatment justified?,When to start treatment?,How to start drug treatment?,Which AED?,Risks associated AED treatment?,Which dosage?,When should AED combinations be used?,How long should treatment be continued?,单药治疗与多药治疗,?,单药治疗可控制,60%,何时开始联合治疗,?,2,种单药治疗失败后,!,药物抵抗性癫痫,如果患者,2-3,单药治疗失败,:,多药 联合治疗,加用哪种药物？,全面性癫痫的联合用药,DRUG IN USE,RECOMMEDED COMBINATION,Valproate,Lamotrigine,Topiramate,Levetiracetum,zonisamide,部分性癫痫的联合用药DRUG IN USE,RECOMMEDED COMBINATION,Carbamazepine,Levetiracetum,Lamotrigine,Topiramate,Zonisamide,如何联合治疗,?,不同机制药物联合用药,:,e.g.a sodium channel blocker(carbamazepine)with a GABA-ergic agent(valproate);,利用药物间相互作用联合,:,e.g.valproate and lamotrigine.,(enabling lower doses of lamotrigine to be used);,避免同一机制或药代影响不良的药物联用,:,e.g.Carbamazepine and phenytoin,Carbamazepine and Lamotrigine,如联合治疗失败,手术,!,如手术不考虑,重新考虑联合治疗是否是,control,癫痫的药物治疗,Is treatment justified?,When to start treatment?,How to start drug treatment?,Which AED?,Risks associated AED treatment?,Which dosage?,When should AED combinations be used?,How long should treatment be continued?,选择适当的剂量,药物剂量是否适当与种类是否适当一样重要,!,有些药物需要逐渐加量,e.g.CBZ,LTG,TPM and TGB,剂量的应用应该个体化,血药浓度的检测对剂量的调整有指导意义,AEDs,间的相互作用,GPB,Gabapentine,LTG,Lamotrigine,TPM,Topiramate,TGN,Tiagabine,LEV,Levetiracetam,ZON,Zonizamide,OXC,Oxcarbazepine,DPH,CBZ,Pheno,None,None,VPA,None,None,None,