儿童原发性癫痫治疗指南(6)

儿童癫痫指南

seizure type or syndrome type with possibleadverse effects and co-morbidities taken intoaccount(37,38).

All drugs are started in low doses and increasedgradually upto a maximum dose till seizurecontrol is achieved or side effects appear.

Dosage needs to be adjusted to the child’s dailyactivity. Extended release formulations in twice aday dosing are preferable(39).

If no control is obtained with maximum doses ofthe first drug, then a second first line drug isinitiated and the first drug tapered(38). If partialcontrol is achieved(37), then a second AEDshould be added. All efforts should be made touse only rational polytherapy.

There are no significant differences in theefficacy or tolerability of the four major first lineanticonvulsants (phenobarbitone, phenytoin,valproate and carbamazepine) and any one can beused first(40), based on side effect profile.Carbamazepine and valproate appear to be bettertolerated than phenobarbitone and phenytoin.A seizure diary should be kept by the parents.Therapeutic drug monitoring is useful in onlyfew situations, including breakthrough orrefractory seizures, to assess compliance, fordiagnosis of clinical toxicity or with use ofphenytoin, which has dose dependentpharmacokinetics(41).

In most epilepsy, AED is withdrawn after 2 yearof seizure freedom. Adolescent onset, remotesymptomatic epilepsy and abnormal EEG after 2years are predictors of relapse(42), warrantingdrug withdrawal after 4 years(43). Drugwithdrawal is over 3-6 months(44,45) and onedrug at a time in cases of polytherapy.

side effects remain a concern, it should be avoided inschoolgoing children.Phenytoin

Though effective, should not be preferred as aprimary AED in newly diagnosed epilepsy,especially in infancy, as levels fluctuate frequently ininfants, making monitoring of drug levelsimperative(41), and in adolescent girls as cosmeticside effects may be unacceptable(48). Maintenancedosages in older children are between 5-6 mg/kggiven in one or two divided doses, but infants mayneed upto 15-18 mg/ kg in 3-4 divided doses.Valproate

As a result of its broad spectrum of efficacy,valproate could be the drug of choice for mostchildren with newly diagnosed epilepsy, likeidiopathic generalized epilepsy (CAE, JAE, BMEI,and JME), epilepsies with prominent myoclonicseizures or with multiple seizure types, andphotosensitive epilepsies(49). However, in adole-scent girls or obese patients, one may not use it asfirst line agent due to concerns of weight gain, hairloss and aggravation of polycystic ovarian disease(PCOD), which should be specifically lookedfor(50). Hair loss may be reduced by use ofsupplemental biotin(51). It could be used in partialepilepsies in infants where carbamazepine mightprecipitate generalized seizures and in refractorystatus epilepticus. The dose averages between 10-40mg/kg/day. Twice-a-day dosing is preferred withextended release preparations(39), except in syrup (3times a day). Parents should be counseled regardingdanger symptoms and signs of hepatitis, like nausea,vomiting, drowsiness etc, especially in childrenbelow the age of 2 years, those on polytherapy andthose with associated IEM, necessitating routinemonitoring of LFT. Enzyme elevation upto twicenormal or borderline elevation of ammonia can bedisregarded when asymptomatic. The drug must bestopped immediately in all symptomatic patientsirrespective of enzyme levels. In case the cause of thehepatitis becomes clear e.g. hepatitis A confirmed byserology, then valproate could be restarted after thehepatitis has resolved. In cryptogenic hepatitis it isbest avoided. Carnitine supplements are notroutinely recommended(52).

10. Conventional Antiepileptic DrugsPhenobarbitone

Phenobarbitone could be used as a first line AED inneonatal seizures(46), in the first two years of life forpartial/GTC seizures(47) and in neonatal and earlyinfantile status epilepticus(SE). The dosage variesbetween 3-6 mg/kg/day given as a single night-timedose for routine use and 20 mg/kg given as loadingfor SE. Since deleterious cognitive and behavioral

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