Parsiyel ve jeneralize epilepsili hastalarda antiepileptik tedavi etkinliği

Abstract

3. ÖZET Epilepsinin ilaçla tedavisinde öncelikle nöbet ve sendrom sınıflamasının doğru yapılması, hastaya ve nöbet tipine uygun ilaç seçilmesi en önemli ilkelerdir. Medikal tedavide, uygulanan monoterapi tercih edilir, tek ilaçla nöbet kontrolü sağlanamadığında politerapiye geçiş planlanır. Parsiyel epilepsili olgularda, ilaç tedavisine direnç söz konusu ise ya da ağır yan etkiler ve nöbetler nedeniyle hastanın yaşam kalitesi etkileniyorsa cerrahi tedavi düşünülmelidir. Bu çalışmada kliniğimizde izlediğimiz parsiyel ve jeneralize epilepsili hastalarda retrospektif olarak tedavi etkinliklerinin karşılaştırılması amaçlandı. Çalışmaya Yüzüncü Yıl Üniversitesi Tıp Fakültesi Nöroloji Kliniğinde Mart 1999 -Mart 2003 yılları arasında izlenen 106 hasta dahil edildi. Tüm olgulara nörolojik muayene, rutin laboratuar tetkikleri, EEG ve MRG incelemesi yapıldı. Epilepsili hastaların 45'i erkek, 61'i kadın olup, parsiyel epilepsi grubunda ortalama yaş 22.1 yıl, jeneralize epilepsi grubunda ise ortalama yaş 18.7 yıl idi. 68'i (%65) parsiyel, 38'i (%3 5) jeneralize tipte idi. Hastalık süresi ortalama 2 yıl idi. İstatistiksel analiz; gruplar ortalamaistandart hata ortalaması şeklinde idi. İstatistiki değerlendirmede tek yönlü varyans analizi (ANOVA), ki-kare testi ve Fisher'in extract testi uygulandı. Jeneralize epilepsili 38 hastanın 17' sinde (%45), parsiyel epilepsili 68 hastanın 26'sında (%38) epilepsi için bilinen ve sorgulanabilen risk faktörlerine (kafa travması, aile öyküsü, akraba evliliği, infeksiyon, zor doğum, febril konvülziyon, sarılık geçirme öyküsü) rastlandı. Parsiyel epilepsi grubunda toplam 43 olgu monoterapi, 25 olgu politerapi almaktaydı. Monoterapi alanlardan 24'ü karbamazepin, 13'ü valproik asit, 5'i okskarbazepin, l'i lamotrijin kullanıyordu. Jeneralize epilepsi grubunda toplam 30 olgu monoterapi ve 8 olgu politerapi almaktaydı. Monoterapi alanlardan 12'si karbamazepin, 15'i valproik asit, 3 olgu okskarbazepin kullanıyordu. Her iki grupta karbamazepin ve valproik asit kan düzeyine bakılarak tedavi etkinlikleri açısından yapılan istatistiksel analizde anlamlı farklılık yoktu. Dirençli nöbetleri olan ve monoterapi alan 33 hastada politerapiye geçildi. Karbamazepin alan hastaların 21'inde (%58) tedaviye cevap tamdı, 6'sında (%17) tedaviye kısmi cevap, 9'unda (%25) tedaviye cevap yoktu. Valproik asit alanların 17'sinde (%61) tedaviye tam cevap, 8'inde (%29) tedaviye kısmi cevap, 3'ünde (%11) tedaviye cevap yoktu. Okskarbazepin alan hastaların 6'sında (%75) tedaviye tam cevap, 2'sinde (%25) kısmicevap vardı. Lamotrijin alan 1 hastada tedaviye cevap tamdı. Politerapi alan hastaların 14'ünde (%42) tedaviye cevap tamdı, 14'ünde (%42) kısmi cevap, 5'inde (%16) tedaviye cevap yoktu. Valproik asit kullanan 6 hastadan parsiyel epilepsili olan 5 hastaya lamotrijin; jeneralize epilepsili 1 hastaya da topiramat tedavisi eklendi. Karbamazepin kullanan 18 hastadan parsiyel epilepsili olan 15 hastanın 10'una valproik asit, 5'ine lamotrijin; jeneralize epilepsili 3 hastanın 2'sine topiramat eklendi. Magnetik rezonans görüntüleme (MRG) 72 hastada normal iken 34 hastada patolojik idi. MRG'de patoloji saptanan hastalarla normal olan hastaların tedavi etkinliği açısından yapılan istatistiksel analizde anlamlı farklılık yoktu. EEG çekimi yapılan hastaların 77'sinde epileptik fenomen ile uyumlu bulgular saptanırken, 29'unda nonspesifık EEG bulguları saptandı. EEG'de patoloji saptanan hastalarla normal olan hastaların tedavi etkinliği bakımından istatistiksel anlamlılık yoktu. Epilepside antiepileptik kan düzeyi, EEG ve MRG tedavi sürekliliğine yardımcı olmaktadır. Ancak tedavi etkinliklerini değerlendirmede belirleyici rolü kesin değildir. Politerapiye geçişten sonra tedaviye cevap oranlarında kısmi ancak belirgin olmayan bir artış görülmektedir. Medikal tedaviye dirençli parsiyel epilepsili olgularda cerrahi tedavinin planlanmasının önemli olduğu kanısına varılmıştır.

4.SUMMARY ANTIEPILEPTIC TPvEATMENT EFFICACY IN THE PATIENTS WITH PARTIAL AND GENERALIZED EPILEPSY In order to conduct an effective medication for epilepsy, it is of preliminary importance to have an accurate classification of seizures and syndromes as well as chosing the right drug for the appropriate patient and the type of seizure. In the medical treatment, monotherapy is preferred. Trancision to polytherapy is made in case a single drug is ineffective for bringing the seizures under control. In cases with partial epilepsy, if there emerges a resistance against drug therapy, or if the quality of life of the patient is affected due to severe side effects and seizures, surgical treatment should be considered. In this study, various treatment protocols were compared on a retrospective level and based on cases with partial and generalized epilepsy. One hundredsix cases, followed up between March 1999 and March 2003 in Neurology clinic, Faculty of Medicine, Yuzuncu Yıl University, were included in our study. Ail of the cases have gone through neurological examination, routine laboratory analysis, EEG and MRI examination. Cases with epilepsy constituted 45 males and 61 females. The mean age of the group with partial epilepsy comprised 22.1, the mean age of the group with generalized epilepsy was 18.7. 68 cases were partial (65%) and 38 of them were generalized (35%). The mean period of the disease was 2 years. Statistical analysis was conducted as group average ± standard deviation average. In the statistical evaluation one-way variance analysis (ANOVA), chi-square test and the extract test of Fisher was used. Of the 38 cases with generalized epilepsy 17 (45%) and of the 68 cases with partial epilepsy 26 (38%) were found to have the known and questioned risk factors like head trauma, family history, marriage among relatives, infection difficulty in birth, febrile convulsion, history of jaundice. In the group with partial epilepsy 43 cases had been given monotherapy, and 25 cases polytherapy. Of the cases going through monotherapy 24 used carbamazepine, 1 3 of them valproic acid, 5 of them oxcarbazepine, 1 of them lamotrigine. In the group with generalized epilepsy 30 cases had gone through monotherapy and 8 cases polytherapy. Of the cases going through monotherapy 1 2 had used carbamazepine, 1 5 of them valproic acid and 3 of them oxcarbazepine.No statistically significant difference was found in both groups in terms of treatment protocols and with respect to valproic acid and carbamazepine serum levels. Polytherapy was initiated in 33 patients going through monotherapy and having resistful seizures. A full response to the treatment was obtained in 21 (58%) of carbamazepine-applied cases. There was a partial response in 6 of them (17%), and no response was received in 9 (25%) of them. Full response was received in 17 (61%) of those taking valproic acid, a partial response in 8 of them (29%) and no response in 3 of them (1 1%). Of the oxcarbazepine-applied patients, 6 showed full response to treatment (75%) 2 of them showed partial response (25%). A full response to the treatment was received in a patient applied to lamotrigine. Fourteen (42%) of the patients undergoing polytherapy showed full response to the treatment 14 (42%) of them had a partial response and 5 of them (16%) had no response. Of the 6 patient applied to valproic acid, 5 with partial epilepsy were given lamotrigine and 1 with generalized epilepsy was given topiramate treatment. Of the 18 patients using carbamazepine, 10 in 15 of partial epilepsy were given valproic acid and 5 of them were given lamotrigine. 2 of the 3 patients with generalized were given topiramate. Three-drug combination was needed for 1 of the 9 patients undergoing carbamazepine and valproic acid combined treatment, and the other patient was needed to be given four-drug combination. Whereas MRI was normal in 72 patients it revealed pathological in 34 of the patients. It revealed pathological in 34 of the patients. There was no statistically significant difference between findings revealed pathological in MRI and those which revealed normal in terms of the efficacy of treatment. Whereas findings related with epileptic phenomena in 77 of the patients undergoing EEG examination, nonspesific EEG findings were observed in 29 of the patients. No statistically significant difference was found between pathologically abnormal findings of EEG and those findings which were normal in terms of the efficacy of the treatment. In epilepsy, antiepileptic serum level, EEG and MRI contribute to the continuation of the treatment. However, determining role in the evaluation of treatment protocols is not absolute. In the rate of the responses to the treatment after polytherapy, there is a partial but not remarkable increase. In the patients with partial epilepsy resisted against medical treatment, surgical treatment is supposed to be of crucial significance.