The effectiveness of the treatment of epilepsy leaves much to be desired. Continuous population studies in different regions of New Zealand give the proportion of patients without seizures of the total number treated, equal to 13–28%, while with the correct formulation of the treatment it should be 50–80% . The failure of treatment is largely associated with errors in the diagnosis of the form of epilepsy and the choice of drug. The purpose of this report is to determine the standards and recommendations based on the experience of the International Antiepileptic League (MPEL) experts and the experience of the algorithm for the treatment of focal epilepsies, which constitute more than half of all cases of epilepsy, also taking into account that the main proportion of pharmacoresistant cases that create the greatest treatment problems.
At the suggestion of the Commission on the classification and terminology of the MPEL, all focal epilepsies and epileptic syndromes are divided into: 1) idiopathic focal infancy and childhood, 2) family focal (autosomal dominant) and 3) symptomatic or likely symptomatic focal . Comparison with the Classification of Epilepsy and Epileptic Syndromes 1989 shows changes in terminology and some features of the rubricification. It is proposed to abandon the term “partial” in favor of “focal”. The incorrectness of the term “partial”, i.e. incomplete, partial, is obvious, since it involves some kind of ideal “full form” seizure, of which partial would be a part. The second innovation is the heading focal family (autosomal dominant) epilepsy. These include the few of the idiopathic focal epilepsies of the previous classification, for which the gene is mapped. Finally, the term “cryptogenic” as redundant and implicit is removed from the terminology and instead of it is used “presumably symptomatic”, which previously served to decipher the term “cryptogenic”.
Immediately it should be said that for a long time, the practice of choosing a drug according to the type of epileptic seizure turned out to be insufficient and its formal observance is one of the most frequent causes of therapy failure. The international experience of recent decades has shown that the algorithm of pharmacological treatment of epilepsy should include the form of epilepsy, features of the electroencephalographic (EEG) pattern, the dynamics of clinical symptoms and EEG during treatment. These provisions are particularly important for the effective use of one of the most widely used drugs in the treatment of focal epilepsy – tegretol.
Pharmacological properties of tegretol and principles of clinical use
Tegretol is a pharmacoform of the chemical compound, carbamazepine. Carbamazepine is a derivative of iminostilbene with a carbamyl group in the 6th position, which mainly determines its anticonvulsant effect. Its structural formula, 5-carbamyl-5-H-dibenzazepine, is close to tricyclic antidepressants.
In the metabolism of carbamazepine, carbamazepine-epoxide is produced, which has the same healing properties as the original product, providing a significant prolongation of the anti-epileptic effect. In experiments, carbamazepine effectively suppresses convulsions at maximum electric shock, inhibits high-frequency discharge activity, enhances the inactivation of Na + channels, and delays the recovery of their activity. In addition, carbamazepine reduces the conductivity of Ca2 + channels, affects synaptic transmission, partially blocking the effect of aspartate and glutamate, inhibits the capture of catecholamines in high concentrations, enhances GABAergic inhibition. Obviously, such a variety of neuropharmacodynamic effects leads to a complex positive effect of carbamazepine, which provides not only effective suppression of epileptic seizures, but also a good thymoleptic effect, elimination of behavioral and mental disorders associated with epilepsy.