Seizure treatment in transplant patients.
Seizure treatment in transplant patients.
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移植患者的癫痫发作治疗。
DOI：
10.1007/s11940-012-0180-y
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发表时间：
2012-08
影响因子：
2
通讯作者：
St Louis, Erik K.
中科院分区：
文献类型：
--
作者：
Shepard, Paul W.;St Louis, Erik K.
关键词：
实体器官移植常常因一系列癫痫类型而变得复杂，包括单次部分性发作或全身强直阵挛性癫痫发作、急性重复性癫痫发作或癫痫持续状态，有时还可能演变为症状性癫痫。目前尚无涉及移植患者群体的具体证据来指导抗癫痫药物 (AED) 治疗的选择、给药或持续时间，因此熟悉临床 AED 药理学并应用合理的判断对于成功的患者治疗结果至关重要。必须对症状性癫痫发作病因进行初步详细研究，包括代谢性、感染性、脑血管性和钙调神经磷酸酶抑制剂治疗相关的神经毒性并发症，如可逆性后部脑病综合征 (PRES)，因为如果不及时发现和适当治疗，潜在的中枢神经系统疾病可能会对大脑或全身健康造成额外的严重风险。移植后癫痫发作管理的主要方法是针对可疑癫痫发作类型的 AED 治疗。不利的药物相互作用可能会使移植器官面临风险，因此选择相互作用潜力有限的 AED 也至关重要。当移植器官功能障碍或易发生排斥反应时，肝移植后患者倾向于使用没有大量肝脏代谢的AED，而肾移植后，主要通过肾脏消除的AED可能需要调整剂量以防止不良反应。左乙拉西坦、加巴喷丁、普加巴林和拉科酰胺是治疗移植后患者部分性癫痫发作的首选药物，因为它们具有疗效谱、通常具有良好的耐受性，并且缺乏药物相互作用的可能性。左乙拉西坦是移植后患者原发性全身性癫痫发作的首选药物。当需要静脉注射药物来治疗急性癫痫发作时，苯二氮卓类药物和磷苯妥英是传统且最佳的循证选择，尽管静脉注射左乙拉西坦、丙戊酸和拉科酰胺是新兴选择。几种新型 AED 的出现极大地扩展了安全有效治疗移植后癫痫发作的治疗手段，但未来还需要针对这一特定患者群体进行前瞻性临床试验和药代动力学研究。
Solid organ transplantation is frequently complicated by a spectrum of seizure types, including single partial-onset or generalized tonic-clonic seizures, acute repetitive seizures or status epilepticus, and sometimes the evolution of symptomatic epilepsy. There is currently no specific evidence involving the transplant patient population to guide the selection, administration, or duration of antiepileptic drug (AED) therapy, so familiarity with clinical AED pharmacology and application of sound judgment are necessary for successful patient outcomes. An initial detailed search for symptomatic seizure etiologies, including metabolic, infectious, cerebrovascular, and calcineurin inhibitor treatment-related neuro-toxic complications such as posterior reversible encephalopathy syndrome (PRES), is imperative, as underlying central nervous system disorders may impose additional serious risks to cerebral or general health if not promptly detected and appropriately treated. The mainstay for post-transplant seizure management is AED therapy directed toward the suspected seizure type. Unfavorable drug interactions could place the transplanted organ at risk, so choosing an AED with limited interaction potential is also crucial. When the transplanted organ is dysfunctional or vulnerable to rejection, AEDs without substantial hepatic metabolism are favored in post-liver transplant patients, whereas after renal transplantation, AEDs with predominantly renal elimination may require dosage adjustment to prevent adverse effects. Levetiracetam, gabapentin, pregabalin, and lacosamide are drugs of choice for treatment of partial-onset seizures in post-transplant patients given their efficacy spectrum, generally excellent tolerability, and lack of drug interaction potential. Levetiracetam is the drug of choice for primary generalized seizures in post-transplant patients. When intravenous drugs are necessary for acute seizure management, benzodiazepines and fosphenytoin are the traditional and best evidence-based options, although intravenous levetiracetam, valproate, and lacosamide are emerging options. Availability of several newer AEDs has greatly expanded the therapeutic armamentarium for safe and efficacious treatment of post-transplant seizures, but future prospective clinical trials and pharmacokinetic studies within this specific patient population are needed.
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