Affordability, availability and tolerability of anti-seizure medications are better predictors of adherence than beliefs: Changing paradigms from a low resource setting

Availability, price, and affordability of antiseizure medicines in Addis Ababa, Ethiopia

OBJECTIVE

Up to 70% of people living with epilepsy could become seizure-free with the appropriate use of antiseizure medicines. However, three quarters of people with epilepsy living in low-income countries do not get the treatment they need and also do not access antiseizure medicines. The purpose of this study was to assess the availability, price, and affordability of antiseizure medicines in Addis Ababa, Ethiopia.

METHODS

A cross-sectional study was done in selected pharmacies using a questioner developed after the modification of World Health Organization/Health Action International methodology. Data on the availability and price of lowest-priced generics and originator brand antiseizure medicines from essential medicines list in Ethiopia were collected from seven public sectors, five private sectors, and seven other sectors (five Kenema Public Community and two Red Cross Pharmacies) in Addis Ababa between 09 May and 31 2022. The data were analyzed using the modified World Health Organization/Health Action International workbook part I excel sheet. Descriptive results were reported in text and table format.

RESULTS

The overall availability of lowest-priced generics medication was 52%. The availability of lowest-priced generics was 62.86%, 30%, 55%, and 50% in public, private, Red Cross, and Kenema Public Community Pharmacies, respectively. The median price ratio in the public, private, Red Cross, and Kenema Public Community Pharmacy was 1.45, 3.72, 1.46, and 1.7, respectively. All the medications were unaffordable. Patients may be required to pay more than 6-month wage to purchase standard treatment for 1 month only.

SIGNIFICANCE

The overall availability of antiseizure medicines was lower than the WHO target for noncommunicable diseases. All the available medicines were unaffordable.

Medication self-management in predominantly African American and Caribbean American people with epilepsy: The role of medication beliefs and epilepsy knowledge

INTRODUCTION

Suboptimal medication adherence is common in people with epilepsy (PWE) and disproportionally prevalent among racially/ethnically diverse patients. Understanding reasons and risks of suboptimal adherence is critical to developing interventions that reduce negative health outcomes. This cross-sectional study characterized common barriers to medication self-management, prevalence of negative medication beliefs, and gaps in epilepsy knowledge among predominantly African American and Caribbean American PWE and examined their interrelationships.

MATERIALS AND METHODS

Sixty-three PWE (Age = 42.1 ± 13.2; 60% female; 79% Black; 19% Hispanic/Latino) completed validated self-report questionnaires about medication self-management, medication beliefs, and epilepsy knowledge. Correlations and t-tests examined interrelationships.

RESULTS

Four barriers to medication self-management were common, including not taking antiseizure medications at the same time every day, forgetting doses, not planning refills before running out, and spreading out doses when running low. More than half the sample believed medications were overused by prescribers. Nearly one-third believed medications were harmful, and nearly a quarter believed their antiseizure medications were minimally necessary with almost half reporting elevated concerns about negative consequences of antiseizure medications. Poorer medication self-management was associated with stronger beliefs that medications in general are harmful/overused by prescribers. Individuals who were "accepting" of their antiseizure medications (i.e., high perceived necessity, low concerns) were less likely to spread out time between doses when running low compared to non-accepting counterparts. Knowledge gaps related to the cause of seizures/epilepsy, chronicity of epilepsy treatment, and seizure semiology/diagnosis were common. Nevertheless, epilepsy knowledge was unrelated to medication self-management and medication beliefs.

CONCLUSIONS

In these PWE, the most prevalent reasons for suboptimal medication self-management were behaviorally mediated and potentially modifiable. Negative medication beliefs and misconceptions about epilepsy and its treatment were common. Results further suggest that interventions addressing negative medication beliefs will be more effective than knowledge-based psychoeducation alone to improve medication self-management in this patient population.

Current Principles in the Management of Drug-Resistant Epilepsy

Drug-resistant epilepsy is associated with poor health outcomes and increased economic burden. In the last three decades, various new antiseizure medications have been developed, but the proportion of people with drug-resistant epilepsy remains relatively unchanged. Developing strategies to address drug-resistant epilepsy is essential. Here, we define drug-resistant epilepsy and emphasize its relationship to the conceptualization of epilepsy as a symptom complex, delineate clinical risk factors, and characterize mechanisms based on current knowledge. We address the importance of ruling out pseudoresistance and consider the impact of nonadherence on determining whether an individual has drug-resistant epilepsy. We then review the principles of epilepsy drug therapy and briefly touch upon newly approved and experimental antiseizure medications.

Excessive Daytime Sleepiness and Sleep Quality and their Impact on Health-Related Quality of Life in People with Epilepsy: A study from Pakistan

BACKGROUND

Epilepsy is one of the most common but manageable neurological disorder. The relation between epilepsy, sleep, and health-related quality of life (HRQoL) in culturally distinct environment of Pakistan remains unclear. The purpose of this study was to determine prevalence and predictors of excessive daytime sleepiness (EDS), poor sleep quality (SQ), and to analyze their association with HRQoL in people with epilepsy (PWE).

METHODS

A study was conducted among PWE attending two tertiary care hospitals of Islamabad and Rawalpindi, Pakistan. The EDS, SQ, and HRQoL were evaluated by Urdu versions of Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), and Quality of Life in Epilepsy-31 (QOLIE-31).

RESULTS

The study included 200 PWE and 51 healthy controls with mean (SD) ages of 33.1 ± 13.9, 32.9 ± 10.9, and a disease duration of 5.01 ± 6.17, respectively. The majority of the respondents (n = 130, 65%) had poor seizure control, and most of these (n = 88, 68%) were on combination antiepileptic drug (AED) therapy. In comparison to controls, a higher number of PWE had EDS by ESS (score ≥ 11, 10% vs. 40%, p-value 0.00), and poor SQ by PSQI (score > 5, 9% vs. 71%, p-value 0.00). A multiple logistic regression analysis reveals that the factors significantly associated with EDS were: female gender; increasing age; seizure control; duration of epilepsy; and combination AED therapy. A second multiple binary logistic regression analysis suggests that factors significantly associated with poor SQ were: increasing age; female gender; poor seizure control; and combination therapy. The Hierarchical multivariate analysis suggests that poor seizure control, EDS, and poor SQ were significant predictors of low HRQoL.

CONCLUSION

The findings suggest high prevalence of EDS and poor SQ in PWE in Pakistan. A significant negative association exists between sleep complaints and HRQoL. During routine clinical consultations, awareness about sleep hygiene practices must be provided to enhance HRQoL.

Effects of the Full Coverage Policy of Essential Medicines on Inequality in Medication Adherence: A Longitudinal Study in Taizhou, China

The full coverage policy for essential medicines (FCPEMs) was proposed and implemented in Taizhou city of Zhejiang Province, China, to promote equal access and adherence to medicines. This study aimed to examine the effects of FCPEMs on the income-related inequality in medication adherence among local patients with hypertension or diabetes. We collected electronic health records of patients with hypertension or diabetes of three districts of Taizhou from 2011 to 2016. As the implementation schedule of the FCPEMs varied across districts, we applied a retrospective longitudinal study design and assigned records from 1 year before to 3 years following the implementation of FCPEMs as baseline and follow-up data. We thus generated a dataset with 4-year longitudinal data. The concentration index (CI) and its decomposition method were employed to measure factors contributing to inequality in medication adherence and the role played by FCPEMs. The sample size rose from 264,836 at the baseline to 315,677, 340,512, and 355,676 by each follow-up year, and the proportion of patients taking free medicines rose from 17.6 to 25.0 and 29.8% after FCPEMs implementation. The proportion of patients with high adherence increased from 39.9% at baseline to 51.6, 57.2, and 60.5%, while CI decreased from 0.073 to −0.011, −0.029, and −0.035. The contribution of FCPEMs ranked at 2nd/13, 7th/13, and 2nd/13 after the implementation of FCPEMs. Changes in CI of medication adherence for every 2 years were −0.084, −0.018, and −0.006, and the contribution of FCPEMs was −0.006, 0.006, and 0.007, ranking at 2nd/13, 2nd/13, and 1st/13, respectively. Most changes in CI of medication adherence can be attributed to FCPEMs. The medication adherence of patients with hypertension or diabetes improved after the implementation FCPEMs in Taizhou, although inequality did not improve consistently. In general, FCPEMs could be a protective factor against income-related inequalities in access and adherence to medicines. Future research is needed to investigate the change mechanism and the optimal design of similar interventions.

Knowledge gap exists among caregivers of adults compared to caregivers of children with epilepsy: a comparative analysis from a low resource setting

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We compared knowledge, attitude, behavior, belief and seizure recognition among CG-A and CG-C.

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Overall performance of caregivers of adults and children in tested domains was good.

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Knowledge-behavior, knowledge-faith and knowledge-seizure recognition gaps existed in CG-A.

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Lack of formal education in CG-A lead to inadequate factual knowledge and the knowledge gaps.

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CG-A need focused education to improve seizure recognition and response and dispel epilepsy myths.

Caregivers of adults (CG-A) and caregivers of children (CG-C) may differ in their knowledge, attitude and behavior and hence their education requirements during epilepsy counseling could vary. This study compares the current knowledge, attitudes, behavior during a seizure, presence of myths surrounding epilepsy and ability to recognize seizures among a sample of CG-A and CG-C. Caregivers of children and adult patients with minimum 6 months history of epilepsy were enrolled. Information was collected using a questionnaire about clinical and demographic details and five domains (KAP-plus); knowledge, attitude, behavior, presence of myths and a video data for identification of focal impaired awareness seizures (FIAS) and generalized tonic-clonic seizures (GTCS). There were 132 CG-A and 127 CG-C. CG-C were younger and better educated compared to CG-A (formal education of 64.6% vs 44.7% p = 0.001). CG-A and CG-C were comparable in the knowledge and attitude domains. CG-A scored less than CG-C in the domains of behavior (15.5 vs 16.8 p = <0.001), myths (15.4 vs 16.2 p = 0.002), video recognition of FIAS and GTCS (0.7 vs 0.94 p = 0.001) and KAP-plus score (22.9 vs 24.6 p = 0.017). The knowledge-behavior or knowing-doing gap, knowledge-faith gap and knowledge-recognition gaps existed more among CG-A compared to CG-C. Focused education strategies are required to bridge the gap among CG-A.

Preferences for Attributes of Sodium Oxybate Treatment: A Discrete Choice Experiment in Patients with Narcolepsy

PURPOSE

Current US FDA-approved treatments for narcolepsy include sodium oxybate (SXB) and calcium, magnesium, potassium, and sodium oxybates (mixed-salt oxybates), which require 2 nightly doses, 1 at bedtime and another 2.5 to 4 hours later. Once-nightly SXB (ON-SXB; FT218) is under FDA review to treat adults with narcolepsy. This study quantitatively characterized attributes of SXB treatment preferred by individuals with narcolepsy via a discrete choice experiment (DCE) and evaluated preferences for the product profiles of once-nightly vs twice-nightly SXB treatment.

PATIENTS AND METHODS

Adults with self-reported physician-diagnosed narcolepsy for ≥1 year and current or prior twice-nightly SXB treatment were eligible for this 30-minute, web-based study capturing patient experiences and a DCE. Participants responded to a survey instrument using 9-point scales; higher scores indicated greater severity/preference/satisfaction. In the DCE, hundreds of profiles were generated, each combining attributes of twice-nightly SXB and ON-SXB based on clinical trial data. The DCE was analyzed using a hierarchical Bayesian model.

RESULTS

Seventy-five participants were surveyed (50 current and 25 past twice-nightly SXB users). Dosing frequency was the most important attribute of SXB treatment; once nightly was significantly preferred vs twice nightly. The most common reasons for overall product preference were lack of need to wake up in the middle of the night for a second dose (48%), fewer side effects (46%), and ease of administration (32%). Number of nightly doses was the most important driver of taking the medication exactly as directed and reduced anxiety/stress. Participants were significantly more likely to prefer the blinded product profile of once-nightly SXB over twice-nightly SXB (mean rating, 7.5 vs 4.3; P<0.05).

CONCLUSION

Among the choices presented, dosing frequency was the most important attribute for overall product choice, likelihood to take medication exactly as directed, and reducing anxiety/stress. The ON-SXB blinded profile was significantly preferred over twice-nightly SXB.

Evaluation of medication adherence and medication beliefs among patients with epilepsy

AIM

This study explored medication adherence and medication beliefs of patients with epilepsy and evaluated the relationship between these two factors.

METHODS

This descriptive, cross-sectional, correlational study was conducted with 174 patients with epilepsy who were referred to the neurology outpatient clinic of a university hospital in Erzurum, Turkey, between February 10, 2020 and December 30, 2020. The data were collected using the Descriptive Information Form, The eight-item Morisky Medication Adherence Scale (MMAS-8), and the Beliefs about Medicines Questionnaire (BMQ-T).

RESULTS

The mean age of the patients was 33.06 ± 11.94 years, and the mean duration of time since diagnosis was 12.91 ± 10.73 years. In terms of demographic information, 60.3% of the patients were single, 58% had low income or were unemployed, 53.4% had five or more seizures within the last year, 40.8% had focal onset seizures, 69% had no other chronic disease, and 76.4% used more than one medicine. The patients' mean MMAS-8 score was 3.25 ± 2.13. The mean scores for the specific concern subscale was 3.65 ± 0.85, 1.81 ± 0.75 for the specific necessity subscale, 4.19 ± 0.76 for the general overuse subscale, and 3.14 ± 1.41 for the general harm subscale. The regression analysis revealed that general overuse and general harm negatively affected the MMAS-8 total score.

CONCLUSION

Patients with epilepsy reported low medication adherence and were found to have concerns about the harms and side effects of the medicines they were using; they had negative perceptions of the purpose of medicines; they had high beliefs about the harms of medicines; and they had low beliefs about their personal treatment needs. The patients were generally found to have negative beliefs about medicines, which negatively affected their medication adherence.