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Noble AJ, Dixon P, Mathieson A, Ridsdale L, Morgan M, McKinlay A, Dickson J, Goodacre S, Jackson M, Morris B, Hughes D, Marson A, Holmes E. Developing feasible person-centred care alternatives to emergency department responses for adults with epilepsy: a discrete choice analysis mixed-methods study. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-158. [PMID: 39206517 DOI: 10.3310/hkqw4129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Background Calls have been made for paramedics to have some form of care pathway that they could use to safely divert adults with epilepsy away from emergency departments and instigate ambulatory care improvements. Different configurations are possible. To know which to prioritise for implementation/evaluation, there is a need to determine which are acceptable to service users and likely National Health Service-feasible. Objective(s) (1) Identify configurations being considered, (2) understand service users' views of them and current provision, (3) identify what sort of care service users want and (4) determine which configuration(s) is considered to achieve optimal balance in meeting users' preference and being National Health Service-feasible. Design Service providers were surveyed to address objective 1. Interviews with service users addressed objective 2. Objective 3 was addressed by completing discrete choice experiments. These determined users' care preferences for different seizure scenarios. Objective 4 was addressed by completing 'knowledge exchange' workshops. At these, stakeholders considered the findings on users' stated preferences and judged different pathway configurations against Michie's 'acceptability, practicability, effectiveness, affordability, side-effects and equity' feasibility criteria. Setting This project took place in England. The survey recruited representatives from neurology and neuroscience centres and from urgent and emergency care providers. For the interviews, recruitment occurred via third-sector support groups. Recruitment for discrete choice experiments occurred via the North West Ambulance Service NHS Trust and public advert. Workshop participants were recruited from neurology and neuroscience centres, urgent and emergency care providers, support groups and commissioning networks. Participants Seventy-two services completed the survey. Interviews were conducted with 25 adults with epilepsy (and 5 relatives) who had emergency service contact in the prior 12 months. Discrete choice experiments were completed by 427 adults with epilepsy (and 167 relatives) who had ambulance service contact in the prior 12 months. Workshops were completed with 27 stakeholders. Results The survey identified a range of pathway configurations. They differed in where they would take the patient and their potential to instigate ambulatory care improvements. Users had been rarely consulted in designing them. The discrete choice experiments found that users want a configuration of care markedly different to that offered. Across the seizure scenarios, users wanted their paramedic to have access to their medical records; for an epilepsy specialist (e.g. an epilepsy nurse, neurologist) to be available to advise; for their general practitioner to receive a report; for the incident to generate an appointment with an epilepsy specialist; for the care episode to last < 6 hours; and there was a pattern of preference to avoid conveyance to emergency departments and stay where they were. Stakeholders judged this configuration to be National Health Service-feasible within 5-10 years, with some elements being immediately deployable. Limitations The discrete choice experiment sample was broadly representative, but those reporting recent contact with an epilepsy specialist were over-represented. Conclusions Users state they want a configuration of care that is markedly different to current provision. The configuration they prefer was, with support and investment, judged to likely be National Health Service-feasible. The preferred configuration should now be developed and evaluated to determine its actual deliverability and efficacy. Study registration The study is registered as researchregistry4723. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/62) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 24. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Adam J Noble
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Pete Dixon
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Amy Mathieson
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Leone Ridsdale
- Department of Basic and Clinical Neuroscience, King's College London, London, UK
| | - Myfanwy Morgan
- Institute of Pharmaceutical Science, King's College London, London, UK
| | - Alison McKinlay
- Institute of Pharmaceutical Science, King's College London, London, UK
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Jon Dickson
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Mike Jackson
- North West Ambulance Service NHS Trust, Bolton, UK
| | - Beth Morris
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Anthony Marson
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Emily Holmes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
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Colmers PLW, Antonoudiou P, Basu T, Scapa G, Fuller P, Maguire J. Loss of PV interneurons in the BLA contributes to altered network and behavioral states in chronically epileptic mice. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.12.05.570112. [PMID: 38106120 PMCID: PMC10723361 DOI: 10.1101/2023.12.05.570112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Psychiatric disorders, including anxiety and depression, are highly comorbid in people with epilepsy. However, the mechanisms mediating the shared pathophysiology are currently unknown. There is considerable evidence implicating the basolateral amygdala (BLA) in the network communication of anxiety and fear, a process demonstrated to involve parvalbumin-positive (PV) interneurons. The loss of PV interneurons has been well described in the hippocampus of chronically epileptic mice and in postmortem human tissue of patients with temporal lobe epilepsy (TLE). We hypothesize that a loss of PV interneurons in the BLA may contribute to comorbid mood disorders in epilepsy. To test this hypothesis, we employed a ventral intrahippocampal kainic acid (vIHKA) model of chronic epilepsy in mice, which exhibits profound behavioral deficits associated with chronic epilepsy. We demonstrate a loss of PV interneurons and dysfunction of remaining PV interneurons in the BLA of chronically epileptic mice. Further, we demonstrate altered principal neuron function and impaired coordination of BLA network and behavioral states in chronically epileptic mice. To determine whether these altered network and behavioral states were due to the loss of PV interneurons, we ablated a similar percentage of PV interneurons observed in chronically epileptic mice by stereotaxically injecting AAV-Flex-DTA into the BLA of PV-Cre mice. Loss of PV interneurons in the BLA is sufficient to alter behavioral states, inducing deficits in fear learning and recall of fear memories. These data suggest that compromised inhibition in the BLA in chronically epileptic mice contributes to behavioral deficits, suggesting a novel mechanism contributing to comorbid anxiety and epilepsy. Significance Statement Psychiatric illnesses and epilepsy are highly comorbid and negatively impact the quality of life of people with epilepsy. The pathophysiological mechanisms mediating the bidirectional relationship between mood disorders and epilepsy remain unknown and, therefore, treatment options remain inadequate. Here we demonstrate a novel mechanism, involving the loss of PV interneurons in the BLA, leading to a corruption of network and behavioral states in mice. These findings pinpoint a critical node and demonstrate a novel cellular and circuit mechanism involved in the comorbidity of psychiatric illnesses and epilepsy.
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Solomon Y, Teshome Y, Ejigu S, Bezabih M. Prevalence of anti-seizure medication nonadherence and its associated factors, among people with epilepsy in North Shewa, Ethiopia, 2021. Epilepsy Behav 2023; 145:109301. [PMID: 37336134 DOI: 10.1016/j.yebeh.2023.109301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 06/02/2023] [Accepted: 06/02/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Epilepsy is a worldwide neurologic illness, characterized by recurrent unprovoked epileptic seizures and can affect people of all age groups. Patients who are receiving drug therapy for chronic diseases, such as epilepsy, must fit complex medication regimens into their everyday routines. Managing medication schedules may pose a significant burden on patients' lives. Anti-seizure medication choices should therefore be tailored to patients' factors that may limit medication use. The study aimed to determine the prevalence and Predictors of anti-seizure medication nonadherence among patients with epilepsy. METHODOLOGY An institutional-based cross-sectional study was conducted among 352 people with epilepsy who were selected by systematic random sampling method at government hospitals in North Shewa Ethiopia. Data were collected by reviewing patients' charts and interviewing people with epilepsy by using structured and pretested questionnaires. Data obtained were encoded into EPI-INFO software and exported to SPSS version 25 for analysis. Logistic regression was employed to assess independent factors associated with medication non-adherence. RESULT The prevalence of anti-seizure medication non-adherence was 40%. Being female [AOR = 3.37, 95%, CI: 1.84, 6.18], Divorced [AOR = 9.13, 95%, CI: 1.80, 46.34], Being jobless [AOR = 7.33, 95%, CI: 3.24, 16.56], Perceived poor social support [AOR = 2.73, 95%, CI: 1.28, 5.82], perceived stigma [AOR = 5.07, 95%, CI: 2.40, 10.68], polytherapy [AOR = 2.23, 95%, CI: 1.06, 4.71], drug side effects[AOR = 6.03, 95%, CI: 3.17, 11.45], buying medications [AOR = 5.81, 95%, CI: 3.63,16.79] and duration of stay on treatment [AOR = 4.31, 95%, CI: 1.863, 9.97] were significant predictors of anti-seizure medication non-adherence. CONCLUSION Non-adherence to anti-seizure medication among people with epilepsy in the study area was relatively higher as compared with study reports from different parts of the country. Health and clinical, socio-economy, and patients' psychological mindset were among the determinant factors affecting the consistency of epilepsy treatment adherence. Enhanced professional, health education for patients as well as for society and financial support, are basic pillars to reduce the constraints of effective treatment.
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Affiliation(s)
- Yerukneh Solomon
- Department of Biomedical Sciences, College of Health Sciences, Debre Berhan University, Debre Berhan, Ethiopia.
| | - Yonas Teshome
- Department of Biomedical Sciences, College of Health Sciences, Debre Berhan University, Debre Berhan, Ethiopia
| | - Solomon Ejigu
- Department of Biomedical Sciences, College of Medicine and Health Sciences, Mizan-Tepi University, Mizan-Aman, Ethiopia
| | - Mihret Bezabih
- Department of Public Health, Arba Minch College of Health Sciences, Arba Minch, Ethiopia
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Hakeem H, Alsfouk BAA, Kwan P, Brodie MJ, Chen Z. Should substitution monotherapy or combination therapy be used after failure of the first antiseizure medication? Observations from a 30-year cohort study. Epilepsia 2023; 64:1248-1258. [PMID: 36869855 DOI: 10.1111/epi.17573] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/23/2023] [Accepted: 03/02/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVES To assess the temporal trends in the use of second antiseizure (ASM) regimens and compare the efficacy of substitution monotherapy and combination therapy after failure of initial monotherapy in people with epilepsy. METHODS This was a longitudinal observational cohort study conducted at the Epilepsy Unit of the Western Infirmary in Glasgow, Scotland. We included patients who were newly treated for epilepsy with ASMs between July 1982, and October 2012. All patients were followed up for a minimum of 2 years. Seizure freedom was defined as no seizure for at least 1 year on unchanged medication at the last follow up. RESULTS During the study period, 498 patients were treated with a second ASM regimen after failure of the initial ASM monotherapy, of whom 346 (69%) were prescribed combination therapy and 152 (31%) were given substitution monotherapy. The proportion of patients receiving second regimen as combination therapy increased during the study period from 46% in first epoch (1985-1994) to 78% in the last (2005-2015) (RR = 1.66, 95% CI: 1.17-2.36, corrected-p = .010). Overall, 21% (104/498) of the patients achieved seizure freedom on the second ASM regimen, which was less than half of the seizure-free rate on the initial ASM monotherapy (45%, p < .001). Patients who received substitution monotherapy had similar seizure-free rate compared with those who received combination therapy (RR = 1.17, 95% CI: 0.81-1.69, p = .41). Individual ASMs used, either alone or in combination, had similar efficacy. However, the subgroup analysis was limited by small sample sizes. SIGNIFICANCE The choice of second regimen used based on clinical judgment was not associated with treatment outcome in patients whose initial monotherapy failed due to poor seizure control. Alternative approaches such as machine learning should be explored to aid individualized selection of the second ASM regimen.
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Affiliation(s)
- Haris Hakeem
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Bshra Ali A Alsfouk
- Department of Pharmaceutical Sciences, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
- University of Glasgow, Glasgow, UK
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | | | - Zhibin Chen
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Clinical Epidemiology, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Li ZR, Wang CY, Lin WW, Chen YT, Liu XQ, Jiao Z. Handling Delayed or Missed Dose of Antiseizure Medications: A Model-Informed Individual Remedial Dosing. Neurology 2023; 100:e921-e931. [PMID: 36450606 PMCID: PMC9990430 DOI: 10.1212/wnl.0000000000201604] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 10/11/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Delayed or missed antiseizure medications (ASMs) doses are common during long-term or lifelong antiepilepsy treatment. This study aims to explore optimal individualized remedial dosing regimens for delayed or missed doses of 11 commonly used ASMs. METHODS To explore remedial dosing regimens, Monte Carlo simulation was used based on previously identified and published population pharmacokinetic models. Six remedial strategies for delayed or missed doses were investigated. The deviation time outside the individual therapeutic range was used to evaluate each remedial regimen. The influences of patients' demographics, concomitant medication, and scheduled dosing intervals on remedial regimens were assessed. RxODE and Shiny in R were used to perform Monte Carlo simulation and recommend individual remedial regimens. RESULTS The recommended remedial regimens were highly correlated with delayed time, scheduled dosing interval, and half-life of the ASM. Moreover, the optimal remedial regimens for pediatric and adult patients were different. The renal function, along with concomitant medication that affects the clearance of the ASM, may also influence the remedial regimens. A web-based dashboard was developed to provide individualized remedial regimens for the delayed or missed dose, and a user-defined module with all parameters that could be defined flexibly by the user was also built. DISCUSSION Monte Carlo simulation based on population pharmacokinetic models may provide a rational approach to propose remedial regimens for delayed or missed doses of ASMs in pediatric and adult patients with epilepsy.
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Affiliation(s)
- Zi-Ran Li
- From the Department of Pharmacy (Z.L., C.W., Y.C., X.L., Z.J.), Shanghai Chest Hospital, Shanghai Jiao Tong University, China; Department of Pharmacy (Z.L., X.L.), Huashan Hospital, Fudan University, Shanghai, China; Department of Pharmacy (W.L.), The First Affiliated Hospital, Fujian Medical University, Fuzhou, China; and School of Basic Medicine and Clinical Pharmacy (Y.C.), China Pharmaceutical University, Nanjing, China.
| | - Chen-Yu Wang
- From the Department of Pharmacy (Z.L., C.W., Y.C., X.L., Z.J.), Shanghai Chest Hospital, Shanghai Jiao Tong University, China; Department of Pharmacy (Z.L., X.L.), Huashan Hospital, Fudan University, Shanghai, China; Department of Pharmacy (W.L.), The First Affiliated Hospital, Fujian Medical University, Fuzhou, China; and School of Basic Medicine and Clinical Pharmacy (Y.C.), China Pharmaceutical University, Nanjing, China
| | - Wei-Wei Lin
- From the Department of Pharmacy (Z.L., C.W., Y.C., X.L., Z.J.), Shanghai Chest Hospital, Shanghai Jiao Tong University, China; Department of Pharmacy (Z.L., X.L.), Huashan Hospital, Fudan University, Shanghai, China; Department of Pharmacy (W.L.), The First Affiliated Hospital, Fujian Medical University, Fuzhou, China; and School of Basic Medicine and Clinical Pharmacy (Y.C.), China Pharmaceutical University, Nanjing, China.
| | - Yue-Ting Chen
- From the Department of Pharmacy (Z.L., C.W., Y.C., X.L., Z.J.), Shanghai Chest Hospital, Shanghai Jiao Tong University, China; Department of Pharmacy (Z.L., X.L.), Huashan Hospital, Fudan University, Shanghai, China; Department of Pharmacy (W.L.), The First Affiliated Hospital, Fujian Medical University, Fuzhou, China; and School of Basic Medicine and Clinical Pharmacy (Y.C.), China Pharmaceutical University, Nanjing, China
| | - Xiao-Qin Liu
- From the Department of Pharmacy (Z.L., C.W., Y.C., X.L., Z.J.), Shanghai Chest Hospital, Shanghai Jiao Tong University, China; Department of Pharmacy (Z.L., X.L.), Huashan Hospital, Fudan University, Shanghai, China; Department of Pharmacy (W.L.), The First Affiliated Hospital, Fujian Medical University, Fuzhou, China; and School of Basic Medicine and Clinical Pharmacy (Y.C.), China Pharmaceutical University, Nanjing, China
| | - Zheng Jiao
- From the Department of Pharmacy (Z.L., C.W., Y.C., X.L., Z.J.), Shanghai Chest Hospital, Shanghai Jiao Tong University, China; Department of Pharmacy (Z.L., X.L.), Huashan Hospital, Fudan University, Shanghai, China; Department of Pharmacy (W.L.), The First Affiliated Hospital, Fujian Medical University, Fuzhou, China; and School of Basic Medicine and Clinical Pharmacy (Y.C.), China Pharmaceutical University, Nanjing, China.
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Namusisi J, Kyoyagala S, Nantongo J, Kyewalyanga M, Sabiiti S, Murorunkwere A, Najjuma JN, Nakibuuka J, Kaddumukasa M, Sajatovic M, Kalubi P. Poor Seizure Control Among Children Attending a Tertiary Hospital in South Western Uganda - A Retrospective Study. Int J Gen Med 2023; 16:895-904. [PMID: 36915422 PMCID: PMC10007866 DOI: 10.2147/ijgm.s398318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/01/2023] [Indexed: 03/09/2023] Open
Abstract
Background Seizure control among children with epilepsy (CWE) receiving anti-seizure medications (ASMs) remains a challenge in low-resource settings. Uncontrolled seizures are significantly associated with increased morbidity and mortality among CWE. This negatively impacts their quality of life and increases stigma. Aim This study determined seizure control status and described the factors associated among CWE receiving ASMs at Mbarara Regional Referral Hospital (MRRH). Methods In a retrospective chart review study, socio-demographic and clinical data were obtained from 112 medical records. CWE receiving ASMs for at least six months and regularly attending the clinic were included in the study. Physical or telephone interviews were conducted with the immediate caregivers of the CWE to establish the current seizure control status of the participants. Results A total of 112 participants were enrolled. Of these, three-quarters had generalized onset seizures, 23% had focal onset seizures, while 2% had unknown onset motor seizures. About 60.4% of the study participants had poor seizure control. Having a comorbidity (p-value 0.048, AOR 3.2 (95% CI 1.0-9.9)), history suggestive of birth asphyxia (p-value 0.014, AOR 17.8 (95% CI 1.8-176.8)), and being an adolescent (p-value 0.006, AOR 6.8 (95% CI 1.8-26.6)) were significantly associated with poor seizure control. Conclusion Seizure control among CWE receiving ASMs at MRRH remains poor. Efforts geared to addressing seizure control and optimizing drugs are needed, especially among children with comorbidities, those with history of birth asphyxia, and adolescents.
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Affiliation(s)
- Jane Namusisi
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology (MUST), Mbarara, Uganda.,Department of Pediatrics and Child Health, Mbarara Regional Referral Hospital (MRRH), Mbarara, Uganda
| | - Stella Kyoyagala
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
| | - Josephine Nantongo
- Department of Pediatrics and Child Health, Mbarara Regional Referral Hospital (MRRH), Mbarara, Uganda
| | - Mike Kyewalyanga
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology (MUST), Mbarara, Uganda.,Department of Pediatrics and Child Health, Holy Innocents Children's Hospital, Mbarara, Uganda
| | - Stephen Sabiiti
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
| | - Angelique Murorunkwere
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
| | - Josephine Nambi Najjuma
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
| | - Jane Nakibuuka
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mark Kaddumukasa
- Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospital Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Peter Kalubi
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
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Kanhere S, Kacheria A, Goel A. Epilepsy in children: Cognitive development and academic performance. J Pediatr Neurosci 2023. [DOI: 10.4103/jpn.jpn_64_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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Sun H, Ma D, Cheng Y, Li J, Zhang W, Jiang T, Li Z, Li X, Meng H. The JAK-STAT Signaling Pathway in Epilepsy. Curr Neuropharmacol 2023; 21:2049-2069. [PMID: 36518035 PMCID: PMC10556373 DOI: 10.2174/1570159x21666221214170234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 11/08/2022] [Accepted: 11/21/2022] [Indexed: 12/16/2022] Open
Abstract
Epilepsy is defined as spontaneous recurrent seizures in the brain. There is increasing evidence that inflammatory mediators and immune cells are involved in epileptic seizures. As more research is done on inflammatory factors and immune cells in epilepsy, new targets for the treatment of epilepsy will be revealed. The Janus kinase-signal transducer and transcriptional activator (JAKSTAT) signaling pathway is strongly associated with many immune and inflammatory diseases, At present, more and more studies have found that the JAK-STAT pathway is involved in the development and development of epilepsy, indicating the JAK-STAT pathway's potential promise as a target in epilepsy treatment. In this review, we discuss the composition, activation, and regulation of the JAK-STAT pathway and the relationship between the JAK-STAT pathway and epilepsy. In addition, we summarize the common clinical inhibitors of JAK and STAT that we would expect to be used in epilepsy treatment in the future.
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Affiliation(s)
- Huaiyu Sun
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Di Ma
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Yu Cheng
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Jiaai Li
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Wuqiong Zhang
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Ting Jiang
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Zhaoran Li
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Xuewei Li
- Department of Radiology, The First Hospital of Jilin University, Changchun, China
| | - Hongmei Meng
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
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Chuah A, Ding K, Morgado A, McCreary M, Zuberi F, Agostini M, Doyle A. Effects of psychiatric comorbidities in persons with epilepsy on recurrent emergency department visits. Epilepsy Behav 2022; 136:108909. [PMID: 36152383 DOI: 10.1016/j.yebeh.2022.108909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 08/28/2022] [Accepted: 08/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Coexisting mental health disorders in persons with epilepsy present as substantial burdens to patients and healthcare systems. STUDY DESIGN AND METHODS In this retrospective study, we reviewed 160 patients presenting to a safety net hospital Emergency Department (ED) with seizures to investigate whether differences in clinical workup, follow-ups, and ED visit recurrence existed between epilepsy patients with epilepsy with and without a coexisting psychiatric disorder. RESULTS Patients with epilepsy with a psychiatric comorbidity had more subsequent ED visits (45 % vs 26 %, p = 0.01) and fewer outpatient follow-up opportunities (74 % vs 87 %, p = 0.042) compared to patients with epilepsy without psychiatric comorbidities, highlighting a healthcare gap that needs to be addressed. INTERPRETATION Our findings suggest a need for ED providers to shift their clinical practice in favor of offering more outpatient follow-up opportunities, to ensure long-term management of seizures in patients with epilepsy with comorbid psychiatric disorders.
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Affiliation(s)
- Ashleigh Chuah
- UT Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Kan Ding
- UT Southwestern Medical Center, Department of Neurology, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Anika Morgado
- UT Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Morgan McCreary
- UT Southwestern Medical Center, Department of Neurology, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Fatima Zuberi
- UT Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Mark Agostini
- UT Southwestern Medical Center, Department of Neurology, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Alexander Doyle
- UT Southwestern Medical Center, Department of Neurology, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
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Rashid M, Rajan AK, Chhabra M, Kashyap A, Chandran VP, Venkataraman R, Nair S, Thunga G. Role of human leukocyte antigen in anti-epileptic drugs-induced Stevens-Johnson Syndrome/toxic epidermal necrolysis: A meta-analysis. Seizure 2022; 102:36-50. [PMID: 36183454 DOI: 10.1016/j.seizure.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 10/31/2022] Open
Abstract
PURPOSE Antiepileptic drugs (AEDs) are extensively used to manage epilepsy and other comorbidities associated with seizures. Human Leukocyte Antigen (HLA) has a strong association with AED-induced severe cutaneous adverse drug reactions. OBJECTIVE We aimed to perform a systematic review and meta-analysis to identify, critically evaluate, and synthesize the best possible evidence on HLA-associated AED-induced Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN). METHODS MEDLINE/PubMed, Scopus, and the Cochrane Library were searched for literature from inception up to July 2022. We included case control studies analyzing association between HLA and AED-induced SJS/TEN. We assessed the studies' risk of bias in using Quality of genetic studies (Q-genie) tool. Outcomes focused on association (risk) between HLA and AED-induced SJS/TEN. The estimated risk was presented in the form of odds ratio (OR). RESULTS We included 37 studies (51,422 participants; 7027 cases and 44,395 controls). There was a significantly higher risk of Carbamazepine-induced SJS/TEN with HLA-A (OR: 1.50; 95% CI: 1.03 to 2.17), HLA-B (OR: 1.94; 95% CI: 1.45 to 2.58), HLA-C (OR: 7.83; 95% CI: 4.72 to 12.98), and HLA-DRB1 (OR: 2.82; 95% CI: 1.94 to 4.12). Lamotrigine-induced SJS/TEN posed a higher risk with HLA-A (OR: 2.38; 95% CI: 1.26 to 4.46) and HLA-B (OR: 2.79; 95% CI: 1.75 to 4.46). Phenytoin-induced SJS/TEN showed a higher risk with HLA-A (OR: 3.47; 95% CI: 2.17 to 5.56), HLA-B (OR: 1.72; 95% CI: 1.38 to 2.15), and HLA-C (OR: 2.92; 95% CI: 1.77 to 4.83). Phenobarbital-induced SJS/TEN had a higher risk with HLA-A (OR: 6.98; 95% CI: 1.81 to 26.84), HLA-B (OR: 2.40; 95% CI: 1.39 to 4.17), and HLA-C (OR: 3.37; 95% CI: 1.03 to 11.01). Zonisamide-induced SJS/TEN was significantly associated with HLA-A*02:07 (OR: 9.77; 95% CI: 3.07 to 31.1), HLA-B*46:01 (OR: 6.73; 95% CI: 2.12 to 21.36), and HLA-DRB1×08:03 (OR: 3.78; 95% CI: 1.20 to 11.97). All other alleles of HLA were observed to have a non-significant association with AED-induced SJS/TEN. All included studies were of good quality, with a score of >50 and a mean score of 54.96 out of 77. CONCLUSION Our study showed a significant association between few variants of HLA alleles and AED-induced SJS/TEN. Evidences from our study could help in population-based studies and in implementation of individualized treatment regimens. These findings could be part of translational research helping in precision therapy.
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Affiliation(s)
- Muhammed Rashid
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Asha K Rajan
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Manik Chhabra
- Department of Pharmacology and Therapeutics, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Ananth Kashyap
- Department of Pharmacy Practice, Sarada Vilas College of Pharmacy, Mysuru, Karnataka, India
| | - Viji Pulikkel Chandran
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Rajesh Venkataraman
- Department of Pharmacy Practice, Sri Adichunchanagari College of Pharmacy, Adichunchanagari University, BG Nagara, Karnataka, India
| | - Sreedharan Nair
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Girish Thunga
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, India; Coordinator, Centre for Toxicovigilance and Drug Safety, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, India.
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Abstract
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.
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Nevitt SJ, Sudell M, Cividini S, Marson AG, Tudur Smith C. Antiepileptic drug monotherapy for epilepsy: a network meta-analysis of individual participant data. Cochrane Database Syst Rev 2022; 4:CD011412. [PMID: 35363878 PMCID: PMC8974892 DOI: 10.1002/14651858.cd011412.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane Review published in 2017. Epilepsy is a common neurological condition with a worldwide prevalence of around 1%. Approximately 60% to 70% of people with epilepsy will achieve a longer-term remission from seizures, and most achieve that remission shortly after starting antiepileptic drug treatment. Most people with epilepsy are treated with a single antiepileptic drug (monotherapy) and current guidelines from the National Institute for Health and Care Excellence (NICE) in the United Kingdom for adults and children recommend carbamazepine or lamotrigine as first-line treatment for focal onset seizures and sodium valproate for generalised onset seizures; however, a range of other antiepileptic drug (AED) treatments are available, and evidence is needed regarding their comparative effectiveness in order to inform treatment choices. OBJECTIVES To compare the time to treatment failure, remission and first seizure of 12 AEDs (carbamazepine, phenytoin, sodium valproate, phenobarbitone, oxcarbazepine, lamotrigine, gabapentin, topiramate, levetiracetam, zonisamide, eslicarbazepine acetate, lacosamide) currently used as monotherapy in children and adults with focal onset seizures (simple focal, complex focal or secondary generalised) or generalised tonic-clonic seizures with or without other generalised seizure types (absence, myoclonus). SEARCH METHODS For the latest update, we searched the following databases on 12 April 2021: the Cochrane Register of Studies (CRS Web), which includes PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Epilepsy Group Specialised Register and MEDLINE (Ovid, 1946 to April 09, 2021). We handsearched relevant journals and contacted pharmaceutical companies, original trial investigators and experts in the field. SELECTION CRITERIA We included randomised controlled trials of a monotherapy design in adults or children with focal onset seizures or generalised onset tonic-clonic seizures (with or without other generalised seizure types). DATA COLLECTION AND ANALYSIS This was an individual participant data (IPD) and network meta-analysis (NMA) review. Our primary outcome was 'time to treatment failure', and our secondary outcomes were 'time to achieve 12-month remission', 'time to achieve six-month remission', and 'time to first seizure post-randomisation'. We performed frequentist NMA to combine direct evidence with indirect evidence across the treatment network of 12 drugs. We investigated inconsistency between direct 'pairwise' estimates and NMA results via node splitting. Results are presented as hazard ratios (HRs) with 95% confidence intervals (CIs) and we assessed the certainty of the evidence using the CiNeMA approach, based on the GRADE framework. We have also provided a narrative summary of the most commonly reported adverse events. MAIN RESULTS IPD were provided for at least one outcome of this review for 14,789 out of a total of 22,049 eligible participants (67% of total data) from 39 out of the 89 eligible trials (43% of total trials). We could not include IPD from the remaining 50 trials in analysis for a variety of reasons, such as being unable to contact an author or sponsor to request data, data being lost or no longer available, cost and resources required to prepare data being prohibitive, or local authority or country-specific restrictions. No IPD were available from a single trial of eslicarbazepine acetate, so this AED could not be included in the NMA. Network meta-analysis showed high-certainty evidence that for our primary outcome, 'time to treatment failure', for individuals with focal seizures; lamotrigine performs better than most other treatments in terms of treatment failure for any reason and due to adverse events, including the other first-line treatment carbamazepine; HRs (95% CIs) for treatment failure for any reason for lamotrigine versus: levetiracetam 1.01 (0.88 to 1.20), zonisamide 1.18 (0.96 to 1.44), lacosamide 1.19 (0.90 to 1.58), carbamazepine 1.26 (1.10 to 1.44), oxcarbazepine 1.30 (1.02 to 1.66), sodium valproate 1.35 (1.09 to 1.69), phenytoin 1.44 (1.11 to 1.85), topiramate 1.50 (1.23 to 1.81), gabapentin 1.53 (1.26 to 1.85), phenobarbitone 1.97 (1.45 to 2.67). No significant difference between lamotrigine and levetiracetam was shown for any treatment failure outcome, and both AEDs seemed to perform better than all other AEDs. For people with generalised onset seizures, evidence was more limited and of moderate certainty; no other treatment performed better than first-line treatment sodium valproate, but there were no differences between sodium valproate, lamotrigine or levetiracetam in terms of treatment failure; HRs (95% CIs) for treatment failure for any reason for sodium valproate versus: lamotrigine 1.06 (0.81 to 1.37), levetiracetam 1.13 (0.89 to 1.42), gabapentin 1.13 (0.61 to 2.11), phenytoin 1.17 (0.80 to 1.73), oxcarbazepine 1.24 (0.72 to 2.14), topiramate 1.37 (1.06 to 1.77), carbamazepine 1.52 (1.18 to 1.96), phenobarbitone 2.13 (1.20 to 3.79), lacosamide 2.64 (1.14 to 6.09). Network meta-analysis also showed high-certainty evidence that for secondary remission outcomes, few notable differences were shown for either seizure type; for individuals with focal seizures, carbamazepine performed better than gabapentin (12-month remission) and sodium valproate (six-month remission). No differences between lamotrigine and any AED were shown for individuals with focal seizures, or between sodium valproate and other AEDs for individuals with generalised onset seizures. Network meta-analysis also showed high- to moderate-certainty evidence that, for 'time to first seizure,' in general, the earliest licensed treatments (phenytoin and phenobarbitone) performed better than the other treatments for individuals with focal seizures; phenobarbitone performed better than both first-line treatments carbamazepine and lamotrigine. There were no notable differences between the newer drugs (oxcarbazepine, topiramate, gabapentin, levetiracetam, zonisamide and lacosamide) for either seizure type. Generally, direct evidence (where available) and network meta-analysis estimates were numerically similar and consistent with confidence intervals of effect sizes overlapping. There was no important indication of inconsistency between direct and network meta-analysis results. The most commonly reported adverse events across all drugs were drowsiness/fatigue, headache or migraine, gastrointestinal disturbances, dizziness/faintness and rash or skin disorders; however, reporting of adverse events was highly variable across AEDs and across studies. AUTHORS' CONCLUSIONS High-certainty evidence demonstrates that for people with focal onset seizures, current first-line treatment options carbamazepine and lamotrigine, as well as newer drug levetiracetam, show the best profile in terms of treatment failure and seizure control as first-line treatments. For people with generalised tonic-clonic seizures (with or without other seizure types), current first-line treatment sodium valproate has the best profile compared to all other treatments, but lamotrigine and levetiracetam would be the most suitable alternative first-line treatments, particularly for those for whom sodium valproate may not be an appropriate treatment option. Further evidence from randomised controlled trials recruiting individuals with generalised tonic-clonic seizures (with or without other seizure types) is needed.
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Affiliation(s)
- Sarah J Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Maria Sudell
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Sofia Cividini
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Anthony G Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Catrin Tudur Smith
- Department of Health Data Science, University of Liverpool, Liverpool, UK
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Ji ZY, Huang YQ, He WZ. Sodium Valproate Combined With Topiramate vs. Sodium Valproate Alone for Refractory Epilepsy: A Systematic Review and Meta-Analysis. Front Neurol 2022; 12:794856. [PMID: 35069424 PMCID: PMC8766331 DOI: 10.3389/fneur.2021.794856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/26/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Among antiepileptic drugs (AEDs), sodium valproate alone or in the combination of topiramate (TPM) for treating refractory epilepsy was controversial. This meta-analysis aimed to systematically evaluate the clinical effects of these two regimens in this population. Methods: Relevant studies up to August 2021 were identified through systematic searches of CNKI, Wanfang, PubMed, and Embase databases. We assessed the effectiveness and the frequency of absence seizures, atonic seizures, and tonic-clonic seizures. The included literature's risk of bias was evaluated using the Cochrane Collaboration's Risk of Bias tool. Sensitivity analysis was conducted to confirm the results' stability. STATA 15.0 was utilized for all pooled analyses in the included studies. Results: Totally 10 articles were determined for our meta-analysis, involving 976 patients with epilepsy in total (combined group, n = 488; monotherapy group, n = 488). The results of this meta-analysis indicated that the total effective rate of sodium valproate combined with TPM was higher than that of sodium valproate alone (random-effect model: OR = 3.52; 95% CI 1.47 to 8.47; p < 0.001; I 2 = 73.8%). The frequency of absence seizures in the combined group was lower (fixed-effect model: WMD = -6.02; 95% CI -6.50 to -5.54; I 2 = 0.0%) than that in the monotherapy group, with a statistical difference (p < 0.05). The combined group had lower frequency of atonic seizures (WMD = -4.56, 95% CI -6.02 to -3.10; I 2 = 82.6%) and lower frequency of tonic-clonic seizures (WMD = -3.32; 95% CI -4.75 to -1.89; I 2 = 96.4%). In addition, the distinct difference of adverse events was non-existent between two groups. Conclusions: Sodium valproate combined with TPM was more effective than sodium valproate alone for epilepsy therapy. This meta-analysis provides feasibility data for a larger-scale study on AED therapy of refractory epilepsy and may contribute to better therapy strategies for epilepsy clinically.
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Affiliation(s)
- Zhen-Ye Ji
- The Second Department of Neurology, First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Yi-Qian Huang
- Department of Internal Neurology, First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Wen-Zhen He
- Department of Internal Neurology, First Affiliated Hospital of Shantou University Medical College, Shantou, China
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Amha H, Memiah P, Getnet A, Mengist B, Gedfew M, Ayenew T, Akalu TY, Mulugeta H, Bewket B, Kebede B, Petrucka P. Antiseizure medication nonadherence and its associated factors among Epileptic patients in Ethiopia, a systematic review and meta-analysis. Seizure 2021; 91:462-475. [PMID: 34340192 DOI: 10.1016/j.seizure.2021.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/21/2021] [Accepted: 07/23/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The majority of patients with epilepsy in resource-poor countries never receive proper treatment, and those who are started on anti-seizure medications quickly discontinue them. Medication noncompliance is extremely common, with estimates ranging from 26 to 79 percent. Non-adherence to antiseizure medications is associated with poor seizure control, increased morbidity, increased hospitalization time, poor quality of life, increased health care costs, and increased mortality in adults. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 guideline was used for this systematic review and meta-analysis. The databases Pub Med, Cochrane Library, Scopus Online, and Google Scholar were all searched. STATA™ version 11 software was used for the meta-analysis. The I2 test and Egger's tests were used to assess heterogeneity and publication bias. The random-effects method was used to estimate the pooled adherence level with a 95 percent confidence interval. RESULTS This meta-analysis included twelve Ethiopian studies involving a total of 3416 epileptic patients. The national pooled prevalence of antiseizure medication non-adherence was 41.96%. Patients who paid for their medications, took them for more than a year, had co-morbidity, and felt stigmatized were more likely to be non-adherent than their counterparts. CONCLUSION According to this systematic review and meta-analysis, more than two out of every five epileptic patients did not take their antiseizure medications as prescribed. Clinicians must educate epileptic patients about the importance of medication adherence. SYSTEMATIC REVIEW REGISTRATION The review has been registered on an International Prospective Register of Systematic Review with registration number CRD42019142905.
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Affiliation(s)
- Haile Amha
- Lecturer of Psychiatry, Department of Nursing, College of Health Science, Debre Markos University, Ethiopia.
| | - Peter Memiah
- Division of Epidemiology and Prevention Director of Continuous Quality Improvement (CQI) Biosecurity, Institute of Human Virology, University of Maryland School of Medicine, USA.
| | - Asmamaw Getnet
- Lecturer of Psychiatry, Department of Nursing, College of Health Science, Debre Markos University, Ethiopia.
| | - Belayneh Mengist
- Lecturer of Epidemiology, Department of Public Health, College of Health Science, Debre Markos University, Ethiopia.
| | - Mihretie Gedfew
- Lecturer of Nursing, department of Nursing, College of Health Science, Debre Markos University, Ethiopia.
| | - Temesgen Ayenew
- Lecturer of Nursing, department of Nursing, College of Health Science, Debre Markos University, Ethiopia.
| | - Tadesse Yirga Akalu
- Lecturer of Nursing, department of Nursing, College of Health Science, Debre Markos University, Ethiopia.
| | - Henok Mulugeta
- Lecturer of Nursing, department of Nursing, College of Health Science, Debre Markos University, Ethiopia.
| | - Bekalu Bewket
- Lecturer of Nursing, department of Nursing, College of Health Science, Debre Markos University, Ethiopia.
| | - Bekalu Kebede
- Lecturer of Pharmacy, Department of Pharmacy, College of Health Science, Debre Markos University, Ethiopia.
| | - Pammla Petrucka
- College of Nursing, University of Saskatchewan, Saskatoon, Canada; School of Life Sciences and Bioengineering, Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania.
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Adverse Drug Reactions of Antiepileptic Drugs in the Neurology Department of a Tertiary Care Hospital, Srinagar, Jammu & Kashmir, India. ARCHIVES OF NEUROSCIENCE 2021. [DOI: 10.5812/ans.112364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Epilepsy is a disorder that affects 1% of the global population. It is the second most common serious neurologic disorder after stroke, affecting humans. Since antiepileptic drugs have a narrow therapeutic index and their adverse effects can affect any organ, their widespread use has significant safety implications. Objectives: The study assessed adverse drug reactions (ADRs) using antiepileptic drugs in the Department of Neurology at a Tertiary Care Hospital, Srinagar, Jammu & Kashmir, India. Methods: This prospective observational study was conducted in the Department of Neurology of a Tertiary Care Hospital, Srinagar, Jammu & Kashmir, India, for eight months. It was a spontaneous reporting of ADRs by practicing physicians in the outpatient and inpatient settings that were included in the study. Results: Of the 3,300 patients who were on the anti-epileptic drug (AED), 92 (3.07%) had AED-related ADRs. A total of 18 cases were reported in the inpatient department and 74 cases in the outpatient setting. The most common ADRs were loss of appetite (34.78%), skin rashes (17.39%), and gum hypertrophy (9.78%). Of 80 ADRs, 42.5% were related to valproate, followed by phenytoin, carbamazepine, and levetiracetam. The suspected drug was changed in 22 patients with ADRs. Conclusions: For the early diagnosis and avoidance of ADRs, the frequent follow-up of patients on AEDs is needed to improve patient compliance with drug therapy and provide better drug therapy for avoiding associated morbidity and mortality.
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Singh S, Singh TG, Rehni AK. An Insight into Molecular Mechanisms and Novel Therapeutic Approaches in Epileptogenesis. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2021; 19:750-779. [PMID: 32914725 DOI: 10.2174/1871527319666200910153827] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 11/22/2022]
Abstract
Epilepsy is the second most common neurological disease with abnormal neural activity involving the activation of various intracellular signalling transduction mechanisms. The molecular and system biology mechanisms responsible for epileptogenesis are not well defined or understood. Neuroinflammation, neurodegeneration and Epigenetic modification elicit epileptogenesis. The excessive neuronal activities in the brain are associated with neurochemical changes underlying the deleterious consequences of excitotoxicity. The prolonged repetitive excessive neuronal activities extended to brain tissue injury by the activation of microglia regulating abnormal neuroglia remodelling and monocyte infiltration in response to brain lesions inducing axonal sprouting contributing to neurodegeneration. The alteration of various downstream transduction pathways resulted in intracellular stress responses associating endoplasmic reticulum, mitochondrial and lysosomal dysfunction, activation of nucleases, proteases mediated neuronal death. The recently novel pharmacological agents modulate various receptors like mTOR, COX-2, TRK, JAK-STAT, epigenetic modulators and neurosteroids are used for attenuation of epileptogenesis. Whereas the various molecular changes like the mutation of the cell surface, nuclear receptor and ion channels focusing on repetitive episodic seizures have been explored by preclinical and clinical studies. Despite effective pharmacotherapy for epilepsy, the inadequate understanding of precise mechanisms, drug resistance and therapeutic failure are the current fundamental problems in epilepsy. Therefore, the novel pharmacological approaches evaluated for efficacy on experimental models of epilepsy need to be identified and validated. In addition, we need to understand the downstream signalling pathways of new targets for the treatment of epilepsy. This review emphasizes on the current state of novel molecular targets as therapeutic approaches and future directions for the management of epileptogenesis. Novel pharmacological approaches and clinical exploration are essential to make new frontiers in curing epilepsy.
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Affiliation(s)
- Shareen Singh
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | | | - Ashish Kumar Rehni
- Cerebral Vascular Disease Research Laboratories, Department of Neurology and Neuroscience Program, University of Miami School of Medicine, Miami, Florida 33101, United States
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Li X, Frech F, Plauschinat CA, Gore M. Real-world hospitalization risk in patients with epilepsy treated with perampanel. Epilepsy Behav 2021; 114:107270. [PMID: 32713716 DOI: 10.1016/j.yebeh.2020.107270] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 11/18/2022]
Abstract
AIM The aim of this study was to evaluate the risk of hospitalization and emergency department admission following initiation of perampanel treatment in patients with epilepsy. METHODS This study is a retrospective longitudinal cohort study (Optum® Clinformatics® Datamart). Patients 4 to 11 years of age with a diagnosis of partial onset seizures or ≥12 years of age with primary generalized tonic-clonic seizures who had ≥1 perampanel prescription between 1/1/2014 and 3/31/2018 were eligible for the study. Additionally, patients were required to have 12-months of continuous enrollment before (pre-) and after (post-) the date of the first perampanel prescription (index-date). One-year relative-risks of all-cause and epilepsy-related hospitalizations and emergency department (ED) visits were estimated following initiation of perampanel treatment. Outcomes were also evaluated among a subsets of patients who were adherent to perampanel treatment, defined as a Medication Possession Ratio (MPR) ≥80%. RESULTS A total of 320 patients were included in the study, mean age 38.2 ± 19 years, 56.6% female. In the overall population, the relative risks of hospitalizations or ED visits after perampanel initiation were not significantly different. Among the 145 patients who had an MPR ≥80%, initiation of perampanel treatment resulted in a significantly lower risk of epilepsy-related hospitalization (relative risk [RR] = 0.68, confidence interval [CI] [0.47, 0.98]), all-cause ED visits (RR = 0.80, CI [0.66, 0.98]), and epilepsy-related ED visits (RR = 0.74, CI [0.57, 0.95]) in the follow-up period. CONCLUSIONS Adherence to perampanel treatment was associated with significant reductions in one-year hospitalizations and ED visit risk in real world settings.
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Affiliation(s)
- Xuan Li
- Eisai Inc., 100 Tice Blvd, Woodcliff Lake, NJ 07677, USA
| | - Feride Frech
- Eisai Inc., 100 Tice Blvd, Woodcliff Lake, NJ 07677, USA
| | | | - Mugdha Gore
- Avalon Health Solutions, 36 River Street, #430, Waltham, MA 02453, USA
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Wagner RG, Norström F, Bertram MY, Tollman S, Forsgren L, Newton CR, Lindholm L. Community health workers to improve adherence to anti-seizure medication in rural South Africa: Is it cost-effective? Epilepsia 2021; 62:98-106. [PMID: 33236782 PMCID: PMC7839757 DOI: 10.1111/epi.16756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 10/20/2020] [Accepted: 10/20/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Epilepsy is a common, chronic neurological disorder that disproportionately affects individuals living in low- and middle-income countries (LMICs), where the treatment gap remains high and adherence to medication remains low. Community health workers (CHWs) have been shown to be effective at improving adherence to chronic medications, yet no study assessing the costs of CHWs in epilepsy management has been reported. METHODS Using a Markov model with age- and sex-varying transition probabilities, we determined whether deploying CHWs to improve epilepsy treatment adherence in rural South Africa would be cost-effective. Data were derived using published studies from rural South Africa. Official statistics and international disability weights provided cost and health state values, respectively, and health gains were measured using quality adjusted life years (QALYs). RESULTS The intervention was estimated at International Dollars ($) 123 250 per annum per sub-district community and cost $1494 and $1857 per QALY gained for males and females, respectively. Assuming a costlier intervention and lower effectiveness, cost per QALY was still less than South Africa's Gross Domestic Product per capita of $13 215, the cost-effectiveness threshold applied. SIGNIFICANCE CHWs would be cost-effective and the intervention dominated even when costs and effects of the intervention were unfavorably varied. Health system re-engineering currently underway in South Africa identifies CHWs as vital links in primary health care, thereby ensuring sustainability of the intervention. Further research on understanding local health state utility values and cost-effectiveness thresholds could further inform the current model, and undertaking the proposed intervention would provide better estimates of its efficacy on reducing the epilepsy treatment gap in rural South Africa.
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Affiliation(s)
- Ryan G. Wagner
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS) – INDEPTH NetworkAccraGhana
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Epidemiology and Global HealthUmeå UniversityUmeåSweden
- Department of Clinical Sciences, NeurosciencesUmeå UniversityUmeåSweden
| | - Fredrik Norström
- Department of Epidemiology and Global HealthUmeå UniversityUmeåSweden
| | | | - Stephen Tollman
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS) – INDEPTH NetworkAccraGhana
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Epidemiology and Global HealthUmeå UniversityUmeåSweden
| | - Lars Forsgren
- Department of Clinical Sciences, NeurosciencesUmeå UniversityUmeåSweden
| | - Charles R. Newton
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS) – INDEPTH NetworkAccraGhana
- KEMRI/Wellcome Trust Research ProgrammeCentre for Geographic Medicine Research – CoastKilifiKenya
- Department of PsychiatryUniversity of OxfordOxfordUK
| | - Lars Lindholm
- Department of Epidemiology and Global HealthUmeå UniversityUmeåSweden
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Liu DF, Chen YC, Zhu GY, Wang X, Jiang Y, Liu HG, Zhang JG. Effects of anterior thalamic nuclei stimulation on gene expression in a rat model of temporal lobe epilepsy. Acta Neurol Belg 2020; 120:1361-1370. [PMID: 31758405 DOI: 10.1007/s13760-019-01240-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/06/2019] [Indexed: 12/13/2022]
Abstract
Deep brain stimulation of the anterior nucleus of the thalamus (ANT-DBS) has been shown to be effective and safe in the long-term treatment of refractory epilepsy. However, the mechanisms by which ANT-DBS controls epilepsy at the gene expression level (e.g., which regulatory mechanisms are altered) is not well understood. Nine rats were randomly assigned to the control group, the kainic acid (KA) group, and the DBS group. Temporal lobe epilepsy in rats was induced by a stereotaxic KA injection (KA group). The DBS group received the KA injection followed by treatment with ANT-DBS. Video-electroencephalogram (EEG) was used to monitor seizures. Total RNA samples were isolated from the hippocampus of three groups. Microarray was used to detect differentially regulated mRNAs. GO and pathway analysis were performed to analyze the functional categories and affected pathways. qPCR was used to prove the reliability of the microarray results. The differentially expressed genes the KA group and the DBS group, relative to the control group, were screened and a total of 2910 genes were identified. These genes were involved in functional categories such as ion channel activity (P = 5.01 × 10-8), gated channel activity (P = 1.42 × 10-7), lipid binding (P = 4.97 × 10-5), and hydrolase activity (P = 5.02 × 10-5) and pathways such as calcium signaling pathway (P = 2.09 × 10-8), glutamatergic synapse (P = 4.09 × 10-8) and NOD-like receptor signaling pathway (P = 2.70 × 10-6). Differentially expressed mRNAs might play a role in the pathogenesis of temporal lobe epilepsy. Calcium signaling pathways, synaptic glutamate, and NOD-like receptor signaling pathway play a central role in normal-epilepsy-ANT-DBS treatment series. ANT-DBS achieves its antiepileptic effects by modulating target genes involved in a variety of functions and pathways.
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Affiliation(s)
- De-Feng Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China
| | - Ying-Chuan Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China
| | - Guan-Yu Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China
| | - Xiu Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China
| | - Yin Jiang
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China
| | - Huan-Guang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China.
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China.
| | - Jian-Guo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China.
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Tiantan Xili, No.6, Dongcheng, Beijing, 100050, China.
- Beijing Key Laboratory of Neurostimulation, Beijing, 100050, China.
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Nonadherence to Antiepileptic Medications and Its Determinants among Epileptic Patients at the University of Gondar Referral Hospital, Gondar, Ethiopia, 2019: An Institutional-Based Cross-Sectional Study. Neurol Res Int 2020; 2020:8886828. [PMID: 33194230 PMCID: PMC7641705 DOI: 10.1155/2020/8886828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/18/2020] [Accepted: 10/05/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction Nonadherence to antiepileptic medication is the extent of a patient's passive failure to follow the prescribed therapeutic regimen. The prevalence and impact of nonadherence to antiepileptic medication are high globally. The main purpose of this study was to assess nonadherence to antiepileptic medications and its associated factors among epileptic patients at the University of Gondar Referral Hospital, Gondar, Ethiopia, 2019. Methods An institutional-based cross-sectional study was conducted among 365 epileptic patients at the University of Gondar Referral Hospital, who were selected by a systematic random sampling technique. Data were collected by face to face interviews using a structured pretested questionnaire. Data were entered into EPI Info version 7 and then exported to SPSS version 22 for analysis. The data were described by descriptive statistics. Binary logistic regression analysis was used as a model, and variables with a p value of less than 0.05 were considered as statistically significant with nonadherence to antiepileptic medications. Results A total of 356 epileptic patients participated in the study yielding a response rate of 97.5%. The overall prevalence of nonadherence to antiepileptic medications among epileptic patients attending at the University of Gondar Referral Hospital was 38.5% (95% CI: 33.1–43.8). Divorced and/or widowed marital status (AOR: 3.38 (95% CI: 1.54, 7.44)), treatment duration of 3–5 years (AOR = 3.58 (95% CI: 1.38, 9.29)), treatment duration of 5 and above years (AOR: 3.49 (95% CI: 1.53, 7.95)), comorbidity (AOR: 2.42 (95% CI: 1.08, 5.43)), side effects of antiepileptic medications (AOR: 3.36 (95% CI: 1.67, 6.74)), absence of health information (AOR: 1.98 (95% CI: 1.11, 3.52)), epilepsy-related stigma (AOR: 2.81 (95% CI: 1.57, 5.02)), and negative attitude towards antiepileptic medications (AOR: 2.46 (95% CI: 1.36, 4.45)) were significantly associated with nonadherence to antiepileptic medications. Conclusions Prevalence of nonadherence to antiepileptic medications among epileptic patients at the University of Gondar Referral Hospital was found to be high. Hence, giving health information about epilepsy and its management will help to reduce antiepileptic medications' nonadherence.
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Li R, Zhou Q, Ou S, Wang Y, Li Y, Xia L, Pan S. Comparison of long-term efficacy, tolerability, and safety of oxcarbazepine, lamotrigine, and levetiracetam in patients with newly diagnosed focal epilepsy: An observational study in the real world. Epilepsy Res 2020; 166:106408. [DOI: 10.1016/j.eplepsyres.2020.106408] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 06/16/2020] [Accepted: 06/23/2020] [Indexed: 10/24/2022]
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McKinlay A, Morgan M, Noble A, Ridsdale L. Patient views on use of emergency and alternative care services for adult epilepsy: A qualitative study. Seizure 2020; 80:56-62. [PMID: 32540637 PMCID: PMC7443693 DOI: 10.1016/j.seizure.2020.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/18/2020] [Accepted: 04/22/2020] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Emergency Department (ED) visits are costly to the health service and alternative care pathways may address this whilst improving outcomes. We aimed to describe decision-making and preferences of people with epilepsy (PWE) during emergency service use, and views of ED alternatives, including use of an Urgent Treatment Centre and telephone-based support from an epilepsy nurse specialist. METHODS We conducted a community-based interview study in South East England, informed by a qualitative framework approach. 25 adults with epilepsy and 5 of their carers took part. RESULTS Participants' choice to attend ED generally corresponded with guidelines, including continuing seizures and injury. Nevertheless, over half reported unwanted or unnecessary ED attendance, mainly due to lack of access to individual patient history, a carer, or seizures occurring in a public place. Participants used proactive strategies to communicate their care needs to others, including 24 -h alarm devices and care plans. Some suggested preventative strategies including referral after ED. Participants highlighted the importance of ambulance staff in providing fast and efficient care that gives reassurance. CONCLUSION Improving communication and access to preventative, proactive services may facilitate better outcomes within existing care pathways. PWE felt ED alternatives were helpful in some circumstances, but Urgent Treatment Centres or epilepsy nurse specialists were not viewed as an ED replacement.
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Affiliation(s)
- Alison McKinlay
- King's College London, Department of Basic and Clinical Neuroscience, London, UK.
| | - Myfanwy Morgan
- King's College London, Institute of Pharmaceutical Science, London, UK.
| | - Adam Noble
- University of Liverpool, Department of Health Services Research, UK.
| | - Leone Ridsdale
- King's College London, Department of Basic and Clinical Neuroscience, London, UK.
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Wagner RG, Kabudula CW, Forsgren L, Ibinda F, Lindholm L, Kahn K, Tollman S, Newton CR. Epilepsy care cascade, treatment gap and its determinants in rural South Africa. Seizure 2020; 80:175-180. [PMID: 32593141 PMCID: PMC7443697 DOI: 10.1016/j.seizure.2020.06.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/14/2020] [Accepted: 06/06/2020] [Indexed: 12/20/2022] Open
Abstract
Most people with active convulsive epilepsy in rural South Africa are diagnosed. Most individuals diagnosed have some blood level of anti-seizure medication. Most individuals do not have optimal levels of medication. The epilepsy treatment gap is high in rural South Africa, especially in children. Identifying the epilepsy care cascade may better allow for targeting of interventions.
Purpose The percentage of people who are diagnosed with epilepsy (diagnostic gap), access, receive and adhere (treatment gap) to anti-seizure medication (ASM) in low- and middle- income countries remains low. We explored the epilepsy care cascade, measured the diagnostic and treatment gaps, and examined socio-demographic factors associated with adherence to ASMs in rural South Africa. Methods Utilizing a population-based cohort of 311 people with active convulsive epilepsy (ACE) residing in rural northeastern South Africa, a questionnaire was administered to examine associations between demographic and socioeconomic factors and the epilepsy treatment gap. Blood was taken to measure levels of ASMs. Results Of the 311 individuals diagnosed, 93 % of individuals reported being previously told they had epilepsy and 94 % reported previously attending a health facility for their epilepsy. ASMs were detected in 138 individuals (76 %) and optimal levels were detected in 67 individuals, resulting in a treatment gap of 63 % (95 % confidence interval [95 %CI]: 56 %–70 %). Self-reported specificity of ASM use was 23 % (95 %CI: 12–39 %) and individuals ≥18 years were significantly more likely to report taking ASM than children and were significantly (p = 0.011) more likely to be adherent. Conclusion Most people with epilepsy in rural South Africa had been previously diagnosed with epilepsy and had accessed care for epilepsy, yet the level of ASM adherence remained low, significantly lower amongst children. Understanding ways of improving knowledge of and adherence to ASM in rural South Africa is necessary, especially amongst children. The epilepsy care cascade can be useful in identifying gaps in care and targeting interventions to reduce these gaps.
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Affiliation(s)
- Ryan G Wagner
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS) - INDEPTH Network, Accra, Ghana; MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden; Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden.
| | - Chodziwadziwa W Kabudula
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lars Forsgren
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
| | - Fredrick Ibinda
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research - Coast, Kilifi, Kenya
| | - Lars Lindholm
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Kathleen Kahn
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden; INDEPTH Network, Accra, Ghana
| | - Stephen Tollman
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden; INDEPTH Network, Accra, Ghana
| | - Charles R Newton
- Studies of Epidemiology of Epilepsy in Demographic Surveillance Systems (SEEDS) - INDEPTH Network, Accra, Ghana; MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research - Coast, Kilifi, Kenya; Neurosciences Unit, UCL Institute of Child Health, London, United Kingdom; Department of Psychiatry, University of Oxford, Oxford, United Kingdom
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Belayneh Z, Mekuriaw B. A systematic review and meta-analysis of anti-epileptic medication non-adherence among people with epilepsy in Ethiopia. ACTA ACUST UNITED AC 2020; 78:23. [PMID: 33072315 PMCID: PMC7562694 DOI: 10.1186/s13690-020-00405-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 03/05/2020] [Indexed: 02/07/2023]
Abstract
Background Epilepsy is the common neurological disorder in the world, affecting approximately 50 million people. Anti-epileptic medication non-adherence can be a reason for long term hospitalization, repeated emergency seizure attacks, increased health care cost and frequent absence of work due to poor seizure control. Existed studies of anti-epileptic medication non-adherence in Ethiopia have reported great discrepant and inconsistent results which calls a growing demand of systematic review and meta-analysis. Therefore, this review aimed to show the pooled prevalence of anti-epileptic medication non-adherence among people with epilepsy attending outpatient department. Methods Literatures were searched from the PubMed/Medline, Science Direct, PsycINFO, Hinnari and Google Scholar for grey literatures. The data were extracted using a prepared data extraction Microsoft Excel format. The data were analyzed using STATA- version 14 (software). The I2 test was used to check the heterogeneity between primary studies with a corresponding 95% confidence interval. Results A total of fourteen primary studies of anti-epileptic medication non-adherence were included in the review showing the pooled prevalence of anti-epileptic medication non-adherence to be 39.77 (95% CI: 32.44, 47.10). The highest prevalence [44.13 95% CI: (29.92, 58.34)] was observed among studies used both self-report and medical record review together, and studies used only self-report to screen medication none adherence had the lowest prevalence [37.95% (24.50, 51.41)]. Presence of co-morbid illness [2.27 (95%CI: 1.01, 5.12)], medication side effects [1.84(95% CI: 1.43, 2.38)], substance use or drug abuse [2.01(95% CI: 1.27, 3.20)] had statistically significant association with anti-epileptic medication non-adherence. Conclusion In this review, we found that there is a high burden of anti-epileptic medication non-adherence among people with epilepsy in Ethiopia. This demonstrates a need for clinicians to give more attention for the monitoring and evaluation of anti-epileptic medication adherence in the health care service. We also highly recommended for the adoption of a standardized and contextualized adherence screening tools. Trial registration PROSPERO registration number- [CRD42019137631].
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Affiliation(s)
- Zelalem Belayneh
- Department of Psychiatry, College of Health and Medical Science, Dilla University, Dilla, Ethiopia
| | - Birhanie Mekuriaw
- Department of Psychiatry, College of Health and Medical Science, Dilla University, Dilla, Ethiopia
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Epilepsy Treatment Outcome and Its Predictors among Ambulatory Patients with Epilepsy at Mizan-Tepi University Teaching Hospital, Southwest Ethiopia. Neurol Res Int 2020; 2020:8109858. [PMID: 32328306 PMCID: PMC7168704 DOI: 10.1155/2020/8109858] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/24/2020] [Accepted: 03/11/2020] [Indexed: 12/02/2022] Open
Abstract
Background Epilepsy is among the most common neurological disorders which is highly treatable with currently available antiepileptic drugs at a reasonable price. In Ethiopia, despite a number of studies revealed high prevalence of epilepsy, little is known on predictors of poorly controlled seizures. Thus, the aim of this study was to assess epilepsy treatment outcome and its predictors among patients with epilepsy on follow-up at the ambulatory care unit of Mizan-Tepi University Teaching Hospital, Southwest Ethiopia. Methods A hospital-based cross-sectional study involving patient interview and chart review was conducted from March 10 to April 10, 2018. Drug use patterns and sociodemographic data of the study participants were accustomed to descriptive statistics. Backward logistic regression analysis was done to identify predictors of poor seizure control. Statistical significance was considered at p value <0.05. Results From a total of 143 studied patients with epilepsy, 60.8% had uncontrolled seizures. Monotherapy (79%) was commonly used for the treatment of seizures, of which phenobarbital was the most commonly utilized single anticonvulsant drug (62.9%). The majority (72.7%) of the patients had developed one or more antiepileptic-related adverse effects. Medium medication adherence (adjusted odds ratio (AOR) = 5.4; 95% CI = 1.52–19.23; p=0.009), poor medication adherence (AOR = 8.16; 95% CI = 3.04–21.90; p=0.001), head injury before seizure occurrence (AOR = 4.9; 95% CI = 1.25–19.27; p=0.02), and seizure attacks ≥4 episodes/week before AEDs initiation (AOR = 8.52; % CI = 2.41–13.45; p=0.001) were the predictors of uncontrolled seizure. Conclusions Based on our findings, more than half of the patients with epilepsy had poorly controlled seizures. Nonadherence to antiepileptic drugs, high frequency of seizure attack before AEDs initiation, and history of a head injury before the occurrence of seizure were predictors of uncontrolled seizure. Patient medication adherence should be increased by the free access of antiepileptic drugs and attention should be given for the patients with a history of head injury and high frequency of seizure attacks before AEDs initiation.
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Myland M, Buysse B, Tsong W, Power GS, Nordli D, Chin RFM. Seizure frequency, healthcare resource utilisation and mortality in childhood epilepsy: a retrospective cohort study using the THIN database. Arch Dis Child 2019; 104:1070-1076. [PMID: 31272968 PMCID: PMC6837252 DOI: 10.1136/archdischild-2019-316910] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To understand the association of seizure frequency with healthcare resource utilisation (HCRU) and mortality in UK children with epilepsy (CWE). DESIGN Retrospective cohort study. SETTING Routinely collected data in primary care from The Health Improvement Network UK database. PATIENTS CWE ≥1 and<18 years of age with a record of seizure frequency were included in mortality analyses from 2005 to 2015 and HCRU analyses from 2010 to 2015. MAIN OUTCOME MEASURES Frequency of HCRU contacts during the year following latest seizure frequency and mortality (descriptive and Cox proportional hazards regression) from first record of seizure frequency. RESULTS Higher seizure frequency was related to increased HCRU utilisation and mortality. In negative binomial regression, each category increase in seizure frequency related to 11% more visits to general practitioners, 35% more inpatient admissions, 15% more outpatient visits and increased direct HCRU costs (24%). 11 patients died during 12 490 patient-years follow-up. The unadjusted HR of mortality per higher category of seizure frequency was 2.56 (95% CI: 1.52 to 4.31). Adjustment for age and number of prescribed anti-epileptic drugs at index attenuated this estimate to 2.11 (95% CI: 1.24 to 3.60). CONCLUSION Higher seizure frequency is associated with greater HCRU and mortality in CWE in the UK. Improvement in seizure control may potentially lead to better patient outcomes and reduced healthcare use.
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Affiliation(s)
| | | | | | | | | | - Richard F M Chin
- Muir Maxwell Epilepsy Centre, Edinburgh, UK,Paediatric Neurosciences, Royal Hospital for Sick Children, Edinburgh, UK
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Fernandez H, Cooke M, Patel T. Epilepsy and lifestyle behaviors related to bone health. Epilepsia 2019; 60:2306-2313. [DOI: 10.1111/epi.16351] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/03/2019] [Accepted: 09/03/2019] [Indexed: 01/16/2023]
Affiliation(s)
- Haya Fernandez
- School of Pharmacy University of Waterloo Waterloo Canada
| | - Martin Cooke
- School of Public Health and Health Systems University of Waterloo Waterloo Canada
- Department of Sociology & Legal Studies University of Waterloo Waterloo Canada
| | - Tejal Patel
- School of Pharmacy University of Waterloo Waterloo Canada
- Michael G DeGroote School of Medicine McMaster University Hamilton Canada
- Centre for Family Medicine Family Health Team Kitchener Canada
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Nevitt SJ, Tudur Smith C, Marson AG. Phenobarbitone versus phenytoin monotherapy for epilepsy: an individual participant data review. Cochrane Database Syst Rev 2019; 7:CD002217. [PMID: 31425629 PMCID: PMC6699655 DOI: 10.1002/14651858.cd002217.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND This is an update of a Cochrane Review first published in 2001, and last updated in 2013. This review is one in a series of Cochrane Reviews investigating pair-wise monotherapy comparisons.Epilepsy is a common neurological condition in which abnormal electrical discharges from the brain cause recurrent unprovoked seizures. It is believed that with effective drug treatment, up to 70% of individuals with active epilepsy have the potential to become seizure-free and go into long-term remission shortly after starting drug therapy with a single antiepileptic drug in monotherapy.Worldwide, particularly in the developing world, phenytoin and phenobarbitone are commonly used antiepileptic drugs, primarily because they are inexpensive. The aim of this review is to summarise data from existing trials comparing phenytoin and phenobarbitone. OBJECTIVES To review the time to treatment failure, remission and first seizure with phenobarbitone compared with phenytoin when used as monotherapy in people with focal onset seizures (simple or complex focal and secondarily generalised), or generalised onset tonic-clonic seizures (with or without other generalised seizure types). SEARCH METHODS For the latest update, we searched the following databases on 21 August 2018: the Cochrane Register of Studies (CRS Web), which includes Cochrane Epilepsy's Specialized Register and CENTRAL; MEDLINE; the US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov); and the World Health Organization International Clinical Trials Registry Platform (ICTRP). We handsearched relevant journals and contacted pharmaceutical companies, original trial investigators, and experts in the field. SELECTION CRITERIA: Randomised controlled trials comparing monotherapy with either phenobarbitone or phenytoin in children or adults with focal onset seizures or generalised onset tonic-clonic seizures. DATA COLLECTION AND ANALYSIS This was an individual participant data (IPD), review. Our primary outcome was time to treatment failure. Our secondary outcomes were time to first seizure post-randomisation, time to six-month remission and time to 12-month remission. We used Cox proportional hazards regression models to obtain trial-specific estimates of hazard ratios (HRs), with 95% confidence intervals (CIs), using the generic inverse variance method to obtain the overall pooled HR and 95% CI. MAIN RESULTS Individual participant data were obtained for five studies, which recruited a total of 635 participants, representing 80% of 798 individuals from all seven identified eligible trials. For remission outcomes, an HR of less than 1 indicates an advantage for phenytoin and for first seizure and treatment failure outcomes an HR of less than 1 indicates an advantage for phenobarbitone.Results for the primary outcome of the review were: time to treatment failure for any reason related to treatment (pooled HR adjusted for seizure type for 499 participants: 1.61, 95% CI 1.22 to 2.12, low-certainty evidence), time to treatment failure due to adverse events (pooled HR adjusted for seizure type for 499 participants: 1.99, 95% CI 1.37 to 2.87, low-certainty evidence), time to treatment failure due to lack of efficacy (pooled HR adjusted for seizure type for 499 participants: 1.87, 95% CI 1.32 to 2.66, moderate-certainty evidence), showing a statistically significant advantage for phenytoin compared to phenobarbitone.For our secondary outcomes, we did not find any statistically significant differences between phenytoin and phenobarbitone: time to first seizure post-randomisation (pooled HR adjusted for seizure type for 624 participants: 0.85, 95% CI 0.69 to 1.06, moderate-certainty evidence), time to 12-month remission (pooled HR adjusted for seizure type for 588 participants: 0.90, 95% CI 0.69 to 1.19, moderate-certainty evidence), and time to six-month remission pooled HR adjusted for seizure type for 588 participants: 0.91, 95% CI 0.71 to 1.15, moderate-certainty evidence).For individuals with focal onset seizures (73% of individuals contributing to analysis), numerical results were similar and conclusions the same as for analyses of all individuals and for individuals with generalised onset seizures (27% of individuals contributing to analysis), results were imprecise and no clear differences between the drugs were observed.Several confounding factors, most notably the differences in design of the trials with respect to blinding, were likely to have impacted on the results of the primary outcome 'time to treatment failure', and in turn, the treatment failure rates may have impacted on the secondary efficacy outcomes of time to first seizure and time to 12-month and six-month remission. AUTHORS' CONCLUSIONS Low-certainty evidence from this review suggests that phenytoin may be a more effective drug than phenobarbitone in terms of treatment retention (treatment failures due to lack of efficacy or adverse events or both). Moderate-certainty evidence from this review also indicates no differences between the drugs in terms of time to seizure recurrence and seizure remission.However, the trials contributing to the analyses had methodological inadequacies and methodological design differences that may have impacted upon the results of this review. Therefore, we do not suggest that results of this review alone should form the basis of a treatment choice for a patient with newly onset seizures. We recommend that future trials should be designed to the highest quality possible with consideration of masking, choice of population, classification of seizure type, duration of follow-up, choice of outcomes and analysis, and presentation of results.
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Affiliation(s)
- Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Catrin Tudur Smith
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
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Nevitt SJ, Marson AG, Tudur Smith C. Carbamazepine versus phenytoin monotherapy for epilepsy: an individual participant data review. Cochrane Database Syst Rev 2019; 7:CD001911. [PMID: 31318037 PMCID: PMC6637502 DOI: 10.1002/14651858.cd001911.pub4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND This is an update of a Cochrane Review first published in 2002 and last updated in 2017. This review is one in a series of Cochrane Reviews investigating pair-wise monotherapy comparisons.Epilepsy is a common neurological condition in which abnormal electrical discharges from the brain cause recurrent unprovoked seizures. It is believed that with effective drug treatment, up to 70% of individuals with active epilepsy have the potential to become seizure-free and go into long-term remission shortly after starting drug therapy with a single antiepileptic drug in monotherapy.Worldwide, carbamazepine and phenytoin are commonly-used broad spectrum antiepileptic drugs, suitable for most epileptic seizure types. Carbamazepine is a current first-line treatment for focal onset seizures in the USA and Europe. Phenytoin is no longer considered a first-line treatment, due to concerns over adverse events associated with its use, but the drug is still commonly used in low- to middle-income countries because of its low cost. No consistent differences in efficacy have been found between carbamazepine and phenytoin in individual trials; however, the confidence intervals generated by these trials are wide, and therefore, synthesising the data of the individual trials may show differences in efficacy. OBJECTIVES To review the time to treatment failure, remission and first seizure with carbamazepine compared with phenytoin when used as monotherapy in people with focal onset seizures (simple or complex focal and secondarily generalised), or generalised onset tonic-clonic seizures (with or without other generalised seizure types). SEARCH METHODS For the latest update, we searched the following databases on 13 August 2018: the Cochrane Register of Studies (CRS Web), which includes the Cochrane Epilepsy's Specialised Register and CENTRAL; MEDLINE; the US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov); and the World Health Organization International Clinical Trials Registry Platform (ICTRP). We handsearched relevant journals and contacted pharmaceutical companies, original trial investigators, and experts in the field. SELECTION CRITERIA Randomised controlled trials comparing monotherapy with either carbamazepine or phenytoin in children or adults with focal onset seizures or generalised onset (tonic-clonic) seizures. DATA COLLECTION AND ANALYSIS This was an individual participant data (IPD) review. Our primary outcome was time to treatment failure. Our secondary outcomes were time to first seizure post-randomisation, time to six-month remission, time to 12-month remission, and incidence of adverse events. We used Cox proportional hazards regression models to obtain trial-specific estimates of hazard ratios (HRs), with 95% confidence intervals (CIs), using the generic inverse variance method to obtain the overall pooled HR and 95% CI. MAIN RESULTS IPD were available for 595 participants out of 1102 eligible individuals, from four out of 11 trials (i.e. 54% of the potential data). For remission outcomes, a HR greater than 1 indicates an advantage for phenytoin; and for first seizure and withdrawal outcomes, a HR greater than 1 indicates an advantage for carbamazepine. Most participants included in analysis (78%) were classified as experiencing focal onset seizures at baseline and only 22% were classified as experiencing generalised onset seizures; the results of this review are therefore mainly applicable to individuals with focal onset seizures.Results for the primary outcome of the review were: time to treatment failure for any reason related to treatment (pooled HR adjusted for seizure type for 546 participants: 0.94, 95% CI 0.70 to 1.26, moderate-certainty evidence); time to treatment failure due to lack of efficacy (pooled HR adjusted for seizure type for 546 participants: 0.99, 95% CI 0.69 to 1.41, moderate-certainty evidence); both showing no clear difference between the drugs and time to treatment failure due to adverse events (pooled HR adjusted for seizure type for 546 participants: 1.27, 95% CI 0.87 to 1.86, moderate-certainty evidence), showing that treatment failure due to adverse events may occur earlier on carbamazepine than phenytoin, but we cannot rule out a slight advantage to carbamazepine or no difference between the drugs.For our secondary outcomes (pooled HRs adjusted for seizure type), we did not find any clear differences between carbamazepine and phenytoin: time to first seizure post-randomisation (582 participants): 1.15, 95% CI 0.94 to 1.40, moderate-certainty evidence); time to 12-month remission (551 participants): 1.00, 95% CI 0.79 to 1.26, moderate-certainty evidence); and time to six-month remission (551 participants): 0.90, 95% CI 0.73 to 1.12, moderate-certainty evidence).For all outcomes, results for individuals with focal onset seizures were similar to overall results (moderate-certainty evidence), and results for the small subgroup of individuals with generalised onset seizures were imprecise, so we cannot rule out an advantage to either drug, or no difference between drugs (low-certainty evidence). There was also evidence that misclassification of seizure type may have confounded the results of this review, particularly for the outcome 'time to treatment failure'. Heterogeneity was present in analysis of 'time to first seizure' for individuals with generalised onset seizures, which could not be explained by subgroup analysis or sensitivity analyses.Limited information was available about adverse events in the trials and we could not compare the rates of adverse events between carbamazepine and phenytoin. Some adverse events reported on both drugs were abdominal pain, nausea, and vomiting, drowsiness, motor and cognitive disturbances, dysmorphic side effects (such as rash). AUTHORS' CONCLUSIONS Moderate-certainty evidence provided by this systematic review does not show any differences between carbamazepine and phenytoin in terms of effectiveness (retention) or efficacy (seizure recurrence and seizure remission) for individuals with focal onset or generalised onset seizures.However, some of the trials contributing to the analyses had methodological inadequacies and inconsistencies, which may have had an impact on the results of this review. We therefore do not suggest that results of this review alone should form the basis of a treatment choice for a person with newly-onset seizures. We did not find any evidence to support or refute current treatment policies. We implore that future trials be designed to the highest quality possible, with consideration of masking, choice of population, classification of seizure type, duration of follow-up, choice of outcomes and analysis, and presentation of results.
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Affiliation(s)
- Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
| | - Catrin Tudur Smith
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
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Nevitt SJ, Sudell M, Tudur Smith C, Marson AG. Topiramate versus carbamazepine monotherapy for epilepsy: an individual participant data review. Cochrane Database Syst Rev 2019; 6:CD012065. [PMID: 31233229 PMCID: PMC6590101 DOI: 10.1002/14651858.cd012065.pub3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane Review published in Issue 12, 2016. This review is one in a series of Cochrane Reviews investigating pair-wise monotherapy comparisons.Epilepsy is a common neurological condition in which abnormal electrical discharges from the brain cause recurrent unprovoked seizures. It is believed that with effective drug treatment, up to 70% of individuals with active epilepsy have the potential to become seizure-free and go into long-term remission shortly after starting drug therapy, the majority of which may be able to achieve remission with a single antiepileptic drug (AED).The correct choice of first-line AED for individuals with newly diagnosed seizures is of great importance and should be based on the highest-quality evidence available regarding the potential benefits and harms of various treatments for an individual.Topiramate and carbamazepine are commonly used AEDs. Performing a synthesis of the evidence from existing trials will increase the precision of results of outcomes relating to efficacy and tolerability, and may help inform a choice between the two drugs. OBJECTIVES To review the time to treatment failure, remission and first seizure with topiramate compared with carbamazepine when used as monotherapy in people with focal onset seizures (simple or complex focal and secondarily generalised), or generalised onset tonic-clonic seizures (with or without other generalised seizure types). SEARCH METHODS For the latest update we searched the Cochrane Register of Studies (CRS Web), which includes the Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (Ovid); ClinicalTrials.gov; and the WHO International Clinical Trials Registry Platform (ICTRP) to 22 May 2018. We imposed no language restrictions. We also contacted pharmaceutical companies and trial investigators. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing monotherapy with either topiramate or carbamazepine in children or adults with focal onset seizures or generalised onset tonic-clonic seizures (with or without other generalised seizure types). DATA COLLECTION AND ANALYSIS This was an individual participant data (IPD), review. Our primary outcome was time to treatment failure. Our secondary outcomes were time to first seizure post-randomisation, time to six-month remission, time to 12-month remission, and incidence of adverse events. We used Cox proportional hazards regression models to obtain trial-specific estimates of hazard ratios (HRs), with 95% confidence intervals (CIs), using the generic inverse variance method to obtain the overall pooled HR and 95% CI. MAIN RESULTS IPD were available for 1151 of 1239 eligible individuals from two of three eligible studies (93% of the potential data). A small proportion of individuals recruited into these trials had 'unclassified seizures;' for analysis purposes, these individuals are grouped with those with generalised onset seizures. For remission outcomes, a HR < 1 indicated an advantage for carbamazepine, and for first seizure and treatment failure outcomes, a HR < 1 indicated an advantage for topiramate.The main overall results for the primary outcome, time to treatment failure, given as pooled HR adjusted for seizure type were: time to failure for any reason related to treatment 1.16 (95% CI 0.97 to 1.38); time to failure due to adverse events 1.02 (95% CI 0.82 to 1.27); and time to failure due to lack of efficacy 1.46 (95% CI 1.08 to 1.98). Overall results for secondary outcomes were time to first seizure 1.11 (95% CI 0.96 to 1.29); and time to six-month remission 0.88 (0.76 to 1.01). There were no statistically significant differences between the drugs. A statistically significant advantage for carbamazepine was shown for time to 12-month remission: 0.84 (95% CI 0.71 to 0.99).The results of this review are applicable mainly to individuals with focal onset seizures; 81% of individuals included within the analysis experienced seizures of this type at baseline. For individuals with focal onset seizures, a statistically significant advantage for carbamazepine was shown for time to failure for any reason related to treatment (HR 1.21, 95% CI 1.01 to 1.46), time to treatment failure due to lack of efficacy (HR 1.47, 95% CI 1.07 to 2.02), and time to 12-month remission (HR 0.82, 95% CI 0.69 to 0.99). There was no statistically significant difference between topiramate and carbamazepine for 'time to first seizure' and 'time to six-month remission'.Evidence for individuals with generalised tonic-clonic seizures (9% of participants contributing to the analysis), and unclassified seizure types (10% of participants contributing to the analysis) was very limited; no statistically significant differences were found but CIs were wide; therefore we cannot exclude an advantage to either drug, or a difference between drugs.The most commonly reported adverse events with both drugs were drowsiness or fatigue, "pins and needles" (tingling sensation), headache, gastrointestinal disturbance and anxiety or depression. The rate of adverse events was similar across the two drugs.We judged the methodological quality of the included trials generally to be good; however, there was some evidence that the open-label design of the larger of the two trials may have influenced the treatment failure rate within the trial. Hence, we judged the certainty of the evidence for treatment failure to be moderate for individuals with focal onset seizures and low for individuals with generalised onset seizures. For efficacy outcomes (first seizure, remission), we judged the certainty of evidence from this review to be high for individuals with focal onset seizures and moderate for individuals with generalised onset or unclassified seizures. AUTHORS' CONCLUSIONS For individuals with focal onset seizures, there is moderate-certainty evidence that carbamazepine is less likely to be withdrawn and high-certainty evidence that 12-month remission will be achieved earlier than with topiramate. We did not find any differences between the drugs in terms of the other outcomes measured in the review and for individuals with generalised tonic-clonic seizures or unclassified epilepsy; however, we encourage caution in the interpretation of results including small numbers of participants with these seizure types.Future trials should be designed to the highest quality possible and take into consideration masking, choice of population, classification of seizure type, duration of follow-up, choice of outcomes and analysis, and presentation of results.
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Affiliation(s)
- Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Maria Sudell
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Catrin Tudur Smith
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
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Du Y, Lin J, Shen J, Ding S, Ye M, Wang L, Wang Y, Wang X, Xia N, Zheng R, Chen H, Xu H. Adverse drug reactions associated with six commonly used antiepileptic drugs in southern China from 2003 to 2015. BMC Pharmacol Toxicol 2019; 20:7. [PMID: 30642405 PMCID: PMC6332546 DOI: 10.1186/s40360-019-0285-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 01/04/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND This active, open observational study aimed to investigate adverse drug reactions (ADRs) associated with six commonly used antiepileptic drugs (AEDs) in southern Chinese outpatients with epilepsy from 2003 to 2015. METHODS The Wenzhou Epilepsy Follow-Up Registry Database (WEFURD) was established by a single epilepsy center in China in January 2003 to record AED efficacy and the associated ADRs by registered outpatients diagnosed with epilepsy. We reviewed the data of outpatients who had only taken one or more of six commonly used AEDs, namely, carbamazepine (CBZ), valproate (VPA), lamotrigine (LTG), oxcarbazepine (OXC), topiramate (TPM) and levetiracetam (LEV), and were registered in the WEFURD between 2003 and 2015. We evaluated the ADRs caused by the single or combined use of the above six specific AEDs based on the WHO-UMC scale. The data of the ADRs were categorized by age, sex, number of AEDs related to ADRs, medications, seriousness of ADRs, causality levels of the WHO-UMC scale and system organ class (SOC). The unit of analysis was one ADR. RESULTS A total of 3069 epilepsy outpatients (1807 outpatients with 5049 eligible ADRs and 1262 outpatients without ADRs) were included. The overall ADR rate was 58.88% (1807/3069). An average of 2.79 ADRs (5049/1807) occurred per patient with an ADR; 53.8% of the 5049 ADRs were recorded in females, and 50.4% were caused by monotherapy. Of the ADRs, 10.6% (537/5049) were severe adverse reactions (SARs), including 34 serious adverse effects (SAEs). The SAR rates caused by one, two and three or more AEDs were 9.9, 10.0 and 19.6%, respectively (p < 0.001). Eighteen SOC categories were identified, and the top three were psychiatric disorders (1633/5049, 32.3%), neurological disorders (1222/5049, 24.2%) and gastrointestinal disorders (564/5049, 11.2%). Of the 537 SARs, skin and appendage disorders accounted for 24.4% (131/537). Among the 34 SAEs, serious allergies, fetal malformations, renal calculus and pancreatitis accounted for the majority. CONCLUSIONS Our findings suggest that clinicians should pay attention to psychiatric ADRs and be alert for SARs, especially when three or more AEDs are used together. Moreover, active surveillance might provide another method of pharmacovigilance in China.
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Affiliation(s)
- Yanru Du
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Shangcai Village, Ouhai District, Wenzhou, Zhejiang Province, People's Republic of China
| | - Jiahe Lin
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Shangcai Village, Ouhai District, Wenzhou, Zhejiang Province, People's Republic of China
| | - Jingzan Shen
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Shangcai Village, Ouhai District, Wenzhou, Zhejiang Province, People's Republic of China
| | - Siqi Ding
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Shangcai Village, Ouhai District, Wenzhou, Zhejiang Province, People's Republic of China
| | - Mengqian Ye
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Shangcai Village, Ouhai District, Wenzhou, Zhejiang Province, People's Republic of China
| | - Li Wang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Shangcai Village, Ouhai District, Wenzhou, Zhejiang Province, People's Republic of China
| | - Yi Wang
- Department of Preventive Medicine, School of Public Health and Management, Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
| | - Xinshi Wang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Shangcai Village, Ouhai District, Wenzhou, Zhejiang Province, People's Republic of China
| | - Niange Xia
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Shangcai Village, Ouhai District, Wenzhou, Zhejiang Province, People's Republic of China
| | - Rongyuan Zheng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Shangcai Village, Ouhai District, Wenzhou, Zhejiang Province, People's Republic of China
| | - Hong Chen
- Department of Psychiatry, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
| | - Huiqin Xu
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Shangcai Village, Ouhai District, Wenzhou, Zhejiang Province, People's Republic of China.
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John K, Tailor S, Anderson J, Lawthom C. Managing epilepsy in austerity - Evaluating the utility and value of the epilepsy specialist nurse in an open access model of service delivery. Aneurin Bevan Epilepsy Specialist Team (A.B.E.S.T.). Seizure 2019; 65:98-100. [PMID: 30660000 DOI: 10.1016/j.seizure.2019.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/08/2019] [Accepted: 01/10/2019] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Healthcare organisations in the UK primarily measure clinical activity from data collected on numbers of attendances at outpatient clinics, inpatient admissions and procedures performed etc. Telephone contacts with patients are not typically measured as clinical activity. This service evaluation examines the utility and value of the Epilepsy Specialist Nurse (ESN) within an innovative 'Open Access Model', giving a breakdown of clinical workload and outcomes. METHODS A retrospective service evaluation analysing all patient encounters made by the ESN and their outcomes, over a 3-month period from the 01/02/2017 to 30/04/2017. RESULTS During the 3-month data collection period there were 620 patient encounters with 251 different patients. Nurse-led clinic appointments and telephone calls were the two most common types of encounter. Eighteen percent of ESN time was spent on the phone directly addressing patient concerns (368 encounters). Of these calls, 72% led to prevention of a clinic appointment (268 appointments avoided) while only 22% needed a subsequent clinic appointment. The most common outcome of telephone encounters was 'medication management' (25%). CONCLUSIONS The evaluation demonstrates that timely intervention by telephone reduces the need for outpatient appointments and leads to treatment changes being implemented quickly to address individual need.
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Affiliation(s)
- Keri John
- Aneurin Bevan University Health Board, United Kingdom
| | - Sunil Tailor
- School of Medicine, Cardiff University, United Kingdom
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Xu MY. Poststroke seizure: optimising its management. Stroke Vasc Neurol 2018; 4:48-56. [PMID: 31105979 PMCID: PMC6475084 DOI: 10.1136/svn-2018-000175] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 09/12/2018] [Accepted: 10/11/2018] [Indexed: 01/01/2023] Open
Abstract
Seizure after stroke or poststroke seizure (PSS) is a common and very important complication of stroke. It can be divided into early seizure and late seizure, depending on seizure onset time after the stroke. It has been reported that ischaemic and haemorrhagic stroke accounts for about 11% of all adult epilepsy cases and 45% of epilepsy cases over 60 years of age. However, there are no reliable guidelines in clinical practice regarding most of the fundamental issues of PSS management. In recent years there has been an increased interest in the study of PSS which may give clinical practitioners a better picture of how to optimise PSS management. Studies have indicated two peaks in PSS occurrence—the first day and 6–12 months after a stroke. Haemorrhagic stroke, cortical involvement, severity of initial neurological deficit, younger patients (<65 years of age), family history of seizures and certain genetic factors carry a higher risk of PSS. The use of continuous electroencephalogram has demonstrated significant benefits in capturing interictal or ictal abnormalities, especially in cases of non-convulsive seizures and non-convulsive status epilepticus. Current available data indicated that there was no significant difference in antiepileptic efficacy among most of the antiepileptic drugs (AEDs) in PSS. Levetiracetam and lamotrigine are the most studied newer generation AEDs and have the best drug tolerance. The purpose of this review is to summarise the recent advances in PSS research and focus on the most important practice issues of PSS management.
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Affiliation(s)
- Michael Y Xu
- Department of Neurology, OSF Illinois Neurological Institute, University of Illinois College of Medicine, Peoria, Illinois, USA
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Nevitt SJ, Marson AG, Tudur Smith C. Carbamazepine versus phenobarbitone monotherapy for epilepsy: an individual participant data review. Cochrane Database Syst Rev 2018; 10:CD001904. [PMID: 30353945 PMCID: PMC6517155 DOI: 10.1002/14651858.cd001904.pub4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND This is an updated version of the Cochrane Review previously published in 2016. This review is one in a series of Cochrane Reviews investigating pair-wise monotherapy comparisons.Epilepsy is a common neurological condition in which abnormal electrical discharges from the brain cause recurrent unprovoked seizures. It is believed that with effective drug treatment, up to 70% of individuals with active epilepsy have the potential to become seizure-free and go into long-term remission shortly after starting drug therapy with a single antiepileptic drug in monotherapy.Worldwide, carbamazepine and phenobarbitone are commonly used broad-spectrum antiepileptic drugs, suitable for most epileptic seizure types. Carbamazepine is a current first-line treatment for focal onset seizures, and is used in the USA and Europe. Phenobarbitone is no longer considered a first-line treatment because of concerns over associated adverse events, particularly documented behavioural adverse events in children treated with the drug. However, phenobarbitone is still commonly used in low- and middle-income countries because of its low cost. No consistent differences in efficacy have been found between carbamazepine and phenobarbitone in individual trials; however, the confidence intervals generated by these trials are wide, and therefore, synthesising the data of the individual trials may show differences in efficacy. OBJECTIVES To review the time to treatment failure, remission and first seizure with carbamazepine compared with phenobarbitone when used as monotherapy in people with focal onset seizures (simple or complex focal and secondarily generalised), or generalised onset tonic-clonic seizures (with or without other generalised seizure types). SEARCH METHODS For the latest update, we searched the following databases on 24 May 2018: the Cochrane Register of Studies (CRS Web), which includes Cochrane Epilepsy's Specialized Register and CENTRAL; MEDLINE; the US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov); and the World Health Organization International Clinical Trials Registry Platform (ICTRP). We handsearched relevant journals and contacted pharmaceutical companies, original trial investigators, and experts in the field. SELECTION CRITERIA Randomised controlled trials comparing monotherapy with either carbamazepine or phenobarbitone in children or adults with focal onset seizures or generalised onset tonic-clonic seizures. DATA COLLECTION AND ANALYSIS This was an individual participant data (IPD), review. Our primary outcome was time to treatment failure. Our secondary outcomes were time to first seizure post-randomisation, time to six-month remission, time to 12-month remission, and incidence of adverse events. We used Cox proportional hazards regression models to obtain trial-specific estimates of hazard ratios (HRs), with 95% confidence intervals (CIs), using the generic inverse variance method to obtain the overall pooled HR and 95% CI. MAIN RESULTS We included 13 trials in this review and IPD were available for 836 individuals out of 1455 eligible individuals from six trials, 57% of the potential data. For remission outcomes, a HR of less than 1 indicates an advantage for phenobarbitone and for first seizure and treatment failure outcomes a HR of less than 1 indicates an advantage for carbamazepine.Results for the primary outcome of the review were: time to treatment failure for any reason related to treatment (pooled HR adjusted for seizure type for 676 participants: 0.66, 95% CI 0.50 to 0.86, moderate-quality evidence), time to treatment failure due to adverse events (pooled HR adjusted for seizure type for 619 participants: 0.69, 95% CI 0.49 to 0.97, low-quality evidence), time to treatment failure due to lack of efficacy (pooled HR adjusted for seizure type for 487 participants: 0.54, 95% CI 0.38 to 0.78, moderate-quality evidence), showing a statistically significant advantage for carbamazepine compared to phenobarbitone.For our secondary outcomes, we did not find any statistically significant differences between carbamazepine and phenobarbitone: time to first seizure post-randomisation (pooled HR adjusted for seizure type for 822 participants: 1.13, 95% CI 0.93 to 1.38, moderate-quality evidence), time to 12-month remission (pooled HR adjusted for seizure type for 683 participants: 1.09, 95% CI 0.84 to 1.40, low-quality evidence), and time to six-month remission pooled HR adjusted for seizure type for 683 participants: 1.01, 95% CI 0.81 to 1.24, low-quality evidence).Results of these secondary outcomes suggest that there may be an association between treatment effect in terms of efficacy and seizure type; that is, that participants with focal onset seizures experience seizure recurrence later and hence remission of seizures earlier on phenobarbitone than carbamazepine, and vice versa for individuals with generalised seizures. It is likely that the analyses of these outcomes were confounded by several methodological issues and misclassification of seizure type, which could have introduced the heterogeneity and bias into the results of this review.Limited information was available regarding adverse events in the trials and we could not compare the rates of adverse events between carbamazepine and phenobarbitone. Some adverse events reported on both drugs were abdominal pain, nausea, and vomiting, drowsiness, motor and cognitive disturbances, dysmorphic side effects (such as rash), and behavioural side effects in three paediatric trials. AUTHORS' CONCLUSIONS Moderate-quality evidence from this review suggests that carbamazepine is likely to be a more effective drug than phenobarbitone in terms of treatment retention (treatment failures due to lack of efficacy or adverse events or both). Moderate- to low-quality evidence from this review also suggests an association between treatment efficacy and seizure type in terms of seizure recurrence and seizure remission, with an advantage for phenobarbitone for focal onset seizures and an advantage for carbamazepine for generalised onset seizures.However, some of the trials contributing to the analyses had methodological inadequacies and inconsistencies that may have impacted upon the results of this review. Therefore, we do not suggest that results of this review alone should form the basis of a treatment choice for a patient with newly onset seizures. We recommend that future trials should be designed to the highest quality possible with consideration of masking, choice of population, classification of seizure type, duration of follow-up, choice of outcomes and analysis, and presentation of results.
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Affiliation(s)
- Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
| | - Catrin Tudur Smith
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
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Nevitt SJ, Tudur Smith C, Marson AG. Oxcarbazepine versus phenytoin monotherapy for epilepsy: an individual participant data review. Cochrane Database Syst Rev 2018; 10:CD003615. [PMID: 30350354 PMCID: PMC6516888 DOI: 10.1002/14651858.cd003615.pub4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This is an updated version of the Cochrane Review previously published in 2013. This review is one in a series of Cochrane Reviews investigating pair-wise monotherapy comparisons.Epilepsy is a common neurological condition in which abnormal electrical discharges from the brain cause recurrent unprovoked seizures. It is believed that with effective drug treatment, up to 70% of individuals with active epilepsy have the potential to become seizure-free and go into long-term remission shortly after starting drug therapy with a single antiepileptic drug in monotherapy.Worldwide, phenytoin is a commonly used antiepileptic drug. It is important to know how newer drugs, such as oxcarbazepine, compare with commonly used standard treatments. OBJECTIVES To review the time to treatment failure, remission and first seizure with oxcarbazepine compared to phenytoin, when used as monotherapy in people with focal onset seizures or generalised tonic-clonic seizures (with or without other generalised seizure types). SEARCH METHODS We searched the following databases on 20 August 2018: the Cochrane Register of Studies (CRS Web), which includes the Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid, 1946 to 20 August 2018), ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We handsearched relevant journals and contacted pharmaceutical companies, original trial investigators and experts in the field. SELECTION CRITERIA We included randomised controlled trials comparing monotherapy with either oxcarbazepine or phenytoin in children or adults with focal onset seizures or generalised onset tonic-clonic seizures. DATA COLLECTION AND ANALYSIS This was an individual participant data (IPD) review. Our primary outcome was time to treatment failure and our secondary outcomes were time to first seizure post-randomisation, time to six-month and 12-month remission, and incidence of adverse events. We used Cox proportional hazards regression models to obtain trial-specific estimates of hazard ratios (HRs) with 95% confidence intervals (CIs), using the generic inverse variance method to obtain the overall pooled HR and 95% CI. MAIN RESULTS Individual participant data were available for 480 out of a total of 517 participants (93%), from two out of three included trials. For remission outcomes, a HR of less than one indicated an advantage for phenytoin; and for first seizure and treatment failure outcomes, a HR of less than one indicated an advantage for oxcarbazepine.The results for time to treatment failure for any reason related to treatment showed a potential advantage of oxcarbazepine over phenytoin, but this was not statistically significant (pooled HR adjusted for epilepsy type: 0.78 95% CI 0.53 to 1.14, 476 participants, two trials, moderate-quality evidence). Our analysis showed that treatment failure due to adverse events occurred later on with oxcarbazepine than phenytoin (pooled HR for all participants: 0.22 (95% CI 0.10 to 0.51, 480 participants, two trials, high-quality evidence). Our analysis of time to treatment failure due to lack of efficacy showed no clear difference between the drugs (pooled HR for all participants: 1.17 (95% CI 0.31 to 4.35), 480 participants, two trials, moderate-quality evidence).We found no clear or statistically significant differences between drugs for any of the secondary outcomes of the review: time to first seizure post-randomisation (pooled HR adjusted for epilepsy type: 0.97 95% CI 0.75 to 1.26, 468 participants, two trials, moderate-quality evidence); time to 12-month remission (pooled HR adjusted for epilepsy type 1.04 95% CI 0.77 to 1.41, 468 participants, two trials, moderate-quality evidence) and time to six-month remission (pooled HR adjusted for epilepsy type: 1.06 95% CI 0.82 to 1.36, 468 participants, two trials, moderate-quality evidence).The most common adverse events reported in more than 10% of participants on either drug were somnolence (28% of total participants, with similar rates for both drugs), headache (15% of total participants, with similar rates for both drugs), dizziness (14.5% of total participants, reported by slightly more participants on phenytoin (18%) than oxcarbazepine (11%)) and gum hyperplasia (reported by substantially more participants on phenytoin (18%) than oxcarbazepine (2%)).The results of this review are applicable mainly to individuals with focal onset seizures; 70% of included individuals experienced seizures of this type at baseline. The two studies included in IPD meta-analysis were generally of good methodological quality but the design of the studies may have biased the results for the secondary outcomes (time to first seizure post-randomisation, time to six-month and 12-month remission) as seizure recurrence data were not collected following treatment failure or withdrawal from the study. In addition, misclassification of epilepsy type may have impacted on results, particularly for individuals with generalised onset seizures. AUTHORS' CONCLUSIONS High-quality evidence provided by this review indicates that treatment failure due to adverse events occurs significantly later with oxcarbazepine than phenytoin. For individuals with focal onset seizures, moderate-quality evidence suggests that oxcarbazepine may be superior to phenytoin in terms of treatment failure for any reason, seizure recurrence and seizure remission. Therefore, oxcarbazepine may be a preferable alternative treatment than phenytoin, particularly for individuals with focal onset seizures. The evidence in this review which relates to individuals with generalised onset seizures is of low quality and does not inform current treatment policy.We recommend that future trials should be designed to the highest quality possible with regards to choice of population, classification of seizure type, duration of follow-up (including continued follow-up after failure or withdrawal of randomised treatment), choice of outcomes and analysis, and presentation of results.
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Affiliation(s)
- Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Catrin Tudur Smith
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
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Dickson JM, Jacques R, Reuber M, Hick J, Campbell MJ, Morley R, Grünewald RA. Emergency hospital care for adults with suspected seizures in the NHS in England 2007-2013: a cross-sectional study. BMJ Open 2018; 8:e023352. [PMID: 30344177 PMCID: PMC6196871 DOI: 10.1136/bmjopen-2018-023352] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
AIMS To quantify the frequency, characteristics, geographical variation and costs of emergency hospital care for suspected seizures. DESIGN Cross-sectional study using routinely collected data (Hospital Episode Statistics). SETTING The National Health Service in England 2007-2013. PARTICIPANTS Adults who attended an emergency department (ED) or were admitted to hospital. RESULTS In England (population 2011: 53.11 million, 41.77 million adults), suspected seizures gave rise to 50 111 unscheduled admissions per year among adults (≥18 years). This is 47.1% of unscheduled admissions for neurological conditions and 0.71% of all unscheduled admissions. Only a small proportion of admissions for suspected seizures were coded as status epilepticus (3.5%) and there were a very small number of dissociative (non-epileptic) seizures. The median length of stay for each admission was 1 day, the median cost for each admission was £1651 ($2175) and the total cost of all admissions for suspected seizures in England was £88.2 million ($116.2 million) per year. 16.8% of patients had more than one admission per year. There was significant geographical variability in the rate of admissions corrected for population age and gender differences and some areas had rates of admission which were consistently higher than the average. CONCLUSIONS Our data show that suspected seizures are the most common neurological cause of admissions to hospital in England, that readmissions are common and that there is significant geographical variability in admission rates. This variability has not previously been reported in the published literature. The cause of the geographical variation is unknown; important factors are likely to include prevalence, deprivation and clinical practice and these require further investigation. Dissociative seizures are not adequately diagnosed during ED attendances and hospital admissions.
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Affiliation(s)
- Jon Mark Dickson
- The Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
| | | | - Markus Reuber
- Academic Neurology Unit, The University of Sheffield, Sheffield, UK
| | | | | | | | - Richard A Grünewald
- Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Ciccone O, Chabala C, Tembo O, Mathew M, Grollnek AK, Patel AA, Birbeck GL. A retrospective observational study of EEG findings and antiepileptic drug use among children referred for EEG to Zambia's University Teaching Hospital. Epilepsia Open 2018; 3:503-510. [PMID: 30525119 PMCID: PMC6276775 DOI: 10.1002/epi4.12267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2018] [Indexed: 12/26/2022] Open
Abstract
Objective Despite the heavy burden of epilepsy in Sub‐Saharan Africa, there remains a relative paucity of neurophysiology services and limited published data on electroencephalography (EEG) features among African children. The aim of this study was to describe clinical characteristics, EEG findings, and antiepileptic drug (AED) use among children referred for EEG to the University Teaching Hospital in Zambia. Methods EEG referrals and reports from 2013–2015 were reviewed. Within the context of routine care, EEG studies were interpreted by readers with advanced training in child neurology and clinical neurophysiology. Clinical data provided in the referral including seizure semiology and EEG findings were systematically extracted and analyzed. Results A total of 1,217 EEG reports were reviewed, with 1,187 included in the analysis. Median age was 7 years (interquartile range [IQR] 3–11) and 57% were male. Seventy‐three percent of 554 had documented seizure onset before 5 years of age. Among the 23% with seizure etiology documented, 78% were associated with perinatal injuries and central nervous system (CNS) infections. EEG abnormalities were found in 75% of the studies. Clinical semiology per referral identified focal seizures in 29%, but EEG findings increased this proportion to 63% (p = 0.004). Sixty‐two percent were taking AEDs, with 85% on monotherapy. The most commonly used AED was carbamazepine (49%).There was no association between the choice of AED and clinical semiology (all p's > 0.05). Significance This tertiary care center study identified >60% of referred children to have localization‐related epilepsies, with at least 18% of epilepsies being from potentially preventable causes. These findings are consistent with multi‐country, population‐based data from elsewhere in Africa. Seizure semiology assessed in routine, nonspecialist care does not predict AED choice, and the presence of focality is underestimated in routine care.
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Affiliation(s)
- Ornella Ciccone
- University Teaching Hospitals Children's Hospital Lusaka Zambia.,University of Zambia School of Medicine Lusaka Zambia
| | - Chishala Chabala
- University Teaching Hospitals Children's Hospital Lusaka Zambia.,University of Zambia School of Medicine Lusaka Zambia
| | - Owen Tembo
- University Teaching Hospitals Children's Hospital Lusaka Zambia
| | - Manoj Mathew
- University Teaching Hospitals Children's Hospital Lusaka Zambia.,University of Zambia School of Medicine Lusaka Zambia
| | | | - Archana A Patel
- Department of Neurology Boston Children's Hospital Boston Massachusetts U.S.A
| | - Gretchen L Birbeck
- Epilepsy Division Department of Neurology University of Rochester Rochester New York U.S.A.,Epilepsy Care Team Chikankata Hospital Mazabuka Zambia
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McCudden CR. Quality, origins and limitations of common therapeutic drug reference intervals. ACTA ACUST UNITED AC 2018; 5:47-61. [PMID: 29794249 DOI: 10.1515/dx-2018-0001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 04/24/2018] [Indexed: 12/14/2022]
Abstract
Therapeutic drug monitoring (TDM) is used to manage drugs with a narrow window between effective and toxic concentrations. TDM involves measuring blood concentrations of drugs to ensure effective therapy, avoid toxicity and monitor compliance. Common drugs for which TDM is used include aminoglycosides for infections, anticonvulsants to treat seizures, immunosuppressants for transplant patients and cardiac glycosides to regulate cardiac output and heart rate. An essential element of TDM is the provision of accurate and clinically relevant reference intervals. Unlike most laboratory reference intervals, which are derived from a healthy population, TDM reference intervals need to relate to clinical outcomes in the form of efficacy and toxicity. This makes TDM inherently more difficult to develop as healthy individuals are not on therapy, so there is no "normal value". In addition, many of the aforementioned drugs are old and much of the information regarding reference intervals is based on small trials using methods that have changed. Furthermore, individuals have different pharmacokinetics and drug responses, particularly in the context of combined therapies, which exacerbates the challenge of universal TDM targets. This focused review examines the origins and limitations of existing TDM reference intervals for common drugs, providing targets where possible based on available guidelines.
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Affiliation(s)
- Christopher R McCudden
- Department of Pathology and Laboratory Medicine, Division of Biochemistry, University of Ottawa, 501 Smyth Rd., Ottawa, ON K1H 8L6, Canada
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A randomized, double-blind, double-dummy, multicenter trial comparing the efficacy and safety of extended- and immediate-release levetiracetam in people with partial epilepsy. Seizure 2018; 62:84-90. [PMID: 30308428 DOI: 10.1016/j.seizure.2018.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 09/10/2018] [Accepted: 09/12/2018] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The aim of this trial was to compare the efficacy and safety of two formulations of levetiracetam in people with partial epilepsy over a 12-week treatment period. METHODS We performed a randomized, paralleled, and multicenter trial that consisted of a 4-week single-blind placebo run-in, followed by a 12-week double-blind, double-dummy treatment phase to compare the efficacy and safety of levetiracetam extended-release (LEV-ER) and immediate-release (LEV-IR) tablets as an adjunctive treatment in adult patients with uncontrolled epilepsy. RESULTS The median partial-onset seizure (POS) frequency per week (min-max) was 0.3 (0.0, 17.4; 95% confidence interval [95% CI] 1.3, 4.8) in the LEV-ER group and 0.3 (0.0, 31.4; 95% CI - 0.1, 4.3) in the LEV-IR group. No serious adverse events occurred during the trial period. Both groups had the same responder rate (58.6%), while a higher rate of seizure freedom over the treatment period was noted in the LEV-ER group compared with the LEV-IR group (27.6% vs. 13.8%, respectively). The European Quality of Life-5 Dimensions scores significantly increased in the LEV-ER-treated group, in contrast to the scores in the LEV-IR group, which decreased (7.2 vs. - 1.5, p = 0.03). CONCLUSION These results suggest that LEV-ER is equivalent to LEV-IR in reducing the frequency of POS and has a similar tolerability as LEV-IR as an add-on therapy. In addition, LEV-ER treatment improved the health-related quality of life of people with uncontrolled partial epilepsy.
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Nevitt SJ, Marson AG, Weston J, Tudur Smith C. Sodium valproate versus phenytoin monotherapy for epilepsy: an individual participant data review. Cochrane Database Syst Rev 2018; 8:CD001769. [PMID: 30091458 PMCID: PMC6513104 DOI: 10.1002/14651858.cd001769.pub4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Epilepsy is a common neurological condition in which abnormal electrical discharges from the brain cause recurrent unprovoked seizures. It is believed that with effective drug treatment up to 70% of individuals with active epilepsy have the potential to become seizure-free, and to go into long-term remission shortly after starting drug therapy with a single antiepileptic drug in monotherapy.Worldwide, sodium valproate and phenytoin are commonly used antiepileptic drugs for monotherapy treatment. It is generally believed that phenytoin is more effective for focal onset seizures, and that sodium pvalproate is more effective for generalised onset tonic-clonic seizures (with or without other generalised seizure types). This review is one in a series of Cochrane Reviews investigating pair-wise monotherapy comparisons. This is the latest updated version of the review first published in 2001, and updated in 2013 and 2016. OBJECTIVES To review the time to treatment failure, remission and first seizure of sodium valproate compared to phenytoin when used as monotherapy in people with focal onset seizures or generalised tonic-clonic seizures (with or without other generalised seizure types). SEARCH METHODS We searched the Cochrane Epilepsy Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform ICTRP on 19 February 2018. We handsearched relevant journals, contacted pharmaceutical companies, original trial investigators and experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing monotherapy with either sodium valproate or phenytoin in children or adults with focal onset seizures or generalised onset tonic-clonic seizures DATA COLLECTION AND ANALYSIS: This was an individual participant data (IPD) review. Our primary outcome was time to treatment failure and our secondary outcomes were time to first seizure post-randomisation, time to six-month, and 12-month remission, and incidence of adverse events. We used Cox proportional hazards regression models to obtain trial-specific estimates of hazard ratios (HRs) with 95% confidence intervals (CIs), using the generic inverse variance method to obtain the overall pooled HR and 95% CI. MAIN RESULTS We included 11 trials in this review and IPD were available for 669 individuals out of 1119 eligible individuals from five out of 11 trials, 60% of the potential data. Results apply to focal onset seizures (simple, complex and secondary generalised tonic-clonic seizures), and generalised tonic-clonic seizures, but not other generalised seizure types (absence or myoclonus seizure types). For remission outcomes, a HR of less than 1 indicates an advantage for phenytoin, and for first seizure and treatment failure outcomes a HR of less than 1 indicates an advantage for sodium valproate.The main overall results were: time to treatment failure for any reason related to treatment (pooled HR adjusted for seizure type 0.88, 95% CI 0.61 to 1.27; 5 studies; 528 participants; moderate-quality evidence), time to treatment failure due to adverse events (pooled HR adjusted for seizure type 0.77, 95% CI 0.44 to 1.37; 4 studies; 418 participants; moderate-quality evidence), time to treatment failure due to lack of efficacy (pooled HR for all participants 1.16 (95% CI 0.71 to 1.89; 5 studies; 451 participants; moderate-quality evidence). These results suggest that treatment failure for any reason related to treatment and treatment failure due to adverse events may occur earlier on phenytoin compared to sodium valproate, while treatment failure due to lack of efficacy may occur earlier on sodium valproate than phenytoin; however none of these results were statistically significant.Results for time to first seizure (pooled HR adjusted for seizure type 1.08, 95% CI 0.88 to 1.33; 5 studies; 639 participants; low-quality evidence) suggest that first seizure recurrence may occur slightly earlier on sodium valproate compared to phenytoin. There were no clear differences between drugs in terms of time to 12-month remission (pooled HR adjusted for seizure type 1.02, 95% CI 0.81 to 1.28; 4 studies; 514 participants; moderate-quality evidence) and time to six-month remission (pooled HR adjusted for seizure type 1.05, 95% CI 0.86 to 1.27; 5 studies; 639 participants; moderate-quality evidence).Limited information was available regarding adverse events in the trials and we could not make comparisons between the rates of adverse events on sodium valproate and phenytoin. Some adverse events reported with both drugs were drowsiness, rash, dizziness, nausea and gastrointestinal problems. Weight gain was also reported with sodium valproate and gingival hypertrophy/hyperplasia was reported on phenytoin.The methodological quality of the included trials was generally good, however four out of the five trials providing IPD for analysis were of an open-label design, therefore all results were at risk of detection bias. There was also evidence that misclassification of seizure type may have confounded the results of this review, particularly for the outcome 'time to first seizure' and heterogeneity was present in analysis of treatment failure outcomes which could not be explained by subgroup analysis by epilepsy type or by sensitivity analysis for misclassification of seizure type. Therefore, for treatment failure outcomes we judged the quality of the evidence to be moderate to low, for 'time to first seizure' we judged the quality of the evidence to be low, and for remission outcomes we judged the quality of the evidence to be moderate. AUTHORS' CONCLUSIONS We have not found evidence that a significant difference exists between valproate and phenytoin for any of the outcomes examined in this review. However detection bias, classification bias and heterogeneity may have impacted on the results of this review. We did not find any outright evidence to support or refute current treatment policies. We recommend that future trials be designed to the highest quality possible with consideration of masking, choice of population, classification of seizure type, duration of follow-up, choice of outcomes and analysis, and presentation of results.
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Affiliation(s)
- Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
| | - Jennifer Weston
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
| | - Catrin Tudur Smith
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
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Nevitt SJ, Tudur Smith C, Weston J, Marson AG. Lamotrigine versus carbamazepine monotherapy for epilepsy: an individual participant data review. Cochrane Database Syst Rev 2018; 6:CD001031. [PMID: 29952431 PMCID: PMC6513029 DOI: 10.1002/14651858.cd001031.pub4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane Review published in Issue 11, 2006 of the Cochrane Database of Systematic Reviews.Epilepsy is a common neurological condition in which abnormal electrical discharges from the brain cause recurrent unprovoked seizures. It is believed that with effective drug treatment up to 70% of individuals with active epilepsy have the potential to become seizure-free, and to go into long-term remission shortly after starting drug therapy with a single antiepileptic drug (AED) in monotherapy.The correct choice of first-line AED for individuals with newly diagnosed seizures is of great importance. It is important that the choice of AEDs for an individual is made using the highest quality evidence regarding the potential benefits and harms of the various treatments.Carbamazepine or lamotrigine are recommended as first-line treatments for new onset focal seizures and as a first- or second-line treatment for generalised tonic-clonic seizures. Performing a synthesis of the evidence from existing trials will increase the precision of the results for outcomes relating to efficacy and tolerability and may assist in informing a choice between the two drugs. OBJECTIVES To review the time to treatment failure, remission and first seizure with lamotrigine compared to carbamazepine when used as monotherapy in people with focal onset seizures (simple or complex focal and secondarily generalised) or generalised onset tonic-clonic seizures (with or without other generalised seizure types). SEARCH METHODS We conducted the first searches for this review in 1997. For the most recent update, we searched the Cochrane Epilepsy Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO), MEDLINE, Clinical Trials.gov and the WHO International Clinical Trials Registry Platform on 26 February 2018, without language restrictions SELECTION CRITERIA: Randomised controlled trials comparing monotherapy with either carbamazepine or lamotrigine in children or adults with focal onset seizures or generalised onset tonic-clonic seizures DATA COLLECTION AND ANALYSIS: This was an individual participant data (IPD) review. Our primary outcome was time to treatment failure and our secondary outcomes were time to first seizure post randomisation, time to six-month, 12-month and 24-month remission, and incidence of adverse events. We used Cox proportional hazards regression models to obtain trial-specific estimates of hazard ratios (HRs) with 95% confidence intervals (CIs), using the generic inverse variance method to obtain the overall pooled HR and 95% CI. MAIN RESULTS We included 14 trials in this review. Individual participant data were available for 2572 participants out of 3787 eligible individuals from nine out of 14 trials: 68% of the potential data. For remission outcomes, a HR of less than one indicated an advantage for carbamazepine; and for first seizure and treatment failure outcomes, a HR of less than one indicated an advantage for lamotrigine.The main overall results were: time to treatment failure for any reason related to treatment (pooled HR adjusted for seizure type: 0.71, 95% CI 0.62 to 0.82, moderate-quality evidence), time to treatment failure due to adverse events (pooled HR adjusted for seizure type: 0.55 (95% CI 0.45 to 0.66, moderate-quality evidence), time to treatment failure due to lack of efficacy (pooled HR for all participants: 1.03 (95% CI 0.75 to 1.41), moderate-quality evidence) showing a significant advantage for lamotrigine compared to carbamazepine in terms of treatment failure for any reason related to treatment and treatment failure due to adverse events, but no different between drugs for treatment failure due to lack of efficacy.Time to first seizure (pooled HR adjusted for seizure type: 1.26, 95% CI 1.12 to 1.41, high-quality evidence) and time to six-month remission (pooled HR adjusted for seizure type: 0.86, 95% CI 0.76 to 0.97, high-quality evidence), showed a significant advantage for carbamazepine compared to lamotrigine for first seizure and six-month remission. We found no difference between the drugs for time to 12-month remission (pooled HR for all participants 0.91, 95% CI 0.77 to 1.07, high-quality evidence) or time to 24-month remission (HR for all participants 1.00, 95% CI 0.80 to 1.25, high-quality evidence), however only two trials followed up participants for more than one year so evidence is limited.The results of this review are applicable mainly to individuals with focal onset seizures; 88% of included individuals experienced seizures of this type at baseline. Up to 50% of the limited number of individuals classified as experiencing generalised onset seizures at baseline may have had their seizure type misclassified, therefore we recommend caution when interpreting the results of this review for individuals with generalised onset seizures.The most commonly reported adverse events for both of the drugs across all of the included trials were dizziness, fatigue, gastrointestinal disturbances, headache and skin problems. The rate of adverse events was similar across the two drugs.The methodological quality of the included trials was generally good, however there is some evidence that the design choice of masked or open-label treatment may have influenced the treatment failure and withdrawal rates of the trials. Hence, we judged the quality of the evidence for the primary outcome of treatment failure to be moderate for individuals with focal onset seizures and low for individuals with generalised onset seizures. For efficacy outcomes (first seizure, remission), we judged the quality of evidence to be high for individuals with focal onset seizures and moderate for individuals with generalised onset seizures. AUTHORS' CONCLUSIONS Moderate quality evidence indicates that treatment failure for any reason related to treatment or due to adverse events occurs significantly earlier on carbamazepine than lamotrigine, but the results for time to first seizure suggested that carbamazepine may be superior in terms of seizure control. The choice between these first-line treatments must be made with careful consideration. We recommend that future trials should be designed to the highest quality possible with consideration of masking, choice of population, classification of seizure type, duration of follow-up, choice of outcomes and analysis, and presentation of results.
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Affiliation(s)
- Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Catrin Tudur Smith
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Jennifer Weston
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
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Song P, Liu Y, Yu X, Wu J, Poon AN, Demaio A, Wang W, Rudan I, Chan KY. Prevalence of epilepsy in China between 1990 and 2015: A systematic review and meta-analysis. J Glob Health 2018. [PMID: 29302325 PMCID: PMC5737100 DOI: 10.7189/jogh.07-020706] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Epilepsy is a major neurological disorder that affects approximately 65 million people worldwide. Globally, the burden of epilepsy is not evenly distributed, with more than 80% of sufferers residing in low– and middle–income countries. This study estimates the burden of epilepsy in mainland China from 1990 to 2015 and explores the variations of burden by age and gender. Methods We conducted a systematic review of the peer–reviewed literature from 1990 to 2015 using Chinese and English academic databases (CNKI, WanFang, VIP and PubMed) to identify population–based prospective studies on the prevalence of epilepsy in mainland Chinese. Multilevel mixed–effects logistic regression was used to estimate the prevalence of lifetime epilepsy (LTE), and restricted cubic regression splines were applied to model the functional forms of the non–linear effects of age and LTE prevalence. Random–effect meta–analysis was used to obtain the pooled prevalence of 1–year active epilepsy (AE), 2–year AE and 5–year AE separately. To estimate the number of people with LTE and AE in the years 1990, 2000, and 2015, LTE and AE prevalence were multiplied by the total population of mainland China of the corresponding year. Findings Analyses were conducted using 39 prevalence studies that met the inclusion criteria and comprised 77 separate data points (37 on LTE, 16 on 1–year AE, 12 on 2–year AE and 12 on 5–year AE). In 1990, the prevalence of LTE ranged from 1.31‰ (95% CI = 0.85–2.00) in the 0–4 age group to 2.42‰ (95% confidence interval CI = 1.60–3.65) in the 30–34 age group. By 2015, the LTE prevalence had increased to 4.57‰ (95% CI = 2.52–8.27) in the 0–4 group and 8.43‰ (95% CI = 4.71–15.04) in the 30–34 group. Over the 25–year period, the overall prevalence of LTE had steadily increased by 259%, from 1.99‰ (95% CI = 1.31–3.02) in 1990 to 7.15‰ (95% CI = 3.98–12.82) in 2015. The rates of increase were similar across the whole age spectrum, fluctuating around 250%. Between 1990 and 2015, the total number of people with LTE in mainland China increased by 328%, from 2.30 million (95% CI = 1.51–3.49) in 1990 to 9.84 million (95% CI = 5.48–17.64) in 2015. The pooled 1–year, 2–year, and 5–year AE prevalence were 3.79‰ (95% CI = 3.31–4.34), 4.08‰ (95% CI = 3.41–4.89) and 4.19‰ (95% CI = 3.42–5.15). Conclusions The burden of LTE in China has increased substantially between 1990 and 2015, with the prevalence of LTE having more than doubled and the number of people with LTE more than tripled. The large amount of AE cases in China calls for optimal management and treatment. More high–quality epidemiological studies on LTE and AE prevalence are still needed.
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Affiliation(s)
- Peige Song
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Scotland, UK.,Joint-first authors
| | - Yezhou Liu
- Beijing Municipal Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China.,Xijing Hospital of Digestive Diseases, the Fourth Military Medical University.,Joint-first authors
| | - Xinwei Yu
- Beijing Municipal Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China.,School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia.,Joint-first authors
| | - Jingjing Wu
- Beijing Municipal Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China.,Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Adrienne N Poon
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Scotland, UK.,Department of Internal Medicine, School of Medicine & Health Sciences, The George Washington University, Washington, D.C., USA
| | - Alessandro Demaio
- Harvard Global Equity Initiative, Harvard Medical School, Boston, Massachusetts, USA.,Copenhagen School of Global Health, University of Copenhagen, Denmark
| | - Wei Wang
- Beijing Municipal Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China.,School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia.,Joint-last authors
| | - Igor Rudan
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Scotland, UK.,Joint-last authors
| | - Kit Yee Chan
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Scotland, UK.,Nossal Institute for Global Health, University of Melbourne, Australia.,Joint-last authors
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Fishman J, Kalilani L, Song Y, Swallow E, Wild I. Antiepileptic Drug Titration and Related Health Care Resource Use and Costs. J Manag Care Spec Pharm 2018; 24:929-938. [PMID: 29486142 PMCID: PMC10397847 DOI: 10.18553/jmcp.2018.17337] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Unexpected breakthrough seizures resulting from suboptimal antiepileptic drug (AED) dosing during the titration period, as well as adverse events resulting from rapid AED titration, may influence the titration schedule and significantly increase health care resource use (HRU) and health care costs. OBJECTIVE To assess the relationship between AEDs, HRU, and costs during AED titration and maintenance. METHODS Practicing neurologists were recruited from a nationwide panel to provide up to 3 patient records each for this retrospective medical chart review. Patients with epilepsy who were aged ≥ 18 years and had initiated an AED between January 1, 2014, and January 1, 2016, were followed for 6 months from AED initiation. Titration duration was the time from AED initiation to the beginning of treatment maintenance as determined by the physician. Outcomes were epilepsy-specific HRU (hospitalizations, emergency department visits, outpatient visits, physician referral, laboratory testing/diagnostic imaging, and phone calls) and related costs that occurred during the titration or maintenance treatment periods. RESULTS Of 811 patients, 156, 128, 125, 120, 114, 107, and 61 initiated the following AEDs: levetiracetam, lamotrigine, lacosamide, valproate, topiramate, carbamazepine, and phenytoin, respectively. Most patients (619/803 [77.1%] with complete AED data) received monotherapy. Baseline characteristics were similar across AEDs (mean [SD] age, 36.6 [14.4] years; 59.0% male). Kaplan-Meier estimates of titration duration ranged from 3.3 weeks (phenytoin) to 8.1 weeks (lamotrigine). From titration to maintenance, the overall incidence of HRU per person-month decreased 54.5%-89.3% for each HRU measure except outpatient visits (24.6% decrease). Total epilepsy-related costs decreased from $80.48 to $42.77 per person-month, or 46.9% from titration to maintenance. CONCLUSIONS AED titration periods had higher HRU rates and costs than AED maintenance, suggesting that use of AEDs with shorter titration requirements reduces health care costs, although disease severity may also factor into overall cost. DISCLOSURES UCB Pharma sponsored this study and reviewed the manuscript. Fishman and Kalilani are employees of UCB Pharma. Wild was an employee of UCB Pharma at the time this analysis was conducted. Song and Swallow are employees of Analysis Group, which received funding from UCB Pharma.
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Affiliation(s)
| | | | - Yan Song
- 3 Analysis Group, Boston, Massachusetts
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Nevitt SJ, Sudell M, Weston J, Tudur Smith C, Marson AG. Antiepileptic drug monotherapy for epilepsy: a network meta-analysis of individual participant data. Cochrane Database Syst Rev 2017; 12:CD011412. [PMID: 29243813 PMCID: PMC6486134 DOI: 10.1002/14651858.cd011412.pub3] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Epilepsy is a common neurological condition with a worldwide prevalence of around 1%. Approximately 60% to 70% of people with epilepsy will achieve a longer-term remission from seizures, and most achieve that remission shortly after starting antiepileptic drug treatment. Most people with epilepsy are treated with a single antiepileptic drug (monotherapy) and current guidelines from the National Institute for Health and Care Excellence (NICE) in the United Kingdom for adults and children recommend carbamazepine or lamotrigine as first-line treatment for partial onset seizures and sodium valproate for generalised onset seizures; however a range of other antiepileptic drug (AED) treatments are available, and evidence is needed regarding their comparative effectiveness in order to inform treatment choices. OBJECTIVES To compare the time to withdrawal of allocated treatment, remission and first seizure of 10 AEDs (carbamazepine, phenytoin, sodium valproate, phenobarbitone, oxcarbazepine, lamotrigine, gabapentin, topiramate, levetiracetam, zonisamide) currently used as monotherapy in children and adults with partial onset seizures (simple partial, complex partial or secondary generalised) or generalised tonic-clonic seizures with or without other generalised seizure types (absence, myoclonus). SEARCH METHODS We searched the following databases: Cochrane Epilepsy's Specialised Register, CENTRAL, MEDLINE and SCOPUS, and two clinical trials registers. We handsearched relevant journals and contacted pharmaceutical companies, original trial investigators, and experts in the field. The date of the most recent search was 27 July 2016. SELECTION CRITERIA We included randomised controlled trials of a monotherapy design in adults or children with partial onset seizures or generalised onset tonic-clonic seizures (with or without other generalised seizure types). DATA COLLECTION AND ANALYSIS This was an individual participant data (IPD) review and network meta-analysis. Our primary outcome was 'time to withdrawal of allocated treatment', and our secondary outcomes were 'time to achieve 12-month remission', 'time to achieve six-month remission', 'time to first seizure post-randomisation', and 'occurrence of adverse events'. We presented all time-to-event outcomes as Cox proportional hazard ratios (HRs) with 95% confidence intervals (CIs). We performed pairwise meta-analysis of head-to-head comparisons between drugs within trials to obtain 'direct' treatment effect estimates and we performed frequentist network meta-analysis to combine direct evidence with indirect evidence across the treatment network of 10 drugs. We investigated inconsistency between direct estimates and network meta-analysis via node splitting. Due to variability in methods and detail of reporting adverse events, we have not performed an analysis. We have provided a narrative summary of the most commonly reported adverse events. MAIN RESULTS IPD was provided for at least one outcome of this review for 12,391 out of a total of 17,961 eligible participants (69% of total data) from 36 out of the 77 eligible trials (47% of total trials). We could not include IPD from the remaining 41 trials in analysis for a variety of reasons, such as being unable to contact an author or sponsor to request data, data being lost or no longer available, cost and resources required to prepare data being prohibitive, or local authority or country-specific restrictions.We were able to calculate direct treatment effect estimates for between half and two thirds of comparisons across the outcomes of the review, however for many of the comparisons, data were contributed by only a single trial or by a small number of participants, so confidence intervals of estimates were wide.Network meta-analysis showed that for the primary outcome 'Time to withdrawal of allocated treatment,' for individuals with partial seizures; levetiracetam performed (statistically) significantly better than current first-line treatment carbamazepine and other current first-line treatment lamotrigine performed better than all other treatments (aside from levetiracetam); carbamazepine performed significantly better than gabapentin and phenobarbitone (high-quality evidence). For individuals with generalised onset seizures, first-line treatment sodium valproate performed significantly better than carbamazepine, topiramate and phenobarbitone (moderate- to high-quality evidence). Furthermore, for both partial and generalised onset seizures, the earliest licenced treatment, phenobarbitone seems to perform worse than all other treatments (moderate- to high-quality evidence).Network meta-analysis also showed that for secondary outcomes 'Time to 12-month remission of seizures' and 'Time to six-month remission of seizures,' few notable differences were shown for either partial or generalised seizure types (moderate- to high-quality evidence). For secondary outcome 'Time to first seizure,' for individuals with partial seizures; phenobarbitone performed significantly better than both current first-line treatments carbamazepine and lamotrigine; carbamazepine performed significantly better than sodium valproate, gabapentin and lamotrigine. Phenytoin also performed significantly better than lamotrigine (high-quality evidence). In general, the earliest licenced treatments (phenytoin and phenobarbitone) performed better than the other treatments for both seizure types (moderate- to high-quality evidence).Generally, direct evidence and network meta-analysis estimates (direct plus indirect evidence) were numerically similar and consistent with confidence intervals of effect sizes overlapping.The most commonly reported adverse events across all drugs were drowsiness/fatigue, headache or migraine, gastrointestinal disturbances, dizziness/faintness and rash or skin disorders. AUTHORS' CONCLUSIONS Overall, the high-quality evidence provided by this review supports current guidance (e.g. NICE) that carbamazepine and lamotrigine are suitable first-line treatments for individuals with partial onset seizures and also demonstrates that levetiracetam may be a suitable alternative. High-quality evidence from this review also supports the use of sodium valproate as the first-line treatment for individuals with generalised tonic-clonic seizures (with or without other generalised seizure types) and also demonstrates that lamotrigine and levetiracetam would be suitable alternatives to either of these first-line treatments, particularly for those of childbearing potential, for whom sodium valproate may not be an appropriate treatment option due to teratogenicity.
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Affiliation(s)
- Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Maria Sudell
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Jennifer Weston
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
| | - Catrin Tudur Smith
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolMerseysideUKL9 7LJ
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Abstract
The mainstay of treatment of childhood epilepsy is to administer antiepileptic drugs (AEDs). This article provides an overview of the clinical approach to drug treatment of childhood epilepsy, focusing on general principles of therapy and properties of recently introduced medications. Initiation and cessation of therapy, adverse medication effects, drug interactions, indications for the various AEDs, and off-label use of AEDs are reviewed. The distinct challenges in treatment of epileptic spasms and neonatal seizures are addressed. Finally, ideas for the future of drug treatment of childhood epilepsy are presented, with particular attention to precision medicine.
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Affiliation(s)
- Louis T Dang
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Room 12-733, 1540 East Hospital Drive, Ann Arbor, MI 48109-4279, USA.
| | - Faye S Silverstein
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, 8301 MSRB3, 1150 West Medical Center Drive, Ann Arbor, MI 48109-5646, USA
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Song P, Liu Y, Yu X, Wu J, Poon AN, Demaio A, Wang W, Rudan I, Chan KY. Prevalence of epilepsy in China between 1990 and 2015: A systematic review and meta–analysis. J Glob Health 2017; 7:020706. [DOI: 10.7189/jogh.07.020706] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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D'Anto J, Wnuk W, Rossetti AO, Decosterd LA, Buclin T, Novy J. Lamotrigine serum levels: Ceiling effect in people with epilepsy in remission? Epilepsy Behav 2017; 74:41-44. [PMID: 28686906 DOI: 10.1016/j.yebeh.2017.03.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 02/27/2017] [Accepted: 03/04/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antiepileptic drug titration in epilepsy remains mostly empirical. Since in practice seizure remission may be obtained with low doses, we aimed to determine whether patients in remission have lower lamotrigine levels than those with ongoing seizures. METHODS Retrospective comparison of the distribution of lamotrigine levels among unselected patients in remission and with ongoing seizures. Remission was defined as 3 times the longuest interseizure interval and at least one year. Only trough levels were analyzed. RESULTS Between 2009 and 2014, we identified 93 adults, among whom 10 were in remission. Patients in remission had significantly (p=0.008) lower serum levels (median 2.3mg/L, range: 0.7-8.2) than those with ongoing seizures (median 5.4mg/L, range: 1.1-18.2). We did not find any patient in remission with levels higher than 8.2mg/L. Distribution of dosages also differed among the groups, but less significantly (median: 175 vs 300mg, p=0.03). CONCLUSION An association between lamotrigine serum levels and seizure response can be observed. This suggests the existence of a ceiling level, above which remission is unlikely and should prompt antiepileptic medication switch rather than further up-titration of lamotrigine in drug-naïve patients with epilepsy.
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Affiliation(s)
| | | | - Andrea O Rossetti
- Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, Switzerland
| | - Laurent A Decosterd
- Laboratory and Division of Clinical Pharmacology, Service of Biomedicine, Lausanne University Hospital (CHUV) and University of Lausanne, Switzerland
| | - Thierry Buclin
- Laboratory and Division of Clinical Pharmacology, Service of Biomedicine, Lausanne University Hospital (CHUV) and University of Lausanne, Switzerland
| | - Jan Novy
- Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, Switzerland.
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Kwan P, Palmini A. Association between switching antiepileptic drug products and healthcare utilization: A systematic review. Epilepsy Behav 2017. [PMID: 28641169 DOI: 10.1016/j.yebeh.2017.05.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIMS There is ongoing concern whether switching between different antiepileptic drug (AED) products may compromise patient care. We systematically reviewed changes in healthcare utilization following AED switch. METHODS We searched MEDLINE and EMBASE databases (1980-October 2016) for studies that assessed the effect of AED switching in patients with epilepsy on outpatient visits, emergency room visits, hospitalization and hospital stay duration. RESULTS A total of 14 articles met the inclusion criteria. All were retrospective studies. Four provided findings for specific AEDs only (lamotrigine, topiramate, phenytoin and divalproex), 9 presented pooled findings from multiple AEDs, and 1 study provided both specific (lamotrigine, topiramate, oxcarbazepine, and levetiracetam) and pooled findings. Three studies found an association between a switch of topiramate and an increase in healthcare utilization. Another three studies found that a brand-to-generic lamotrigine switch was not associated with an increased risk of emergently treated events (ambulance use, ER visits or hospitalization). The outcomes of the pooled AED switch studies were inconsistent; 5 studies reported an increased healthcare utilization while 5 studies did not. CONCLUSION Studies that have examined the association between an AED switch and a change in healthcare utilization report conflicting findings. Factors that may explain these inconsistent outcomes include inter-study differences in the type of analysis undertaken (pooled vs individual AED data), the covariates used for data adjustment, and the type of switch examined. Future medical claim database studies employing a prospective design are encouraged to address these and other factors in order to enhance inter-study comparability and extrapolation of findings.
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Affiliation(s)
- Patrick Kwan
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia; Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia.
| | - André Palmini
- Faculty of Medicine, Neurology Service & Porto Alegre Epilepsy Surgery Program, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.
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Abstract
OBJECTIVE The goal of this study was to analyze the persistence with antiepileptic drugs (AED) and associated factors in patients followed in neurological practices in Germany. METHODS This study included patients aged 18years or over who received two initial diagnoses of epilepsy and a first prescription of AED between 2007 and 2015 in a neurological practice (index date). The main outcome measure was the rate of AED persistence within five years of the index date. Kaplan-Meier analyses were performed to study treatment persistence as a function of age. A Cox proportional hazards regression model was used to estimate the relationship between non-persistence and demographic/clinical variables. RESULTS A total of 8192 patients followed in neurological practices were included. After five years of follow-up, 41.1% (≤40years), 45.2%, (41-60years) and 50.1% (>60years) of patients followed in neurological practices were persistent (log-rank p-value<0.001). A negative association was found between discontinuation and age (≤40years vs. >60years: OR=1.19, 95% CI: 1.09-1.31; 41-60years vs. >60years: OR=1.10, 95% CI: 1.01-1.19). Furthermore, patients receiving old AED (OR=1.16, 95% CI: 1.01-1.34) or gabapentin (OR=1.46, 95% CI: 1.16-1.83) and those diagnosed with depression (OR=1.12, 95% CI: 1.03-1.21) were at a higher risk of non-persistence, whereas those receiving levetiracetam (OR=0.69, 95% CI: 0.60-0.80) or lamotrigine (OR=0.88, 95% CI: 0.79-0.97) and those with dementia (OR=0.74, 95% CI: 0.65-0.83) were at a lower risk. CONCLUSIONS The rate of epilepsy patients persistent with AED was low after five years of treatment. Age, gender, co-morbidities, and drug characteristics were associated with this persistence.
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Dickson JM, Dudhill H, Shewan J, Mason S, Grünewald RA, Reuber M. Cross-sectional study of the hospital management of adult patients with a suspected seizure (EPIC2). BMJ Open 2017; 7:e015696. [PMID: 28706099 PMCID: PMC5541576 DOI: 10.1136/bmjopen-2016-015696] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine the clinical characteristics, management and outcomes of patients taken to hospital by emergency ambulance after a suspected seizure. DESIGN Quantitative cross-sectional retrospective study of a consecutive series of patients. SETTING An acute hospital trust in a large city in England. PARTICIPANTS In 2012-2013, the regions' ambulance service managed 605 481 emergency incidents, 74 141/605 481 originated from Sheffield (a large city in the region), 2121/74 141 (2.9%) were suspected seizures and 178/2121 occurred in May 2012. We undertook detailed analysis of the medical records of the 91/178 patients who were transported to the city's acute hospital. After undertaking a retrospective review of the medical records, the best available aetiological explanation for the seizures was determined. RESULTS The best available aetiological explanation for 74.7% (68/91) of the incidents was an epileptic seizure, 11.0% (10/91) were psychogenic non-epileptic seizures and 9.9% (9/91) were cardiogenic events. The epileptic seizures fall into the following four categories: first epileptic seizure (13.2%, 12/91), epileptic seizure with a historical diagnosis of epilepsy (30.8%, 28/91), recurrent epileptic seizures without a historical diagnosis of epilepsy (20.9%, 19/91) and acute symptomatic seizures (9.9%, 9/91). Of those with seizures (excluding cardiogenic events), 2.4% (2/82) of patients were seizing on arrival in the Emergency Department (ED), 19.5% (16/82) were postictal and 69.5% (57/82) were alert. 63.4% (52/82) were discharged at the end of their ED attendance and 36.5% (19/52) of these had no referral or follow-up. CONCLUSIONS Most suspected seizures are epileptic seizures but this is a diagnostically heterogeneous group. Only a small minority of patients require emergency medical care but most are transported to hospital. Few patients receive expert review and many are discharged home without referral to a specialist leaving them at risk of further seizures and the associated morbidity, mortality and health services costs of poorly controlled epilepsy.
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Affiliation(s)
- Jon Mark Dickson
- The Academic Unit of Primary Medical Care, The Medical School, Sheffield, England
| | - Hannah Dudhill
- Sheffield Medical School, The University of Sheffield, Sheffield, South Yorkshire, UK
| | - Jane Shewan
- Research and Development, Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Sue Mason
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Richard A Grünewald
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Markus Reuber
- Academic Neurology Unit, The University of Sheffield, Sheffield, UK
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