Antiepileptic drugs patterns in elderly inpatients in a Brazilian tertiary center, Salvador, Brazil

Trends in prescribing patterns of antiepileptic drugs among older adult inpatients in a Brazilian tertiary center

BACKGROUND

Data on prescribing patterns of antiepileptic drugs (AEDs) to older adult inpatients are limited.

OBJECTIVE

To assess changes in prescribing patterns of AEDs to older adult inpatients with late-onset epilepsy between 2009-2010 and 2015-2019, and to interpret any unexpected patterns over the 2015-2019 period.

METHODS

Patients aged ≥60 years with late-onset epilepsy from a tertiary center were selected. Demographic data, seizure characteristics and etiology, comorbidities, and comedications were analyzed, in addition to prescription regimens of inpatients taking AEDs to treat epilepsy. AED regimens were categorized into two groups: group 1 included appropriate AEDs (carbamazepine, oxcarbazepine, valproic acid, gabapentin, clobazam, lamotrigine, levetiracetam, topiramate, and lacosamide); and group 2 comprised suboptimal AEDs (phenytoin and phenobarbital). Multivariate logistic regression analysis was performed to identify risk factors for prescription of suboptimal AEDs.

RESULTS

134 patients were included in the study (mean age: 77.2±9.6 years). A significant reduction in the prescription of suboptimal AEDs (from 73.3 to 51.5%; p<0.001) was found; however, phenytoin remained the most commonly prescribed AED to older adult inpatients. We also found an increase in the prescription of lamotrigine (from 5.5 to 33.6%) and levetiracetam (from 0 to 29.1%) over time. Convulsive status epilepticus (SE) and acute symptomatic seizures associated with remote and progressive etiologies were risk factors for the prescription of suboptimal AEDs.

CONCLUSIONS

Phenytoin was the main suboptimal AED prescribed in our population, and convulsive SE and acute symptomatic seizures associated with some etiologies were independent risk factors for phenytoin prescription. These results suggest ongoing commitment to reducing the prescription of suboptimal AEDs, particularly phenytoin in Brazilian emergence rooms.

Predictors of long length of hospital stay among elders admitted with seizures in a tertiary centre: a prospective study

OBJECTIVE

Population ageing is a global phenomenon, and life expectancy in Brazil is growing fast. Epilepsy is the third most important chronic neurological disorder, and its incidence is higher among elderly patients than in any other segment of the population. The prevalence of epilepsy is greater among inpatients than in the general population and it is related to long length of hospital stay (LOS), which is associated with hospital mortality and higher healthcare costs. Despite these facts, reports of elderly inpatients admitted with seizures and associated outcomes are scarce. To identify predictors of long LOS among elderly inpatients admitted with seizures.

METHODS

We prospectively enrolled elders admitted with epileptic seizures or who experienced seizures throughout hospitalization between November 2015 and August 2019. We analysed demographic data, neurological disorders, clinical comorbidities, and seizure features to identify risk factors.

RESULTS

The median LOS was 11 days, with an interquartile range (IQR) of 5-21 days. The frequency of long LOS (defined as a period of hospitalization ≥12 days) was 47%. Multivariate analysis showed there was an exponential increase in long LOS if a patient showed any of the following conditions: intensive care unit (ICU) admission (OR=4.562), urinary tract infection (OR=3.402), movement disorder (OR=5.656), early seizure recurrence (OR=2.090), and sepsis (OR=4.014).

CONCLUSION

Long LOS was common among elderly patients admitted with seizures, and most predictors of long LOS found in this cohort might be avoidable; these findings should be confirmed with further research.

Activities of daily living are associated with outcomes of epilepsy treatment in elderly patients

AIM

Controlling epileptic seizures in elderly populations is widely considered to be relatively easy, but we hypothesized that the lifestyles of elderly individuals may affect the outcomes of epilepsy treatment. The purpose of this study was to review the activities of daily living (ADL) of elderly individuals with epilepsy and compare them with the outcomes of epilepsy treatment.

METHODS

Of the 177 patients ≥65 years old who were referred to our epilepsy centre, epilepsy was diagnosed in 84. ADL and treatment outcomes were then reviewed, with ADL classified into three levels: ADL I, without disability; ADL II, disabled only in some instrumental ADL; and ADL III, disabled in some basic ADL. Epilepsy syndromes and use of anti-seizure drugs were also evaluated.

RESULTS

Forty-five patients (53.6%) achieved freedom from seizures, 23 (27.4%) achieved ≥80% but <100% reduction in seizures, 5 (6%) achieved ≥50% but <80% reduction in seizures, and 11 (13.1%) achieved <50% reduction in seizures. Thirty-five patients (81.4%) with ADL I achieved freedom from seizures, compared with seven patients with ADL II (28.0%) and three patients with ADL III (19.0%). A significant difference was evident among the three groups (F = 6.145, P = 0.003).

CONCLUSIONS

ADL should be taken into account when an epilepsy treatment is being selected.

Prescription patterns of antiepileptic drugs in Kazakhstan in 2018: A retrospective study of 57,959 patients

AIM

The goal of this retrospective study was to analyze prescription patterns of antiepileptic drugs (AEDs) in Kazakhstan in 2018.

METHODS

This study used prescription data of patients with epilepsy who received AEDs in Kazakhstan in 2018. The outcome of the study was the prevalence of use of several AEDs (i.e., valproate, carbamazepine, lamotrigine, topiramate, levetiracetam) in these patients. Demographic variables included age and sex. The present study used descriptive statistics only.

RESULTS

In 2018, 57,959 patients with epilepsy with at least one AED prescription were found in the LRx database in Kazakhstan. The three most frequently prescribed AEDs were valproate (54.6%), carbamazepine (49.3%), and lamotrigine (16.8%). Interestingly, 10,745 valproate users were women aged ≤40 years. Monotherapy was more frequent than combination therapy and ranged from 80% in patients receiving topiramate to 90% in those receiving carbamazepine. The three most common combination therapies were valproate-carbamazepine (33.7%), valproate-lamotrigine (16.9%), and lamotrigine-carbamazepine (11.8%).

CONCLUSIONS

Patients with epilepsy were frequently prescribed valproate, carbamazepine, and lamotrigine in Kazakhstan in 2018. Further research is needed to gain a better understanding of the prescription of valproate in women with epilepsy who are of childbearing age.

Antiepileptic drug therapy in the elderly: a clinical pharmacological review

Seizure disorder is the third most common neurological disorder in the elderly after stroke and dementia. With the increasing geriatric population, the situation of clinicians seeing more and more elderly epilepsy patients is very likely. Not only is the diagnosis of epilepsy tedious in the elderly, its management raises many challenging issues for the treating physicians. Altered physiology, age-related decline in organ function, and plasma protein binding and altered pharmacodynamics make the elderly patients with seizure disorder a difficult group to treat. This is further complicated by the presence of comorbidities and polypharmacy which increase the chances of drug interactions. The adverse effects that might be tolerated well in younger populations may be disastrous for the aged. Although the newer antiepileptic drugs are found to have a favorable safety profile, there is relative scarcity of randomized-controlled trials involving older and newer antiepileptics in the geriatric population. This review tries to compile the available literature on management of epilepsy in the elderly population including evidence of safety and efficacy of newer and older antiepileptics with special reference to the 'geriatric giants'. It also deals with the interactions between antiepileptic medications and other commonly prescribed drugs in the elderly such as anti-hypertensives and antiischemic agents. The recommended guidelines of various international bodies are also analyzed from the perspective of elderly with seizure disorder.