Antiepileptic drugs prescription utilization behavior and direct costs of treatment in a national hospital of India

Physical fitness in Indian women with epilepsy on anti-seizure medications and its association with reproductive status, quality of life and stigma: A cross-sectional study

PURPOSE

To determine the status of physical fitness, reproductive abnormalities, QOL and epilepsy associated stigma in women with epilepsy (WWE) and their association with ASM therapy and seizure frequency.

METHODS

This cross-sectional study included WWE of reproductive age (18-50 years) on antiseizure medications (ASMs) for at least three months before enrolment. Physical fitness was assessed using International Physical Activity Questionnaires (IPAQ) and Body composition analysis. Subjects were interviewed for menstrual abnormalities [menstrual disturbance or Polycystic Ovary Syndrome (PCOS)/hirsutism]. Validated questionnaires were used for assessment of, QOL (QOLIE-10) and Stigma in epilepsy (Epilepsy Stigma Scale). Sub-group analysis was done to compare the above parameters on the basis of a) type of therapy (mono or polytherapy), b) type of ASMs treatment (conventional, newer, or conventional + newer ASMs), and c) seizure type and (d) seizure frequency. Correlation and regression analysis were done to find out the association among different variables with physical fitness.

RESULTS

The overall prevalence of poor physical fitness, reproductive abnormalities, worsened QOL and stigma in the enrolled WWE (n = 203) were 21.18 %, 20.19 %, 52.7 %, and 21.67 %, respectively. Sub-group analysis revealed that WWE on monotherapy (n = 99) had higher median IPAQ score (p = 0.002), comparatively less reproductive abnormalities (24.03 %, p = 0.008), and higher stigma (24.03 %, p = 0.04) than polytherapy group. WWE on conventional ASMs had significantly higher IPAQ scores compared to newer and conventional + newer ASMs groups (p = 0.02). The prevalence of poor physical fitness and stigma was significantly higher in WWE with higher number of seizures (p = 0.007, <0.001, respectively). No significant difference in QOL was observed on the basis of ASM type and therapy; however, WWE with generalized onset seizures had worsened QOL compared to those with focal onset seizures (p = 0.04). A significant negative correlation was found among seizure frequency and IPAQ score in WWE (p = 0.04).

CONCLUSION

WWE on polytherapy were physically less active, higher occurrence of reproductive abnormalities, and stigma compared to the monotherapy group. WWE with higher seizure frequency had poor physical fitness, and higher stigma compared to those with lesser number of seizures. These findings may aid value in optimization of ASM treatment in WWE of reproductive age.

Epilepsy-Related Direct Medical and Direct Non-Medical Cost in Adult Patients Living with Epilepsy at a Tertiary Neurology Center in Rwanda

Objective

Up to one in four patients living with epilepsy (PwE) mentions financial constraints as a reason for loss to follow-up at the Ndera tertiary neuropsychiatry hospital. Therefore, we evaluated the annual direct medical cost (DMC) and direct non-medical cost (DnMC) of epilepsy and calculated costs assuming different follow-up frequency.

Materials and Methods

DMC data were obtained from a descriptive retrospective study of medical records, pharmacy dispensation and hospital logs of PwE, following their initial consultation in 2018 and who adhered to the normal clinical practice of monthly consultations for one year. DnMC data were collected through structured interviews of PwE in a cross-sectional cohort in August 2020. DnMC included biomedical care costs (eg, transportation, hospitality) and non-biomedical costs (traditional healer visits). We report weighted means for total costs, health insurance costs, and out-of-pocket costs (OoP).

Results

Mean annual total cost was 389.4 US$, of which 226.2 US$ was covered by the Rwandan Health Insurance co-payment for DMC and 163.2 US$ was OoP paid by patients. Mean weighted annual DMC (n = 55) was 248.9 US$. Mean weighted annual DMC for medical consultations and antiseizure medication accounted for 30.7 US$ and 161.7 US$, respectively. Based on structured interviews (n = 69), mean weighted annual DnMC for biomedical care was 73.0 US$. Mean DnMC for traditional healer care was 67.6 US$. Weighted annual total OoP was 163.2 US$ or 20% of the GDP per capita. OoP consisted of 14% DMC co-payment, 45% biomedical DnMC, and 41% traditional healer DnMC.

Conclusion

Epilepsy-related costs at a tertiary center are an important economic burden for PwE and Rwandan Health Insurance. Biomedical and traditional healer DnMC constitute 86% of total OoP. Future prospective studies should evaluate outcomes and costs of reduced visit frequency, indirect costs, and costs of comorbidities.

Anti-seizure medications and quality of life in person with epilepsy

Objective

The goal of this study was to determine the effects of mono-, bi-, and polytherapy anti-seizure medications (ASMs) in terms of seizure reduction and quality of life (QOL) in persons with epilepsy (PWE).

Methods

A cross-sectional observational study was conducted. All PWE with age <75 years were recruited and further classified into two groups: responders and non-responders, based on the response of the ASMs to the treatments for reduced seizure frequency since the last one year. Other demographic and clinical data such as seizure frequency, type of seizures, age at onset of seizures, and information about ASMs with their daily doses were assessed for the descriptive analysis. The quality of life was assessed in randomly selected PWE (n = 100) using the quality of life in epilepsy inventory-31 (QOLIE-31) in adults.

Results

With a total of 486 PWE, the median age (years) was comparable in both groups. Out of these the non-responders group was found to be significantly higher (77.8%) than the responders group (22.2%). In the responders group, the percentage of PWE who were on monotherapy was significantly higher (51.85 %) than those who were on polytherapy (17.59%), whereas in the non-responders group, 21.16% of PWE were on monotherapy and 44.86% were on polytherapy. The duration of epilepsy was similar in both groups, but the average seizure frequency was significantly higher in the non-responders. In QOL assessments, 43% of PWE were observed in the responders group, whereas 57% of PWE were found in the non-responders group. The overall comparative QOL scores were also significantly higher (p < 0.0001) in the responders group as compared to the non-responders group.

Conclusion

Our findings revealed that those PWE who were on monotherapy showed better reduction in seizure frequency and improved QOL in responder groups as compared to non-responder groups.

Role of human leukocyte antigen in anti-epileptic drugs-induced Stevens-Johnson Syndrome/toxic epidermal necrolysis: A meta-analysis

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.

Demographic Profile and Prescribing Patterns of Anti-epileptic Drugs in Indian Epilepsy Patients: Electronic Medical Record-Based Nation-Wide Retrospective Cohort Study

The aim of this study was to provide real-world data on clinical characteristics, risk factors, and treatment patterns in Indian patients with epilepsy. Electronic medical record (EMR) data of patients diagnosed with epilepsy between January 2001 and December 2019, which included demographics, diagnosis, anti-epileptic drug usage, and underlying risk factors were evaluated. The majority of patients were between the age group of 18 and 55 years (n=3,186), with males accounting for 62% and the remaining 38% being females. Further, the most common comorbidity was hypertension (23.3%, n=1,470), followed by diabetes mellitus (10.8%, n=683) and depression (9.4%, n=597). The most prevalent form of epilepsy was focal epilepsy (n=5,141 81.4%), followed by generalized epilepsy (n=601). Focal epilepsy was most prevalent in males (62%, n=3,167) and most common in the age group of 18-55 years (50.3%, n=2588). Anti-epileptic drug (AED) usage data from 6,318 patients showed that the most commonly prescribed AED alone or in combination for both focal and generalized epilepsy was levetiracetam (41.8%, n= 2645). Data collected from this study are aligned but do not completely agree with the Guidelines for the Management of Epilepsy in India (GEMIND). This affirms treatment initiation with AED monotherapy; however, the treatment choices do not necessarily follow the recommended guidelines to select conventional AEDs, at low strengths, at initiation.

Need for pharmacoeconomic consideration of antiepileptic drugs monotherapy treatment in persons with epilepsy

Objective

Newer antiepileptic drugs (AEDs) are expected to have less adverse effects (AEs) and drug interactions as compared to conventional AEDs but the high cost is the major limitation for their use. This study evaluated variation in the cost of treatment with newer and conventional AEDs through its correlation with treatment efficacy and AEs in persons with epilepsy (PWE).

Methods

This cross-sectional study included PWE (28.9 ± 9.9 years) having focal and generalized seizures on conventional [valproate, carbamazepine, phenytoin] or newer AEDs [levetiracetam, oxcarbazepine] for >6 months. Seizure frequency during the study (6 months) was compared to that within 6 months before the study. Other parameters assessed were Quality of life in epilepsy, Pittsburgh Sleep Quality Index, Gastrointestinal Quality of life Index, and Liverpool AEs Profile. The cost of treatment was determined as direct, indirect, and intangible costs. The incremental cost-effectiveness ratio (ICER) analysis was also performed.

Results

Out of 214 PWE, 51.4% were on newer AEDs. Newer and conventional AEDs did not differ significantly in seizure frequency reduction (60.29 vs. 53.09%), quality of life parameters, though these were improved significantly during the study period. The direct medical cost and total cost of treatment were lesser with conventional AEDs (p < 0.001 in both) than newer AEDs, but the intangible cost did not differ. The total cost of treatment was significantly influenced by factors (as per regression analysis) including the type of AEDs (significant difference between valproate, carbamazepine, and levetiracetam), frequency of seizures, cost of medicine (70.34% of total cost), hospital admission, and treatment of AEs. As per ICER, newer AEDs need an additional USD 8.39 per unit reduction in seizure frequency.

Conclusion

Newer AEDs have comparatively better efficacy, though not significant than conventional AEDs. However, the additional cost per unit improvement is quite high with newer AEDs, necessitating pharmacoeconomic consideration in epilepsy treatment.

Evaluation of adverse drug reaction profile of antiepileptic drugs in persons with epilepsy: A cross-sectional study

INTRODUCTION

Newer antiepileptic drugs (AEDs) are preferred over conventional AEDs with the perception of better safety profile and efficacy though there is a lack of confirmatory evidence. The present study assessed the adverse drug reactions' (ADRs) profile of AEDs prescribed in persons with epilepsy (PWE) as per the System Organ Class (SOC) and compared them on the basis of demographics and treatment pattern.

MATERIAL AND METHODS

This prospective, cross-sectional, and observational study was conducted in PWE attending Neurology Outpatient-Department from February 2016 to April 2019 who were presented with any ADR. World Health Organization-Uppsala Monitoring Centre (WHO-UMC) scale was used for the causality assessment of suspected ADRs.

RESULTS

Among the 1011 PWE on AEDs, male:female ratio was 622:389, adult:pediatric ratio 736:275, and conventional:newer AEDs ratio 624:387. Among monotherapy PWE (47.1%), commonly used AEDs were levetiracetam (34.4%), valproic acid (22.9%), carbamazepine (18.3%), phenytoin (11.9%), and other AEDs (12.5%). A total of 1990 ADRs (1.96 ADRs per PWE) were reported as per SOC; among them, newer vs. conventional AEDs did not reveal any significant difference; however, monotherapy vs. polytherapy showed differences in nervous system disorders (p = 0.01) and skin and subcutaneous tissue disorders (p = 0.005). Causality assessment revealed 0.3% certain, 27.3% probable, 61.3% possible, and 11.1% unlikely association of ADRs with AEDs. Depending on the ADRs, there was either withdrawal of AED (0.9%), reduction in dose (48.4%), or continuation in the same dose as before (50.7%).

CONCLUSION

The ADR analysis showed that newer AEDs were associated with a similar trend of ADRs as that of conventional AEDs. Thus, the choice among newer and conventional AEDs should preferably focus on the experience of better efficacy in addition to safety data.

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.

Adverse effects & drug load of antiepileptic drugs in patients with epilepsy: Monotherapy versus polytherapy

Background & objectives:

Although the need for a combination of antiepileptic drugs (AEDs) in the treatment of epilepsy is well justified, but an associated increase in adverse effects (AEs) lends a restriction to polytherapy. The aim of this study was to evaluate AEs and drug load (prescribed daily dose/defined daily doses) of AEDs in patients with epilepsy (PWE).

Methods:

Consecutive PWEs attending Epilepsy clinic in a tertiary care hospital in New Delhi, India, were enrolled in the study. Demographic variables, such as age, gender, diagnosis, age at onset of seizures, frequency of seizures, use of all AEDs and adverse event profile (AEP) score were noted. Routine laboratory tests including lipid profile, fasting blood glucose, haematological parameters and liver and kidney function tests were done.

Results:

A total of 697 consecutive patients were included in this study. Of them, 64.4 per cent were male; mean age was 29.6 ± 10.6 yr. Generalized seizures and focal seizures were recorded in n=386 (55.4%) and n=311 (44.6%), respectively. Monotherapy and polytherapy with two and greater than or equal to three AEDs were prescribed in 264 (37.9%), 243 (34.9%) and 190 (27.2%) patients, respectively. The average AED load, duration of treatment as well as AEP score were found to be significantly higher in combination of greater than or equal to three AEDs as compared to both monotherapy and combination of two AEDs, whereas no significant difference was observed between monotherapy and combination of two AEDs. Patients on monotherapy were in good control of seizures as compared to polytherapy. There was no significant change in biochemical parameters between the groups.

Interpretation & conclusions:

Polytherapy with combination of greater than or equal to three AEDs was associated with higher AEs and lower seizure control as compared to both monotherapy and combination of two AEDs. AEs did not correlate with AED load, seizure type, gender and age of the patients but were associated with both numbers of AEDs as well as seizure frequency in PWE.

An investigation of the characteristics of outpatients with epilepsy and antiepileptic drug utilization in a multicenter cross-sectional study in China

OBJECTIVES

This study aimed to describe the distribution of seizure types, clinical characteristics, and antiepileptic drug (AED) utilization in patients with epilepsy visiting tertiary hospitals in China.

METHODS

This was an observational, cross-sectional epidemiology study conducted at 11 tertiary hospitals across China from May 2014 to November 2014. A total of 1603 patients, of either sex or any age with confirmed diagnosis of epilepsy, visiting outpatient clinics at tertiary hospitals were screened and enrolled. Demographics, seizure types, frequency, etiologies, comorbidities, and current AED therapy were analyzed using descriptive statistics.

RESULTS

Overall, the majority (n=1201; 74.9%) of patients were adults (16-59years of age), and the mean (SD) age was 27.5 (15.9) years. A total of 989 (61.7%) patients had partial seizures, and 653 (40.7%) had generalized seizures. The majority experienced monthly (n=663) or yearly (n=625) seizures, with 2.7seizures/month or 2.9seizures/year, respectively. The most commonly reported symptomatic etiologies were traumatic brain injury, encephalitis, and stroke, whereas the most common comorbidities were sleep disorder, headache, anxiety, and depression. Overall, monotherapy was used in 54.1% of patients, while 30.6% of patients used dual therapy. The most commonly prescribed monotherapy for patients with partial seizures was oxcarbazepine (25.9%), while that for patients with generalized seizures was valproic acid (38.9%), and the most common AED combination was valproic acid and lamotrigine. Overall, valproic acid was the most commonly prescribed AED as monotherapy and combination therapy.

CONCLUSION

Findings from this study provide extensive information on clinical characteristics and utilization of AEDs in Chinese patients with epilepsy which may help physicians make well-informed clinical decisions.

Mass loading and removal of pharmaceuticals and personal care products including psychoactives, antihypertensives, and antibiotics in two sewage treatment plants in southern India

Environmental contamination by pharmaceuticals and personal care products (PPCPs) is barely studied in India despite being one of the largest global producers and consumers of pharmaceuticals. In this study, 29 pharmaceuticals and six metabolites were determined in sewage treatment plants (STPs) in Udupi (STP_U: population served ∼150,000) and Mangalore (STP_M: population served ∼450,000); the measured mean concentrations ranged from 12 to 61,000 ng/L and 5.0 to 31,000 ng/L, respectively. Atorvastatin (the most prescribed antihypercholesterolemic in India), mefenamic acid, and paraxanthine were found for the first time in wastewater in India at the mean concentrations of 395 ng/L, 1100 ng/L, and 13,000 ng/L, respectively. Select pharmaceutical metabolites (norverapamil and clopidogrel carboxylic acid) were found at concentrations of upto 7 times higher than their parent drugs in wastewater influent and effluent. This is the first study in India to report mass loading and emission of PPCPs and their select metabolites in STPs. The total mass load of all PPCPs analyzed in this study at STP_U (4.97 g/d/1000 inhabitants) was 3.6 times higher than calculated for STP_M. Select recalcitrant PPCPs (carbamazepine, diazepam, and clopidogrel) were found to have negative or no removal from STP_U while additional treatment with upflow anaerobic sludge blanket reactor at STP_M removed (up to 95%) these PPCPs from STP_M. Overall, 5.1 kg of caffeine, 4.1 kg of atenolol, 2.7 kg of ibuprofen, and 1.9 kg of triclocarban were discharged annually from STP_U. The PPCP contamination profile in the Indian STP was compared with a similar study in the USA.

Epilepsy in India II: Impact, burden, and need for a multisectoral public health response

Epilepsy is a common neurological disorder whose consequences are influenced socially and culturally, especially in India. This review (second of the two part series) was carried out to understand the social impact and economic burden to develop comprehensive program for control and prevention of epilepsy. Epilepsy is known to have adverse effect on education, employment, marriage, and other essential social opportunities. Economic burden associated with epilepsy is very high with treatment and travel costs emerging as an important contributing factor. A vicious cycle between economic burden and poor disease outcome is clear. There is no significant change in the perception, stigma, and discrimination of epilepsy across the country despite improvement in educational and social parameters over the time. The huge treatment gap and poor quality of life is further worsened by the associated comorbidities and conditions. Thus, a multidisciplinary response is needed to address the burden and impact of epilepsy which calls for an integrated and multipronged approach for epilepsy care, prevention, and rehabilitation. Service delivery, capacity building, integration into the existing program, mobilizing public support, and increasing public awareness will be the hallmarks of such an integrated approach in a public health model.

The economic impact of epilepsy: a systematic review

BACKGROUND

In this review we aimed to determine the economic impact of epilepsy and factors associated with costs to individuals and health systems.

METHODS

A narrative systematic review of incidence and case series studies with prospective consecutive patient recruitment and economic outcomes published before July 2014 were retrieved from Medline, Embase and PsycInfo.

RESULTS

Of 322 studies reviewed, 22 studies met the inclusion criteria and 14 were from high income country settings. The total costs associated with epilepsy varied significantly in relation to the duration and severity of the condition, response to treatment, and health care setting. Where assessed, 'out of pocket' costs and productivity losses were found to create substantial burden on households which may be offset by health insurance. However, populations covered ostensibly for the upfront costs of care can still bear a significant economic burden.

CONCLUSIONS

Epilepsy poses a substantial economic burden for health systems and individuals and their families. There is uncertainty over the degree to which private health insurance or social health insurance coverage provides adequate protection from the costs of epilepsy. Future research is required to examine the role of different models of care and insurance programs in protecting against economic hardship for this condition, particularly in low and middle income settings.

Valerenic acid and Valeriana officinalis extracts delay onset of Pentylenetetrazole (PTZ)-Induced seizures in adult Danio rerio (Zebrafish)

Background

Anticonvulsant properties have been attributed to extracts of the herbal medicine Valeriana officinalis. Our aims were to examine the anticonvulsant properties of valerenic acid and valerian extracts and to determine whether valerian preparations interact with the activity of other anti-epileptic drugs (phenytoin or clonazepam). To achieve these goals, we validated the adult zebrafish, Danio rerio, as an animal model for studying anticonvulsant drugs.

Methods

All drug treatments were administered by immersion in water containing the drug. For assays of anticonvulsant activity, zebrafish were pretreated with: anti-epileptic drugs, valerenic acid, aqueous or ethanolic valerian extracts, or mixtures (phenytoin or clonazepam with valerenic acid or valerian extracts). Seizures were then induced with pentylenetetrazole (PTZ). A behavioral scale was developed for scoring PTZ-induced seizures in adult zebrafish. The seizure latency was evaluated for all pretreatments and control, untreated fish. Valerenic acid and both aqueous and ethanolic extracts of valerian root were also evaluated for their ability to improve survival after pentylenetetrazole-challenge. The assay was validated by comparison with well-studied anticonvulsant drugs (phenytoin, clonazepam, gabapentin and valproate). One-way ANOVA followed by Tukey post-hoc test was performed, using a p < 0.05 level of significance. All treatments were compared with the untreated animals and with the other pretreatments.

Results

After exposure to pentylenetetrazole, zebrafish exhibited a series of stereotypical behaviors prior to the appearance of clonic-like movements—convulsions. Both valerenic acid and valerian extracts (aqueous and ethanolic) significantly extended the latency period to the onset of seizure (convulsion) in adult zebrafish. The ethanolic valerian extract was a more potent anticonvulsant than the aqueous extract. Valerenic acid and both valerian extracts interacted synergistically with clonazepam to extended the latency period to the onset of seizure. Phenytoin showed interaction only with the ethanolic valerian extracts.

Conclusions

Valerenic acid and valerian extracts have anticonvulsant properties in adult zebrafish. Valerian extracts markedly enhanced the anticonvulsant effect of both clonazepam and phenytoin, and could contribute to therapy of epileptic patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-015-0731-3) contains supplementary material, which is available to authorized users.

A systematic review of prescription pattern monitoring studies and their effectiveness in promoting rational use of medicines

Prescription pattern monitoring studies (PPMS) are a tool for assessing the prescribing, dispensing and distribution of medicines. The main aim of PPMS is to facilitate rational use of medicines (RUM). There is paucity of published data analysing the effectiveness of PPMS. The present review has been done to assess the effectiveness of prescription pattern monitoring studies in promoting RUM. Data search was conducted on internet. A multitude of PPMS done on different classes of drugs were collected and analyzed. PPMS using WHO prescribing indicators were also included. The present article reviews various prescription pattern monitoring studies of drugs conducted all over country and abroad. It was observed in the majority of such studies that physicians do not adhere to the guidelines made by regulatory agencies leading to irrational use of medicines. This in turn leads to increased incidence of treatment failure, antimicrobial resistance and economic burden on the patient and the community as a whole. The treatment of diseases by the use of essential drugs, prescribed by their generic names, has been emphasized by the WHO and the National Health Policy of India. We conclude that the prescription monitoring studies provide a bridge between areas like rational use of drugs, pharmacovigilance, evidence based medicine, pharmacoeconomics, pharmacogenetics and ecopharmacovigilance. In India, this is the need of the hour to utilise the data generated by so many prescription pattern monitoring studies done in every state and on every drug, so that the main aim of promoting rational use of drugs is fulfilled.

The sociodemographic, clinical and pharmacotherapy characteristics influencing quality of life in patients with epilepsy: A cross-sectional study

Context:

Quality of life (QOL) assessment in patients with epilepsy (PWE) is increasingly recognized as an important component in the management of epilepsy.

Aims:

The objective of the present study was to assess influence of sociodemographic, clinical and pharmacotherapy characteristics collectively on QOL in adult PWE.

Settings and Design:

This was a cross-sectional, observational study in patients with confirmed diagnosis of epilepsy.

Materials and Methods:

QOL was assessed using modified QOLIE-10 questionnaire for epilepsy. Univariate and multiple regression analysis were done to determine factors associated with poor QOL, respectively.

Results:

There were 451 PWE, with a mean age 27.3 ± 8.15 years, 251 (56%) males and 191 (42%) had monthly income < 5000 Indian national rupees (INR)/month. The QOLIE score was 64.1 ± 15.97 (Mean ± SD). The univariate analysis showed factors such as lower monthly income, focal epilepsy, seizure frequency, antiepileptic drug (AED) polytherapy, conventional AEDs and frequent adverse drug reactions (ADRs) had significant negative influence on various domains of QOLIE-10 questionnaire. Multiple regression analysis showed seizure frequency as a significant predictor of most QOL domains and overall score, while ADRs as a significant predictor of all the domains. Seizure type was a predictive factor for domains like emotional well-being and overall score.

Conclusion:

Present findings showed patients on monotherapy had better QOL while those having lower monthly income, having focal epilepsy and who received conventional AEDs had negative influence on QOL scores. Further, higher seizure frequency and occurrence of ADRs were significant predictors of all the domains of QOL in PWE.

Ficus religiosa L. figs--a potential herbal adjuvant to phenytoin for improved management of epilepsy and associated behavioral comorbidities

Oxidative stress, together with mitochondrial dysfunction, has been reported to be involved in the pathogenesis of epileptogenesis and its associated comorbidities. Phytoflavonoids have shown numerous beneficial ameliorative effects on different neurological disorders by virtue of their antioxidant effect. The present study investigated the effect of flavonoid-rich ethyl acetate fraction of the crude fig extract of Ficus religiosa in combination with phenytoin on seizure severity, depressive behavior, and cognitive deficit in pentylenetetrazol (PTZ)-kindled mice. The flavonoid-rich ethyl acetate fraction of the crude fig extract was found to show significant antioxidant potential in various in vitro free radical scavenging assays. Combined treatment of this fraction (2.5, 5, and 10 mg/kg; i.p.) along with a subeffective dose of phenytoin (15 mg/kg; i.p.) in postkindled animals once daily for fifteen days showed a dose-dependent decrease in the seizure severity score, a decreased number of mistakes, increased step-down latency in passive shock avoidance paradigm, and decreased immobility time in the tail suspension test in comparison with the phenytoin only-treated group. Biochemical investigations of the brain tissue showed amelioration of thiobarbituric acid reactive substances (TBARS), reduced glutathione (GSH) levels, and reduced catalase and acetylcholinesterase (AChE) activities, thereby indicating suppression of oxidative stress. In conclusion, the results of the present study showed the protective effect of the flavonoid-rich fraction of F. religiosa along with a subeffective dose of phenytoin in PTZ-kindling-associated cognitive deficit and depressive behavior with complete suppression of seizures through reduction of oxidative stress, supporting the the need for clinical evaluation of the supplementation of phytoflavonoids along with antiepileptic drugs (AEDs) for management of epilepsy and its psychiatric and cognitive comorbidities.

Treatment expenditure pattern of epileptic patients: a study from a tertiary care hospital, kolkata, India

Introduction. Neurological diseases are very important causes of prolonged morbidity and disability leading to profound financial loss. Epilepsy is one of the most important neurological disorders. It being a cost intensive disorder poses a significant economic burden to the country. Aims and Objectives. The study was conducted among the persons with epilepsy (PWE) to assess their expenditure pattern for epilepsy treatment and its rural urban difference. Materials and Methods. 315 PWE selected by systematic random sampling and their caregivers were interviewed with the predesigned, pretested semistructured proforma. Subsequently data were compiled and analyzed using SPSS 18.0 software. Results and Conclusion. Majority of the study population were in the age group of 16–30 years. Majority belonged to classes IV and V of Prasad socioeconomic status scale. Average total expenditure per month for treatment of epilepsy was 219 INR, mainly contributed by drugs, travel, investigations, and so forth. Rural population was having higher treatment expenditure for epilepsy specially for travel and food and lodging in order to get epilepsy treatment. Wage loss in the last three months was present in 42.86% study subjects which was both affected by seizure episodes and travel for visits. Better district care would have helped in this situation.