Economic impact of epilepsy and the cost of nonadherence to antiepileptic drugs in older Medicare beneficiaries

Adherence and discontinuation of prescription cannabidiol for the management of seizure disorders at an integrated care center

OBJECTIVE

Evaluate adherence, discontinuation rates, and reasons for non-adherence and discontinuation of prescription CBD during the 12-months post-initiation period at an integrated care center.

METHODS

This was a prospective study of patients prescribed CBD by a neurology clinic provider with initial prescription fulfillment through the center's specialty pharmacy from January 2019 through April 2020. Baseline demographics and reasons for non-adherence and/or discontinuation were collected from the electronic health record and pharmacy claims history was used to calculate adherence using proportion of days covered (PDC). Patients were included in the PDC analysis if they had at least 3 fills during the study period. Non-adherence was defined as a PDC < 0.8. Descriptive statistics were used to summarize data with categorical variables represented as frequencies and percentages and continuous variables as medians and interquartile ranges (IQRs).

RESULTS

We included 136 patients with a median age of 14 years (IQR 9 - 21). Most patients were white (n = 115, 85%), with a diagnosis of intractable epilepsy (n = 100, 74%). Among the 128 patients with 3 or more fills, the median PDC was 0.99 (IQR 0.95 - 1.00) with non-adherence seen in 6% (n = 8) of patients. The most common reason for non-adherence was side effects (n = 2, 25%). Prescription CBD was discontinued by 23% (n = 31) of patients with a median time to discontinuation of 117 days (IQR 68 - 216). The most common reason for discontinuation was major side effects (n = 12, 39%). The most common side effects leading to discontinuation were agitation/irritability (n = 4), mood changes (n = 4), aggressive behavior (n = 3), and increased seizure frequency (n = 3).

CONCLUSION

Adherence to prescription CBD at an integrated care center was high with approximately 94% of patients considered adherent. Providers and pharmacists may improve adherence and discontinuation rates by educating patients on the timeline of response, potential side effects, and potential for dose adjustments.

Self-reported medication adherence instruments and their applicability in low-middle income countries: a scoping review

Introduction

Medication non-adherence is an important public health issue, associated with poor clinical and economic outcomes. Globally, self-reported instruments are the most widely used method to assess medication adherence. However, the majority of these were developed in high-income countries (HICs) with a well-established health care system. Their applicability in low- and middle-income countries (LMICs) remains unclear. The objective of this study is to systematically review the applicability of content and use of self-reported adherence instruments in LMICs.

Method

A scoping review informed by a literature search in Pubmed, EBSCO, and Cochrane databases was conducted to identify studies assessing medication adherence using self-reported instruments for patients with five common chronic diseases [hypertension, diabetes, dyslipidemia, asthma, or Chronic Obstructive Pulmonary Disease (COPD)] in LMICs up to January 2022 with no constraints on publication year. Two reviewers performed the study selection process, data extraction and outcomes assessment independently. Outcomes focused on LMIC applicability of the self-reported adherence instruments assessed by (i) containing LMIC relevant adherence content; (ii) methodological quality and (iii) fees for use.

Findings

We identified 181 studies that used self-reported instruments for assessing medication adherence in LMICs. A total of 32 distinct types of self-reported instruments to assess medication adherence were identified. Of these, 14 self-reported instruments were developed in LMICs, while the remaining ones were adapted from self-reported instruments originally developed in HICs. All self-reported adherence instruments in studies included presented diverse potential challenges regarding their applicability in LMICs, included an underrepresentation of LMIC relevant non-adherence reasons, such as financial issues, use of traditional medicines, religious beliefs, lack of communication with healthcare provider, running out of medicine, and access to care. Almost half of included studies showed that the existing self-reported adherence instruments lack sufficient evidence regarding cross cultural validation and internal consistency. In 70% of the studies, fees applied for using the self-reported instruments in LMICs.

Conclusion

There seems insufficient emphasis on applicability and methodological rigor of self-reported medication adherence instruments used in LMICs. This presents an opportunity for developing a self-reported adherence instrument that is suitable to health systems and resources in LMICs.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022302215.

Synthesis of Molecularly Imprinted Polymers Based on a New Monomer "2-(4-Vinylphenyl) Quinoline-4-Carboxylic Acid" for the Selective Solid-Phase Extraction of Lamotrigine

A new molecularly imprinted polymers (MIPs) have been prepared for the high selective extraction of lamotrigine (LTG), a widely used antiepileptic drug, in human serum. The MIPs were polymerized by bulk polymerization using our synthesized compound, 2-(4-vinylphenyl) quinolin-4-carboxylic acid, as functional monomer, which achieved better adsorption specificity than universal MIPs. Then, the molecularly imprinted solid phase extraction (MISPE) based on this material was coupled with high-performance liquid chromatography (HPLC) for the detection of LTG in human serum. The results of method validation showed that the developed method presented a good precision and accuracy, and the linearity was in the range of 1.50-40.00 mg/mL with the limit of quantitation (LOQ) at 0.20 mg/mL. The recovery ranged from 80.8% to 83.8% with RSD ranges from 5.5% to 11.1%. The validated method was successfully used to determine the concentration of LTG in human simulate serum samples.

Modifiable and Non-modifiable Factors Associated with Low Awareness of Hypertension Treatment in Indonesia: A Cross-Sectional Population-Based National Survey

Introduction:

Low awareness about hypertension treatment is recognized as a significant cause of treatment failure. Therefore, identifying its underlying factors is essential for developing effective intervention strategies. This study aims to identify the modifiable and non-modifiable factors associated with low awareness about hypertension treatment.

Method:

This national, cross-sectional, population-based survey used publicly available data from the Indonesian Family Life Survey (IFLS-5) for 2014 among respondents with hypertension aged ≥15 years. Depression and insomnia, as modifiable factors, were assessed using the Centre for Epidemiologic Studies—Depression (CES-D) and the Patient-Recorded Outcomes Measurement Information System (PROMIS) questionnaire, respectively. Non-modifiable factors, such as sociodemographic information, were obtained from self-reported data. Logistic regression analysis was used to assess the association between these factors and low awareness about hypertension treatment. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported.

Result:

The study recruited 7,920 respondents, the majority of whom were female (53.8%) and aged <60 years (71.1%). The prevalence of low awareness of hypertension treatment was 87.1% (51.8% in women and 48.2% in men). Being an elderly (OR: 1.60, 95%CI 1.36–1.88), being irregularly blood pressure control (OR: 4.40, 95% CI 3.78–5.13), having depressive symptoms (OR: 1.35, 95% CI 1.12–1.62), having insomnia (OR: 1.31, 95% CI 1.11–1.53), and having low satisfaction with health care (OR: 1.28, 95% CI 1.08–1.51) were associated with low awareness of hypertension treatment. Surprisingly, respondents with strong religiosity (OR: 1.62; 95% CI 1.25–2.09) were more likely to display low awareness of hypertension treatment.

Conclusion:

The main factors associated with low awareness of hypertension treatment are modifiable. Thus, health care professionals should integrate more patient-specific factors when designing tailored interventions.

Effect of Reperfusion Therapies on Incidence of Early Post-Stroke Seizures

Objective: This study aimed to determine the effect of reperfusion therapies on the occurrence of early post-stroke seizures (PSS) in patients with acute ischemic stroke (AIS). Background: Reperfusion therapies are paramount to the treatment of stroke in the acute phase. However, their effect on the incidence of early seizures after an AIS remains unclear. Design and Methods: The stroke database at Hamad Medical Corporation was used to identify all patients who received reperfusion therapies for AIS from 2016 to 2019. They were matched with patients of similar diagnosis, gender, age, and stroke severity as measured by National Institutes of Health Stroke Scale (NIHSS) who did not receive such treatment. The rates of early PSS were calculated for each group. Results: The results showed that 508 patients received reperfusion therapies (342 had IV thrombolysis only, 70 had thrombectomies only, and 96 had received both), compared with 501 matched patients receiving standard stroke unit care. Patients who received reperfusion therapies were similar to their matched controls for mean admission NIHSS score (9.87 vs. 9.79; p = 0.831), mean age (53.3 vs. 53.2 years; p = 0.849), and gender distribution (85 vs. 86% men; p = 0.655). The group receiving reperfusion therapies was found to have increased stroke cortical involvement (62 vs. 49.3%, p < 0.001) and hemorrhagic transformation rates (33.5 vs. 18.6%, p < 0.001) compared with the control group. The rate of early PSS was significantly lower in patients who received reperfusion therapies compared with those who did not (3.1 vs. 5.8%, respectively; p = 0.042). When we excluded seizures occurring at stroke onset prior to any potential treatment implementation, the difference in early PSS rates between the two groups was no longer significant (2.6 vs. 3.9%, respectively; p = 0.251). There was no significant difference in early PSS rate based on the type of reperfusion therapy either (3.2% with thrombolysis, 2.9% with thrombectomy, and 3.1% for the combined treatment, p = 0.309). Conclusions: Treatment of AIS with either thrombectomy, thrombolysis, or both does not increase the risk of early PSS.

Decreasing Emergency Department Visits for Children With Epilepsy

Background and Objectives

Epilepsy and seizures represent a frequent cause of emergency department (ED) visits for patients. By implementing quality improvement (QI) methodology, we planned to decrease ED visits for children and adolescents with epilepsy.

Methods

In 2016, a multidisciplinary team was created to implement QI methodology to address ED visits for patients with epilepsy. Based on previous successes, further ED visit reduction was deemed possible. Our aim statement was to decrease the number of ED visits, per 1000 established patients with epilepsy, from 13.03 to 11.6, by December 2019 and sustain for 1 year.

Results

We successfully decreased ED visits for seizure-related care in patients with epilepsy from 13.03% to 10.2% per 1,000 patients, which resulted in a centerline shift.

Discussion

Using QI methodology, we improved the outcome measure of decreasing ED visits for children with epilepsy. Implementations of these interventions can be considered at other institutions that may lead to similar results.

Social determinants of health associated with epilepsy treatment adherence in the United States: A scoping review

PURPOSE

The aim of this paper is to share the results of a scoping review in which we examined the social determinants of health (SDoH) that are associated with anti-seizure medication (ASM) treatment adherence among people living with epilepsy in the United States.

METHODS

Our review was informed by the methods of Arksey and O'Malley for a scoping review. A total of 3,826 articles were identified for reference through a literature search, of which 17 publications were deemed relevant to our scoping review. The final articles were mapped using the Epilepsy SDoH Conceptual Framework to identify gaps.

FINDINGS

Our review suggests that there are multidimensional associations of SDoH in ASM adherence. The SDoH were interrelated. Race/ethnicity and socioeconomic status appeared to have major associations with ASM adherence. Several gaps in the literature were identified, including inadequately exploring the effect that each SDoH has on treatment adherence, and the methods used for assessment.

CONCLUSIONS

Future longitudinal research to address the identified gaps would foster interventions that promote ASM adherence among vulnerable populations living with epilepsy.

CDC-supported epilepsy surveillance and epidemiologic studies: A review of progress since 1994

To report progress, to identify gaps, and to plan epilepsy surveillance and research activities more effectively, the Centers for Disease Control and Prevention (CDC) Epilepsy Program has summarized findings from selected CDC-supported surveillance and epidemiologic studies about epilepsy from 1994 through 2019. We identified publications supported by CDC funding and publications conducted by the CDC Epilepsy Program alone or with partners. We included only epilepsy surveillance and epidemiologic studies focusing on epilepsy burden, epilepsy-related outcomes, and healthcare utilization. We describe the findings of these studies in the following order: 1)prevalence; 2)incidence; 3)epilepsy-related outcomes by selected demographic characteristics; 4)cysticercosis or neurocysticercosis (NCC); 5)traumatic brain injury (TBI); 6)comorbidity; 7)mortality; 8)access to care; 9)quality of care; and 10) cost. We have characterized these findings in relation to the scope of the first three domains of the 2012 Institute of Medicine report on epilepsy and its relevant first four recommendations. From 1994 through 2019, 76 publications on epilepsy-related epidemiologic and surveillance studies were identified. Over the past 25 years, CDC has expanded community, state, and national surveillance on epilepsy and supported epidemiologic studies by using multiple assessment methods and validated case-ascertainment criteria to identify epilepsy burden, epilepsy-related outcomes, and healthcare utilization in the general population or in population subgroups. Among identified research opportunities, studies on epilepsy incidence and risk factors, mortality, and cost are considered as important surveillance gaps. Other remaining gaps and suggested surveillance strategies are also proposed. Findings from this review may help epilepsy researchers and other stakeholders reference and prioritize future activities for epidemiologic and surveillance studies in epilepsy.

A Prospective Study of Usability and Workload of Electronic Medication Adherence Products by Older Adults, Caregivers, and Health Care Providers

Background

A decreased capacity to self-manage medications results in nonadherence, medication errors, and drug-related problems in older adults. Previous research identified 80 electronic medication adherence products available to assist patients with self-management of medications. Unfortunately, the usability and workload of these products are unknown.

Objective

This study aimed to examine the usability and workload of a sample of electronic medication adherence products.

Methods

In a prospective, mixed methods study, a sample of older adults, health care professionals, and caregivers tested the usability and workload of 21 electronic medication adherence products. Each participant tested 5 products, one at a time, after which they completed the system usability scale (SUS) and NASA-task load index (NASA-TLX), instruments that measure the usability and workload involved in using a product. Higher SUS scores indicate more user-friendliness, whereas lower NASA-TLX raw scores indicate less workload when using a product.

Results

Electronic medication adherence products required a mean of 12.7 steps (range 5-20) for the appropriate use and took, on average, 15.19 min to complete the setup tasks (range 1-56). Participants were able to complete all steps without assistance 55.3% of the time (103 out of the 186 tests were completed by 39 participants; range 0%-100%). The mean SUS and NASA-TLX raw scores were 52.8 (SD 28.7; range 0-100) and 50.0 (SD 25.7; range 4.2-99.2), respectively, revealing significant variability among the electronic medication adherence products. The most user-friendly products were found to be TimerCap travel size (mean 78.67, SD 15.57; P=.03) and eNNOVEA Weekly Planner with Advanced Auto Reminder (mean 78.13, SD 14.13; P=.049) as compared with MedReady 1700 automated medication dispenser (mean 28.63, SD 21.24). Similarly, MedReady (72.92, SD 18.69) was found to be significantly more work intensive when compared with TimerCap (29.35, SD 20.35; P=.03), e-pill MedGlider home medication management system (28.43, SD 20.80; P=.02), and eNNOVEA (28.65, SD 14.97; P=.03). The e-pill MedTime Station automatic pill dispenser with tipper (71.77, SD 21.98) had significantly more workload than TimerCap (P=.04), MedGlider (P=.03), and eNNOVEA (P=.04).

Conclusions

This study demonstrated that variability exists in the usability and workload of different electronic medication adherence products among older adults, caregivers, and clinicians. With few studies having investigated the usability and workload of electronic medication adherence products, no benchmarks exist to compare the usability and workload of these products. However, our study highlights the need to assess the usability and workload of different products marketed to assist with medication taking and provides guidance to clinicians regarding electronic medication adherence product recommendations for their patients. Future development of electronic medication adherence products should ensure that the target populations of patients are able to use these products adequately to improve medication management.

Self-reported adherence among people with epilepsy in Brazil

BACKGROUND

Nonadherence rates among people with epilepsy (PWE) are widely variable, ranging from 26% to 95.4%. We aimed to identify nonadherence in Brazil, its determinant factors, its impact on patients' management, and to compare it with other chronic nonparoxysmal diseases.

METHODS

A multicenter observational case-control study was conducted between March 2015 and October 2016, and 153 subjects were included. Subjects' clinical-epidemiological data were surveyed with the Morisky-Green test (MGT), Brief Medication Questionnaire (BMQ), and the Liverpool adverse events profile (LAEP).

RESULTS

One hundred three PWE and 50 controls with other, nonparoxysmal chronic conditions were interviewed; both groups were matched according to age and socioeducational level. People with epilepsy were aged 36.4 ± 13.9 (range 18-67), 55% were women, mean age at epilepsy onset was 18.1 ± 15.5 years, 51.5% had pharmacoresistant epilepsy, and 48.5% were on monotherapy. 74.8% of patients and 70.0% controls were nonadherent to treatment according to MGT (p = 0.58); and barrier of recall (BMQ) was associated with nonadherence in 78% of PWE and 76% of controls (p = 0.84). Binary logistic regression analysis revealed LAEP (OR 1.05; 95%CI = 1.01-1.09; p = 0.03) and self-reported frequency of forgetfulness on the last three months (OR 19.13; 95%CI = 2.40-152.28; p < 0.01) as the main factors associated with nonadherence. Nonadherent subjects did not have more seizures and did not need emergency treatment more often than adherent ones.

CONCLUSION

Three of four PWE were not fully adherent to their treatment. Adherence assessment should be routine in all outpatient visits as well as interventions aimed to improving it. Adverse events are important predictors of adherence, and they should be considered when choosing the initial treatment of epilepsy.

Association between adherence to sodium channel blockers and patient-reported outcomes: Analysis of US survey data among patients with epilepsy

OBJECTIVE

The objective of this study was to examine the relationship between adherence to treatment with sodium channel blockers (SCBs) and health-related quality of life (HRQoL), work productivity and activity impairment (WPAI), healthcare resource utilization (HRU), and associated costs among patients with epilepsy.

METHODS

This retrospective cross-sectional study used data from the 2017 US National Health and Wellness Survey (NHWS; N = 75,004). Health-related quality of life (Study Short-Form 36-Item Health Survey version 2 [SF-36v2]), WPAI (Work Productivity and Activity Impairment-General Health [WPAI-GH] questionnaire), HRU, and annual costs were compared among respondents with epilepsy using SCBs categorized as low/medium adherence (n = 120) and high adherence (n = 80) using generalized linear models, controlling for patient characteristics.

RESULTS

Mental component score, Short-Form 6-Dimension (SF-6D) health utility index, bodily pain, mental health, physical functioning, role emotional, social functioning, and vitality scores were significantly lower in low/medium adherence respondents than in high adherence respondents (for all, p < 0.05). Only activity impairment was significantly higher in low/medium adherence respondents compared with the high adherence group (p < 0.001). Healthcare resource utilization did not differ significantly between the two groups; however, the number of emergency room (ER) visits and total costs were lower in the high adherence group (p = 0.038) compared with the low/medium adherence group (p = 0.040).

CONCLUSION

High adherence to SCBs was associated with improved HRQoL, lower WPAI, and lower HRU and associated costs among patients with epilepsy. Therefore, adherence to SCBs may be an important factor in improving the abovementioned patient-reported outcomes. Findings from this study can help provide further impetus to healthcare policymakers and clinicians for addressing the low antiepileptic drug (AED) adherence levels in adult patients with epilepsy.

Healthcare resource utilization and costs before and after lacosamide initiation as adjunctive therapy among patients with epilepsy in the United States

OBJECTIVE

The objective of this study was to evaluate all-cause and epilepsy-specific healthcare resource utilization and costs following lacosamide (LCM) initiation as adjunctive therapy for the treatment of epilepsy.

METHODS

A noninterventional retrospective database analysis was conducted that examined patients diagnosed as having epilepsy who added LCM to existing antiepileptic drug (AED) therapy between 2009 and 2016 (the first LCM prescription was the index event). This study used a single-case design whereby patients served as their own controls. Patients were further required to have a minimum of 12 months of continuous eligibility before (preindex period) and after (postindex period) their index event. In the 12-month postindex period, the only allowed AED regimen change was the addition of LCM. Demographic and clinical characteristics were measured at index and during the preindex period, respectively. All-cause and epilepsy-specific healthcare resource utilization and costs were measured and compared in the pre- and postindex periods. Paired t- and McNemar's tests were conducted to assess the significant differences between pre- and postindex. Univariate analyses were used to analyze the impact of LCM on specific subpopulations.

RESULTS

The study sample comprised of 2171 patients: mean (standard deviation [SD]) age: 38.9 (19.3) years; 52.6% female. Just over half (56%) of these patients were on monotherapy before adding LCM. Prior to adding LCM, 28.8% of patients had an epilepsy-specific inpatient (IP) admission, and 35.7% of patients had an all-cause IP admission, compared with 18.2% and 26.1% of patients in the post-LCM period, respectively (both p < 0.0001). Likewise, 35.6% of patients had an epilepsy-specific emergency room (ER) visit, and 50.0% had an all-cause ER visit prior to adding LCM, compared with 23.8% and 42.1% in post-LCM, respectively (both p < 0.0001). After adding LCM, one-year mean [SD] epilepsy-specific IP admission costs decreased by 42.9% ($13,647 [$52,290] to $7788 [$32,321]), and all-cause IP admission costs decreased by 38.6% ($20,654 [$72,716] to $12,688 [$46,120]) (both p < 0.0001). One-year epilepsy-specific mean [SD] ER costs decreased by 35.2% ($691 [$1756] to $448 [$1909]; p < 0.0001), and all-cause ER cost decreased by 17.8% ($1217 [$3014] to $1000 [$2970]; p < 0.01).

CONCLUSIONS

Epilepsy-related IP hospitalizations and ER visits (indicators of seizures) were significantly reduced in patients with epilepsy 12 months after adding LCM as an adjunctive therapy to existing AED treatment in a real-world setting, leading to reduced healthcare resource utilization and epilepsy costs.

High health care costs in minority groups of older US Medicare beneficiaries with epilepsy

OBJECTIVE

To examine health care costs in diverse older Medicare beneficiaries with epilepsy.

METHODS

Using 2008-2010 claims data, we conducted a longitudinal cohort study of a random sample of Medicare beneficiaries augmented for minority representation. Epilepsy cases (n = 36 912) had ≥1 International Classification of Diseases, Ninth Edition (ICD-9) 345.x or ≥2 ICD-9 780.3x claims, and ≥1 antiepileptic drug (AED) in 2009; new cases (n = 3706) had no seizure/epilepsy claims nor AEDs in the previous 365 days. Costs were measured by reimbursements for all care received. High cost was defined as follow-up 1-year cost ≥ 75th percentile. Logistic regressions examined association of high cost with race/ethnicity, adjusting for demographic, clinical, economic, and treatment quality factors. In cases with continuous 2-year data, we obtained costs in two 6-month periods before and two after the index event.

RESULTS

Cohort was ~62% African Americans (AAs), 11% Hispanics, 5% Asians, and 2% American Indian/Alaska Natives. Mean costs in the follow-up were ~$30 000 (median = $11 547; new cases, mean = $44 642; median = $25 008). About 19% white compared to 27% AA cases had high cost. AA had higher odds of high cost in adjusted analyses (odds ratio [OR] = 1.20, 95% confidence interval [CI] = 1.11-1.29), although this was only marginally significant when adjusting for AED adherence (OR = 1.09, 95% CI = 1.01-1.18, P = 0.03). Factors associated with high cost included ≥1 comorbidity, neurological care, and low AED adherence. Costs were highest at ~$17 000 in the 6 months immediately before and after the index event (>$29 000 for new cases).

SIGNIFICANCE

The financial sequelae of epilepsy among older Americans disproportionally affect minorities. Studies should examine contributors to high costs.

The Risk Of Seizure-Related Hospitalization Among Older Adults On Levetiracetam Monotherapy: A Retrospective Comparative Cohort Study

BACKGROUND

Antiepileptic drug monotherapy is the mainstay of treatment for epilepsy; however, the efficacy of different antiepileptic drugs in reducing the incidence of seizure-related hospitalization among older adults, who are at higher risk of developing epilepsy compared to their younger counterparts, has not been examined.

PURPOSE

The objective of the present study was to compare the rate of seizure-related hospitalization among older adults on levetiracetam compared to different antiepileptic drugs (AEDs).

PATIENTS AND METHODS

This was a retrospective cohort study of older adults (≥60 years) in two tertiary care hospitals. Patients who are 60 years of age and older, have a confirmed diagnosis of epilepsy, and are taking a single and the same antiepileptic drug for at least 36 months were included. The patients were followed up for 24 months after 12 months of treatment with no incidence of seizure-related hospitalization via their health records. Multiple Poisson regression with robust error variance was used to estimate the relative risk of hospitalization for patients on levetiracetam compared to different antiepileptic drugs controlling for age, gender, number of prescription medications, dosage strengths, and Charlson Comorbidity Index (CCI) score.

RESULTS

One hundred and thirty-six patients met the inclusion criteria and were included in the study. The recruited patients were on one of the following four antiepileptic drugs: carbamazepine (n=44), levetiracetam (n=39), phenytoin (n=31), and valproic acid (n=22). Patients on levetiracetam were more than twice as likely to be hospitalized due to seizures within the 24 months of follow-up compared to their counterparts on other AEDs (RR=2.76, 95% CI=1.16-6.53, P=0.021).

CONCLUSION

This study suggests that older adults on old generation AEDs such as phenytoin, carbamazepine, and valproic acid appear to have a lower risk of seizure-related hospitalization compared to their counterparts on levetiracetam.

Future development of a depot antiepileptic drug: What are the ethical implications?

Depot medications have been used for long-term treatment of many different medical conditions (schizophrenia, opioid addiction) and for prevention of pregnancy (birth control). In addition, proposals for depot medication for antidepressants have been made as a possible treatment for chronic depression. For the treatment of chronic epilepsy, there are currently no depot antiepileptic drugs (AEDs). However, there may be a role for them. Depot AEDs could improve medication adherence rates, thereby reducing the morbidity and mortality that are associated with ongoing seizures. This could help to reduce hospital costs for people with epilepsy. Potential patient populations that could benefit from a depot AED include patients with forgetfulness, socioeconomic barriers to access of daily oral medications, impaired gastric absorption or dysphagia, comorbid epilepsy and psychiatric disease, and personal preference to avoid the inconvenience of taking a medication daily or even multiple times per day. In this article, we review reasons to create a depot AED and the outcomes of doing so in the context of the pillars of bioethics: beneficence (to act in a patient's best interest), autonomy (to respect a patient as an individual and honor their preferences), nonmaleficence (to do no harm), and justice (to treat all persons fairly and equally).