Epilepsy in an Italian community as assessed by a survey for prescriptions of antiepileptic drugs: epidemiology and patterns of care

A cross-sectional study of errors in physicians orders' of antiseizure medications among people with epilepsy from rural India

AIMS

To enumerate and classify errors in physicians' orders of antiseizure medications (ASMs) to people with epilepsy presenting to neurology clinic.

METHODS

This cross-sectional study was conducted in the neurology clinic of a teaching hospital catering to a predominantly rural population. People in whom a diagnosis of epilepsy was confirmed and who presented for the first time with a prior prescription for antiseizure medication/s were included. Their immediate previous prescriptions were assessed for errors, enumerated and classified according to WHO guidelines for prescription writing.

RESULTS

Hundred prescriptions of 334 patients screened were analyzed. The number of ASMs prescribed to a participant was 2 ± 0.6 (mean ± SD). We identified a mean of 5 ± 4 (median: 3; range: 1-7) errors in each order. These included superscription errors, e.g., missing information on seizure control and frequency (n = 90, 90%), generic name (n = 62, 62%), patient identifiers (n = 57, 57%), prescribers' identifiers (n = 29, 29%) and diagnosis or indication for prescribing the medication/s (n = 55, 55%). The most common inscription and subscription errors were dosing errors (22%) and pharmaceutical form errors (20%) followed by omission (13%), duplication (13%), substitution (12%), commission (9%) and frequency errors (8%). Errors were more common among prescriptions provided by primary-care and Ayurvedic, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) physicians compared to specialists (P < 0.05).

CONCLUSIONS

Errors are common among medication orders provided by non-specialist and specialist physicians. Primary care and AYUSH are more liable to make errors underscoring the need to educate them in basic epilepsy treatment.

Epilepsy at different ages-Etiologies in a Norwegian population

The causes of epilepsy are age related, but confirmative data from population-based studies are scarce. Our aim was to describe the typical causes of epilepsy in the different age groups of a defined population. The study was cross-sectional, based on a review of all medical files containing a diagnostic code for epilepsy at Drammen Hospital from 1999-2013. Drammen Hospital serves the population of Buskerud County, with 272 228 residents (as of January 1, 2014), including 1771 people with active epilepsy. This group of persons with active epilepsy was divided into different age groups with the causes of epilepsy mapped in each group. The proportion with unknown etiology ranged from 27% (age 5-9) to 41% (age 10-19). Structural-metabolic epilepsy and perinatal insults were the leading causes of epilepsy in the age group 5-9 (46%), whereas disturbances of brain development dominated in the youngest (23% in patients ≤4 years old). In the group comprising persons with epilepsy ≥60 years old, stroke was the most common cause of epilepsy (44%). Despite recent advances in research and technology, a large number of patients in all age groups (including the youngest) still have an unknown cause of epilepsy. We conclude that an effort must be made to improve the diagnostics for and understanding of the causes of epilepsy across all ages.

Prevalence and cost of epilepsy in Sweden--a register-based approach

OBJECTIVES

To estimate the prevalence of epilepsy, costs associated with in- and outpatient care, drug utilization and productivity losses due to epilepsy in Sweden for the years 2005 and 2011.

METHODS

Cost components were calculated using registry data on inpatient- and outpatient-care utilization, drug sales and early pensions granted due to permanent disability and mortality. Moreover, by cross-identification of information in healthcare and pharmaceutical registries, we were able to distinguish between pharmaceuticals prescribed for epilepsy and non-epilepsy indications.

RESULTS

The prevalence of epilepsy was estimated at 0.62% in 2005 and 0.88% in 2011. The total cost of epilepsy increased during the same period, while the per-patient cost decreased from €2929 to €1729. Direct medical costs accounted for about 36% of the estimated total cost in 2005 and 60% in 2011. The estimated healthcare cost due to epilepsy as a share of total healthcare costs for all illnesses was about the same in 2005 as in 2011 (0.2%), while the corresponding pharmaceutical cost increased from about 0.5% in 2005 to almost 1% in 2011.

CONCLUSIONS

The per-patient cost of epilepsy is substantial, implying a significant aggregated cost incurred on society (despite a prevalence < 1%). Our results suggest that the per-patient pharmaceutical utilization increased, while the per-patient physician visits and hospitalizations decreased, between 2005 and 2011. Moreover, we demonstrate that the 2005 prevalence measure was underestimated the true prevalence in 2005.

Regional variation in prevalence and healthcare utilization due to epilepsy in Sweden

OBJECTIVE

To estimate the regional differences in the prevalence of epilepsy and the associated costs due to inpatient and outpatient care and anti-epileptic drug (AED) utilization for the years 2005 and 2011 in Sweden.

METHODS

Region-specific estimates of the prevalence of epilepsy were obtained using a method based on a linkage of the healthcare and pharmaceutical registries and the cause of death registry. Regional cost components were estimated using registry data by region on inpatient and outpatient care utilization, AED sales, and mortality. Per-patient utilization and monetary costs were calculated.

RESULTS

Estimated prevalence of epilepsy varied substantially across the regions in 2011, from 0.76% in Jämtland to 1.08% in Gotland. The national prevalence was 0.88%. The average number of hospitalizations per patient and year decreased at the national level between 2005 and 2011. At the national level, the per-patient specialized care (outpatient) utilization also decreased between 2005 and 2011. However, at the regional level, the decrease was not uniform, and in some counties, the per-patient utilization increased during the period studied. The per-patient utilization of AEDs increased in all counties, except Kronoberg, between 2005 and 2011. Moreover, between-region differences in healthcare and AED utilization, and significant differences between regions and national averages were revealed. Similarly, regional per-patient costs were shown to deviate from the national average in 13 of 21 regions.

CONCLUSIONS

There is significant variation in the prevalence of epilepsy and the provision of health care for patients with epilepsy across the different regions of Sweden.

Is sodium valproate, an HDAC inhibitor, associated with reduced risk of stroke and myocardial infarction? A nested case-control study

Background

This study aimed to evaluate whether treatment with sodium valproate (SV) was associated with reduced risk of stroke or myocardial infarction (MI).

Methods

Electronic health records data were extracted from Clinical Practice Research Database for participants ever diagnosed with epilepsy and prescribed antiepileptic drugs. A nested case–control study was implemented with cases diagnosed with incident non-haemorrhagic stroke and controls matched for sex, year of birth, and study start date (ratio of 1:6). A second nested study was implemented with MI as outcome. The main exposure variable was SV therapy assessed as: ever prescribed, pre-stroke year treatment, number of SV prescriptions, and cumulative time on SV drug therapy. Odds ratios were estimated using conditional logistic regression.

Results

Data were analysed for 2002 stroke cases and 13 098 controls. MI analyses included 1153 cases and 7109 controls. Pre-year stroke SV treatment (28%) was associated with increased stroke risk (odds ratio 1.22, 95% confidence interval (CI): 1.09 to 1.38, p < 0.001). No association was observed between ever being prescribed SV with ischemic stroke (OR = 1.01, 95% CI: 0.91 to 1.12, p = 0.875). A significant association was observed between ever being prescribed SV with MI (OR = 0.78, 95% CI: 0.67 to 0.90, p < 0.001). Patients in the highest quarter of SV treatment duration had lower odds of ischemic stroke (OR = 0.57, 95% CI: 0.44 to 0.72, p < 0.001) and MI (OR = 0.29, 95% CI: 0.20 to 0.44, p < 0.001).

Conclusion

Sodium valproate exposure was associated with the risk of MI, but not ischemic stroke. However, longer exposure to SV was associated with lower odds of stroke, but this might be explained by survivor bias.

Unexpected finding of delayed-onset seizures in HIV-positive, treatment-experienced subjects in the Phase IIb evaluation of fosdevirine (GSK2248761)

BACKGROUND

Fosdevirine (GSK2248761) is a non-nucleoside reverse transcriptase inhibitor with HIV-1 activity against common efavirenz-resistant strains. Two partially blind, randomized, Phase IIb studies were initiated (1 in treatment-naive and 1 in treatment-experienced subjects with HIV) to select a once-daily dose of fosdevirine for Phase III trials.

METHODS

In the SIGNET study, treatment-naive subjects were randomized 1:1:1 to receive once-daily fosdevirine 100 or 200 mg or efavirenz 600 mg, each along with tenofovir disoproxil fumarate/emtricitabine 300 mg/200 mg or abacavir/lamivudine 600 mg/300 mg. In the SONNET study, treatment-experienced subjects with non-nucleoside reverse transcriptase inhibitor-resistant HIV-1 were randomized 1:1:1 to treatment with fosdevirine 100 or 200 mg once daily or etravirine 200 mg twice daily, each along with twice-daily darunavir/ritonavir 600/100 mg and raltegravir 400 mg. The primary efficacy end point was the proportion of subjects with HIV-1 RNA<50 copies/ml. Safety and pharmacokinetics were also addressed.

RESULTS

A total of 35 subjects were exposed to fosdevirine 100 or 200 mg. Trials were halted when 5 treatment-experienced subjects (1 receiving fosdevirine 100 mg, 4 receiving fosdevirine 200 mg) developed new-onset seizures after ≥4 weeks of exposure to fosdevirine. There was no clear association between seizures and fosdevirine plasma drug levels. Time to seizure onset ranged from 28 to 81 days, and all 5 subjects experienced ≥1 seizure after drug discontinuation.

CONCLUSIONS

The delayed onset of seizures after fosdevirine exposure and persistence after discontinuation is without precedent in antiretroviral drug development, leading to additional investigation and underscoring the need for careful subject monitoring.

Perampanel: What is its Place in the Management of Partial Onset Epilepsy?

Introduction

Current pathways for treatment of partial onset epilepsy are diverse and include 14 new antiepileptic drugs (AEDs) licensed for use as either monotherapy or adjunctive therapy. However, the impact of these new AEDs on the treatment of partial epilepsy has so far been disappointing and there persists a need for additional drugs. Recently, perampanel, a first-in-class AED was licensed as an adjunct for the management of refractory partial onset seizures with or without secondary generalization in patients 12 years and older. This review highlights the current management of partial epilepsy and analyses the published clinical and preclinical data of perampanel to consider its potential role in the treatment of partial epilepsy.

Methods

A literature review of Embase, Medline and PubMed was conducted in April 2013 using the search terms ‘perampanel’ and ‘AMPA receptor antagonist/blocker’. Publications were included if they discussed perampanel in the context of preclinical or clinical epilepsy.

Results

Perampanel acts on the glutamate pathway. It is a novel highly selective non-competitive alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor antagonist. This is a previously untargeted post-synaptic glutamate receptor. It is responsible for mediating rapid trans-synaptic signal transduction and hence believed to play a major role in seizure propagation. The three pivotal placebo-controlled trials of adjunctive perampanel demonstrated that the effective dosing range is 4–12 mg/day. The drug can be prescribed once daily, and its adverse effect profile is minimal with dizziness, fatigue, headache, and somnolence being the most commonly reported.

Conclusions

Perampanel is a welcome addition as it represents an alternative approach in the management of epilepsy with potential to have a significant impact on the prognosis of intractable epilepsy. However, it has only recently been licensed for clinical use in Europe, the USA, and Canada, and there are no data directly comparing it with other AEDs; hence, it remains far too early to ascertain its place in the treatment of patients with partial epilepsy.

Epilepsy in Sweden: health care costs and loss of productivity--a register-based approach

PURPOSE

The objective was to estimate health care costs and productivity losses due to epilepsy in Sweden and to compare these estimates to previously published estimates.

METHODS

Register data on health care utilisation, pharmaceutical sales, permanent disability and mortality were used to calculate health care costs and costs that accrue due to productivity losses. By linkage of register information, we were able to distinguish pharmaceuticals prescribed against epilepsy from prescriptions that were prompted by other indications.

RESULTS

The estimated total cost of epilepsy in Sweden in 2009 was <euro>441 million, which corresponds to an annual per-patient cost of <euro>8,275. Health care accounted for about 16% of the estimated total cost, and drug costs accounted for about 7% of the total cost. The estimated health care cost corresponded to about 0.2% of the total health care cost in Sweden in 2009. Indirect costs were estimated at <euro>370 million, 84% of which was due to sickness absenteeism. Costs resulting from epilepsy-attributable premature deaths or permanent disability to work accounted for about 1% of the total indirect cost in Sweden in 2009.

DISCUSSION

The per-patient cost of epilepsy is substantial. Thus, even though the prevalence of the illness is relatively small, the aggregated cost that epilepsy incurs on society is significant.

Prevalence and clinical characteristics of epilepsy in the South of Spain

PURPOSE

Epilepsy is a common neurological disorder found in all societies. There are extensive epidemiologic studies of different European areas. However, not much information about the South-West of Europe exists. In Málaga, Health Care is free and there are only two public hospitals with Neurological Services that assist Eastern or Western areas depending on the case. The purpose is to estimate the epidemiology in Málaga through a hospital-based study and compare it to the other European studies.

METHODS

Review on the hospital data base and gathering of consecutive patients with a diagnosis of active epilepsy served by the Epilepsy outpatient clinic in Virgen de la Victoria Hospital throughout a year.

RESULTS

2 281 patients fulfilled the criteria and 515 patients were recruited in order to study the epidemiologic characteristics. Male gender and focal onset seizures predominate (75.5%). Medium age 40. 58% of patients have been seizure-free in the last year. Known etiology in half of the patients. 54% of patients are treated with monotherapy. Valproic acid is the commonest drug. Other epidemiologic and demographic important data are provided. Data are analysed and compared to other European studies.

CONCLUSIONS

Prevalence rate in Western Málaga is 4.79 cases/1000 inhabitants. Characteristics of the sample are similar to those of other European studies. Although this is a hospital-based study, the particular characteristics of the Health Care System in our region enable us to gather real data concerning epidemiology and prevalence.

Clinical characteristics and use of antiepileptic drugs among adolescents with uncomplicated epilepsy at a referral center in Novi Sad, Serbia

The study aimed to investigate the type and etiology of epileptic seizures and the use of antiepileptic drugs for the treatment of various forms of epileptic seizures among adolescents with active but uncomplicated epilepsy at a tertiary referral center in Novi Sad, Serbia. The study design was cross sectional. Data were obtained from patients and medical records. A total of 103 adolescents (39 males and 64 females) with active but uncomplicated epilepsy were included. Patients with primary generalized seizures had significantly better control of epilepsy than those with partial seizures with or without secondary generalization. A total of 80 (77.7%) adolescents had no known underlying etiology based on initial diagnosis and evaluation. All adolescents were classified into known idiopathic syndromes (54.4%), non-classifiable cryptogenic etiology (23.3%), and secondary epilepsy attributed to MRI-identified lesions (22.3%). Eighty-eight percent of adolescents were taking monotherapy and 64.8% of these were taking valproate. New antiepileptic drugs (AEDs), topiramate and lamotrigine, the only drugs available free of charge at the Serbian market, were used in 19.4% of patients. A total of 57.3% adolescents were seizure-free, 24.2% had occasional seizures, and 18.5% had seizures despite AED treatment.

The prevalence and demographic distribution of treated epilepsy: a community-based study in Tasmania, Australia

OBJECTIVES

To estimate the prevalence and demographic distribution of treated epilepsy in a community-based population.

MATERIALS & METHODS

We surveyed all residents in Tasmania, Australia, who were supplied at least one antiepileptic drug prescription between July 1, 2001 and June 30, 2002, recorded on the national prescription database. We adjusted for the effect of disease-related non-response bias by imputation methods.

RESULTS

After three mail contacts, 54.0% (4072/7541) responded, with 1774 (43.6%) indicating treatment for epilepsy, representing 86.0% of the estimated total possible cases in Tasmania. The adjusted treated epilepsy prevalence was 4.36 per 1000 (95% CI 4.34, 4.39); lower in women (prevalence ratio 0.92 (95% CI 0.84, 1.00)); greater with increasing age (P < 0.001); similar in the three main geographic regions; and similar with socioeconomic status of postcode of residence.

CONCLUSIONS

Although our estimates are likely to be affected by access to health services, overall treated epilepsy prevalence of 4.4 per 1000 is similar to previous studies. Our finding of high elderly prevalence has been reported in a few recent studies in developed countries and has important clinical and public health implications in populations with similar aging demographics.

Cost of disorders of the brain in Europe 2010

BACKGROUND

The spectrum of disorders of the brain is large, covering hundreds of disorders that are listed in either the mental or neurological disorder chapters of the established international diagnostic classification systems. These disorders have a high prevalence as well as short- and long-term impairments and disabilities. Therefore they are an emotional, financial and social burden to the patients, their families and their social network. In a 2005 landmark study, we estimated for the first time the annual cost of 12 major groups of disorders of the brain in Europe and gave a conservative estimate of €386 billion for the year 2004. This estimate was limited in scope and conservative due to the lack of sufficiently comprehensive epidemiological and/or economic data on several important diagnostic groups. We are now in a position to substantially improve and revise the 2004 estimates. In the present report we cover 19 major groups of disorders, 7 more than previously, of an increased range of age groups and more cost items. We therefore present much improved cost estimates. Our revised estimates also now include the new EU member states, and hence a population of 514 million people.

AIMS

To estimate the number of persons with defined disorders of the brain in Europe in 2010, the total cost per person related to each disease in terms of direct and indirect costs, and an estimate of the total cost per disorder and country.

METHODS

The best available estimates of the prevalence and cost per person for 19 groups of disorders of the brain (covering well over 100 specific disorders) were identified via a systematic review of the published literature. Together with the twelve disorders included in 2004, the following range of mental and neurologic groups of disorders is covered: addictive disorders, affective disorders, anxiety disorders, brain tumor, childhood and adolescent disorders (developmental disorders), dementia, eating disorders, epilepsy, mental retardation, migraine, multiple sclerosis, neuromuscular disorders, Parkinson's disease, personality disorders, psychotic disorders, sleep disorders, somatoform disorders, stroke, and traumatic brain injury. Epidemiologic panels were charged to complete the literature review for each disorder in order to estimate the 12-month prevalence, and health economic panels were charged to estimate best cost-estimates. A cost model was developed to combine the epidemiologic and economic data and estimate the total cost of each disorder in each of 30 European countries (EU27+Iceland, Norway and Switzerland). The cost model was populated with national statistics from Eurostat to adjust all costs to 2010 values, converting all local currencies to Euro, imputing costs for countries where no data were available, and aggregating country estimates to purchasing power parity adjusted estimates for the total cost of disorders of the brain in Europe 2010.

RESULTS

The total cost of disorders of the brain was estimated at €798 billion in 2010. Direct costs constitute the majority of costs (37% direct healthcare costs and 23% direct non-medical costs) whereas the remaining 40% were indirect costs associated with patients' production losses. On average, the estimated cost per person with a disorder of the brain in Europe ranged between €285 for headache and €30,000 for neuromuscular disorders. The European per capita cost of disorders of the brain was €1550 on average but varied by country. The cost (in billion €PPP 2010) of the disorders of the brain included in this study was as follows: addiction: €65.7; anxiety disorders: €74.4; brain tumor: €5.2; child/adolescent disorders: €21.3; dementia: €105.2; eating disorders: €0.8; epilepsy: €13.8; headache: €43.5; mental retardation: €43.3; mood disorders: €113.4; multiple sclerosis: €14.6; neuromuscular disorders: €7.7; Parkinson's disease: €13.9; personality disorders: €27.3; psychotic disorders: €93.9; sleep disorders: €35.4; somatoform disorder: €21.2; stroke: €64.1; traumatic brain injury: €33.0. It should be noted that the revised estimate of those disorders included in the previous 2004 report constituted €477 billion, by and large confirming our previous study results after considering the inflation and population increase since 2004. Further, our results were consistent with administrative data on the health care expenditure in Europe, and comparable to previous studies on the cost of specific disorders in Europe. Our estimates were lower than comparable estimates from the US.

DISCUSSION

This study was based on the best currently available data in Europe and our model enabled extrapolation to countries where no data could be found. Still, the scarcity of data is an important source of uncertainty in our estimates and may imply over- or underestimations in some disorders and countries. Even though this review included many disorders, diagnoses, age groups and cost items that were omitted in 2004, there are still remaining disorders that could not be included due to limitations in the available data. We therefore consider our estimate of the total cost of the disorders of the brain in Europe to be conservative. In terms of the health economic burden outlined in this report, disorders of the brain likely constitute the number one economic challenge for European health care, now and in the future. Data presented in this report should be considered by all stakeholder groups, including policy makers, industry and patient advocacy groups, to reconsider the current science, research and public health agenda and define a coordinated plan of action of various levels to address the associated challenges.

RECOMMENDATIONS

Political action is required in light of the present high cost of disorders of the brain. Funding of brain research must be increased; care for patients with brain disorders as well as teaching at medical schools and other health related educations must be quantitatively and qualitatively improved, including psychological treatments. The current move of the pharmaceutical industry away from brain related indications must be halted and reversed. Continued research into the cost of the many disorders not included in the present study is warranted. It is essential that not only the EU but also the national governments forcefully support these initiatives.

The descriptive epidemiology of epilepsy-a review

Epilepsy is a chronic disease experienced by millions and a cause of substantial morbidity and mortality. This review summarizes prevalence and incidence studies of epilepsy that provided a clear definition of epilepsy and could be age-adjusted: requirements if comparisons across studies are to be made. Although few exceptions, age-adjusted prevalence estimates from record-based studies (2.7-17.6 per 1000), are lower than those from door-to-door surveys (2.2-41.0 per 1000). Age-adjusted incidence ranged from 16 to 51 per 100,000, with one exception in Chile, where incidence was 111 per 100,000. Variation in reported prevalence and incidence may be related to factors such as access to health care, regional environmental exposures, or socioeconomic status. A higher proportion of epilepsy characterized by generalized seizures was reported in most prevalence studies. Epilepsy characterized by partial seizures accounted for 20-66% of incident epilepsies. Virtually all prevalence and incidence studies report a preponderance of seizures of unknown cause. Additional prevalence studies are needed in regions where data does not exist, and additional incidence studies in all regions. Interpretation of differences in prevalence and incidence will require understanding of the role of cultural, social and economic factors influencing epilepsy and its care.

Seizures in patients with multiple sclerosis: epidemiology, pathophysiology and management

Seizures have been recognized to occur in multiple sclerosis (MS) since early descriptions of the disease. Various studies have attempted to determine the incidence and prevalence of seizures in MS; although they differ in the reported prevalence, seizures do appear to be more common in MS cohorts than in the general population. The pathological underpinning of seizures in MS remains indeterminate. Cortical and subcortical demyelination and inflammation may explain the increased frequency of seizures in MS, although this hypothetical correlation remains to be proven. Management of seizures in MS is similar to the management of seizures in other patients. Consideration of the underlying neurological deficits related to MS may be necessary, and dosages of antiepileptic drugs should be adjusted if increased sensitivity to the adverse effects of these agents or interaction with other centrally acting medications is suspected. The prognosis of epilepsy in patients with MS remains uncertain, with some studies suggesting a more favourable prognosis than others.

The incidence rate of seizures in relation to BMI in UK adults

A retrospective cohort study using the data from The Health Improvement Network (THIN) database in the United Kingdom was conducted to examine the incidence rates of seizures across different BMI levels in the adult population aged > or = 18 years. Poisson regression was used to examine the relationship between BMI and seizures. The overall incidence rate of seizures was found to be 31.2 cases per 100,000 person-years. The incidence rate of seizures (cases per 100,000 person-years) in obese patients (BMI > or = 30 kg/m2) was 34.8 (95% confidence interval (CI), 23.1, 46.4), comparable to that in patients with normal weight (BMI between 18.5 and 24.9 kg/m2) (35.8, 95% CI (26.6, 44.9)). In contrast, underweight patients (< 18.5 kg/m2) or extremely obese (> or = 40 kg/m2) patients tended to have higher incidence rates than those with normal weight. After adjustment for age, gender, and smoking status, compared to patients with normal weight, those who were underweight or extremely obese had a rate ratio (RR) for seizures of 1.6 (95% CI (0.7, 3.8)) and 1.7 (95% CI (0.7, 3.9)), respectively. To date, we have not found any study that examines the associations between BMI or obesity and seizures. In this study, the incidence rates of seizures in the extremely obese and underweight patients tended to be higher than that in the normal-weight patients.

Estimating the cost of epilepsy in Europe: a review with economic modeling

PURPOSE

Based on available epidemiologic, health economic, and international population statistics literature, the cost of epilepsy in Europe was estimated.

METHODS

Europe was defined as the 25 European Union member countries, Iceland, Norway, and Switzerland. Guidelines for epidemiological studies on epilepsy were used for a case definition. A bottom-up prevalence-based cost-of-illness approach, the societal perspective for including the cost items, and the human capital approach as valuation principle for indirect costs were used. The cost estimates were based on selected studies with common methodology and valuation principles.

RESULTS

The estimated prevalence of epilepsy in Europe in 2004 was 4.3-7.8 per 1,000. The estimated total cost of the disease in Europe was euro15.5 billion in 2004, indirect cost being the single most dominant cost category (euro8.6 billion). Direct health care costs were euro2.8 billion, outpatient care comprising the largest part (euro1.3 billion). Direct nonmedical cost was euro4.2 billion. That of antiepileptic drugs was euro400 million. The total cost per case was euro2,000-11,500 and the estimated cost per European inhabitant was euro33.

CONCLUSIONS

Epilepsy is a relevant socioeconomic burden at individual, family, health services, and societal level in Europe. The greater proportion of such burden is outside the formal health care sector, antiepileptic drugs representing a smaller proportion. Lack of economic data from several European countries and other methodological limitations make this report an initial estimate of the cost of epilepsy in Europe. Prospective incidence cost-of-illness studies from well-defined populations and common methodology are encouraged.

Epileptic Automatisms in the Criminal Courts: 13 Cases Tried in England and Wales between 1975 and 2001

OBJECTIVES

To explore the relationship of epilepsy and criminal behavior.

METHODS

Case series based on all criminal cases found "not guilty by reason of insanity" (NGRI) because of epilepsy in England and Wales between 1975 and 2001. Data were extracted from medico-legal reports held by the Mental Health Unit at the Home Office and the Department for Constitutional Affairs in London, UK.

RESULTS

Thirteen cases were identified, accounting for 7.3% of all verdicts of NGRI. Charges included murder (1), attempted murder (1) assault (7), arson (2), abduction/kidnapping (3), and burglary (1). Of the defendants, 92.3% were male, 76.9% had neuropsychological impairments, 84.6%% had psychiatric comorbidity, 92.3% were unemployed at the time of the offence, and 69.2% had been convicted of criminal offences previously. Eight of 10 defendants treated with antiepileptic drugs were complying poorly with medication. A total of 61.5% offenses were committed in a state of alcohol intoxication. Psychotic symptoms may have been present when the offense was committed in 52.8% of cases. Over two-thirds of offenses probably occurred during the postictal period.

CONCLUSIONS

This case series suggests that it is exceptional for epileptic seizures to cause criminal acts or omissions. The relatively low standard of proof required means that some of cases found NGRI on account of epilepsy were not actually related to seizures. There were no definite examples of ictal criminal behavior. Most offenses related to seizures are likely to have occurred in the postictal phase.

Prevalence of epilepsy in Croatia: a population-based survey

OBJECTIVES

To investigate the prevalence of active epilepsy in Croatia.

MATERIAL AND METHODS

Patient data collected by means of questionnaires completed by primary healthcare physicians; epilepsy was previously confirmed in the patients by neurologists or neuropaediatricans.

RESULTS

One hundred and twenty-seven of 180 (71%) physicians provided the requested information. The total sample was 212 069 people and of these 1022 had active epilepsy. Prevalence rates (per 1000) for the following age-groups were: age 0-7: 3.5; age 8-18: 6.4; age 19-45: 5.0; age 46-65: 4.7; age >65: 4.4. The age-adjusted prevalence rates for the standard populations were 4.9/1000 (European population) and 5.0/1000 (WHO world population). Fifty-one physicians (29%) stated only the number of patients they considered as having active epilepsy but without the requested details. If their patients were also included, the estimated crude prevalence rate would be 5.5/1000.

CONCLUSIONS

It is likely that the prevalence of active epilepsy in Croatia is between 4.8 and 5.5/1000; this is in keeping with findings from other European countries.

Prescribing patterns of antiepileptic drugs in Italy: a nationwide population-based study in the years 2000-2005

To evaluate prevalence of use and prescribing patterns of antiepileptic drugs (AEDs) in Italian general practice. Primary care data were obtained from the Health Search Database, a longitudinal observational database implemented by the Italian College of General Practitioners (GPs). We selected 465 061 subjects registered by the end of 2005 in the lists of 320 GPs, homogeneously distributed throughout Italy. Prevalence of AED use was assessed in the entire sample and by drug type, age group, year and main geographic area (north, centre and south/islands). Overall, 24 383 subjects (5.2%) received at least one AED prescription in the study period. Prevalence of AED use (with 95% confidence interval) increased progressively from 7.1 (6.9-7.3) in 2000 to 11.8 (11.5-12.1) in 2005 for old AEDs and from 1.1 (1.0-1.2) to 12.2 (11.9-12.5) for new AEDs. Carbamazepine, phenobarbital and valproic acid were the most common AEDs until 2003, when gabapentin became first. There were no differences in prescribing patterns in the three main geographic areas. Newer AEDs were mostly used in patients aged 65 years and older. The more widespread use of newer AEDs was for mood disorders or pain. Older AED currently remain first line drugs for epileptic disorders. An increasing use of AEDs has been recently observed over a 6-year period in Italian general practice, mostly explained by newer compounds used for conditions other than epilepsy.

Trends in utilization of antiepileptic drugs in Denmark

OBJECTIVES

To describe utilization of antiepileptic drugs (AEDs) in Denmark during 1993-2002, with special emphasis on oxcarbazepine, and to assess probable indications for AED use.

MATERIALS AND METHODS

We retrieved prescription data from Odense University Pharmacoepidemiological Database, in Funen County, Denmark (population in 2002: 472,869). Within each calendar year we estimated period prevalence, incidence rate and monotherapy rate. Based on co-medication we defined 'epilepsy' when only AEDs were prescribed, 'pain' with co-prescription of opioids, and 'mood disorder' with co-prescription of antipsychotics or antidepressants.

RESULTS

We identified 15,604 AED users. The prevalence of using AED increased from 9.3 (95% CI, 9-9.5) to 12.1 (11.8-12.4)/1000 persons. The incidence rate increased from 1.4 (1.3-1.6) to 1.7 (1.6-1.9)/1000 personyears. The monotherapy rate was 79-82%. AED use for 'epilepsy' declined by 19.7%, whereas the proportion of 'pain' and 'mood disorder' treatment increased by 11.2% and 8.4% respectively.

CONCLUSIONS

Antiepileptic drug utilization increased during the study period, the increase probably caused by expanding use in areas other than epilepsy.

Use of antiepileptic drugs in Estonia: an epidemiologic study of adult epilepsy

An evaluation of general antiepileptic treatment patterns and utilization of particular drugs was carried out based on the prevalence study of adult active epilepsy in a sample of the Estonian population. The antiepileptic drugs (AEDs) used, and their doses were recorded and compared with clinical characteristics. Nineteen per cent of the subjects did not take any AED on the prevalence day; 83% of those on medication were taking a single drug, 15% two, and 2% three AEDs. Localization-related symptomatic epilepsies were most frequently treated with AEDs and were also the largest group receiving polytherapy. The most common agent was carbamazepine (68%), followed by barbiturates. Valproate and phenytoin were used much less. The study design and its impact on the interpretation of results is discussed. The percentage of sodium-channel blockers is generally comparable with that reported from other European countries. The small share of valproate is probably a result of the extensive utilization of barbiturates, and is partially related to the age distribution in the study. The high figure of AED-free cases, and small percentage of polytherapy indicates a tendency for undertreatment. Some points for improvement in AED therapy are discussed.

Prevalence and Characteristics of Epilepsy in the Aeolian Islands

PURPOSE

To estimate the prevalence and define the clinical characteristics of epileptic disorders in the 13,431 residents of the Sicilian Aeolian archipelago, on June 1, 1999.

METHODS

All established or suspected cases were identified by the neurologists of our working group from available medical information sources. Possible epilepsy cases were then evaluated by the epileptologists by using a standardized questionnaire. The patients were further reviewed by the whole research team to confirm the clinical diagnosis. For a more detailed syndromic definition, some patients underwent EEG or neuroradiologic investigations or both.

RESULTS

The crude point prevalence rate of active epilepsy was 3.13 (95% confidence interval, 2.2-4.2). The prevalence rate age-adjusted to the 2001 Italian population was 3.01. Females had a slightly higher prevalence rate than did males. The highest age-specific prevalence was found in patients aged 5 to 14 years (5.05) and in those aged 65 to 74 years (5.41). Partial seizures with or without secondary generalization were more common (61.7%) than were generalized seizures. Eighty-three percent of cases had symptomatic or cryptogenic localization-related epilepsies, and 8.5% had idiopathic (generalized or partial) epilepsies. Epilepsy was unclassified in 8.5% of cases.

CONCLUSIONS

The prevalence of active epilepsy in the Aeolian islands is lower than that in other developed areas, including northern Italy, but is similar to that in Sicily. Partial seizures were the most common type, and localization-related symptomatic epilepsies were the largest syndromic category.

The epidemiology of epilepsy in Europe - a systematic review

Population-based epidemiological studies on epilepsy are available mainly from the UK and the Nordic, Baltic and western Mediterranean countries. No studies were identified from large areas of Europe, especially from the former eastern Europe (except the Baltic countries) and the eastern Mediterranean countries. Based on the prevalence of epilepsy in different studies and accounting for incomplete case identification the estimated number of children and adolescents in Europe with active epilepsy is 0.9 million (prevalence 4.5-5.0 per 1000), 1.9 million in ages 20-64 years (prevalence six per 1000) and 0.6 million in ages 65 years and older (prevalence seven per 1000). Approximately 20-30% of the epilepsy population have more than one seizure per month. Based on the age-specific incidence rates in European studies, the estimated number of new cases per year amongst European children and adolescents is 130,000 (incidence rate 70 per 100,000), 96,000 in adults 20-64 years (incidence rate 30 per 100,000) and 85,000 in the elderly 65 years and older (incidence 100 per 100,000). The proportion of both new and established cases with epilepsy in the young, adults and elderly in individual countries may differ substantially from total European distribution because of differences in age structure.

Epilepsy in the United Kingdom: seizure frequency and severity, anti-epileptic drug utilization and impact on life in 1652 people with epilepsy

OBJECTIVES

To describe the clinical characteristics of epilepsy in a representative sample of the UK population, including seizure frequency and severity; overall severity of epilepsy; patterns of anti-epileptic drug (AED) use; and the impact of epilepsy on patients' lives. Secondly, to determine if these characteristics differ according to age.

METHOD

A large, geographically comprehensive survey of people with epilepsy by means of a postal questionnaire distributed by general practitioners to 3455 unselected patients receiving AEDs for epilepsy, regardless of age or type of epilepsy and including all regions of the UK. Data were collected on age and gender; age of onset of seizures; seizure frequency and severity; AED use and adverse effect levels; and impact on life of epilepsy. Sub-analyses were performed with stratification by epilepsy severity and age-group.

RESULTS

There were 1652 completed replies. The mean age was 44.2 years; there were 47.2% males, 48.5% females (4.4% not recorded). The mean age at first seizure, 25.1 years, and the mean duration of epilepsy, 19.7 years, were comparable with previous studies. In the preceding one year, 51.7% of patients had no seizures; 7.9% one seizure, 17.2% 2-9 seizures and 23.2% 10 or more. Sixty-four percent of patients had epilepsy classified as mild and 32% severe. There was a marked and significant decrement of seizure frequency with increasing age. The most commonly used AEDs were carbamazepine (37.4%), valproate (35.7%), phenytoin (29.4%), phenobarbitone or primidone (14.2%) and lamotrigine (10.3%). Monotherapy was used in 68% of patients. Patients taking multiple AEDs reported significantly higher levels of adverse effects and worse seizure control. The major impacts of epilepsy on life were work and school difficulties, driving prohibition, psychological and social life. The impacts listed varied with the epilepsy severity and age.

CONCLUSIONS

Seizures remain uncontrolled in up to half of all people with epilepsy in the UK with significant impact on work, family and social life. Previously, there has been a deficiency of data on the characteristics of epilepsy in older people, although it is recognized that the condition is of increasing epidemiological importance in this age group. We have found clear differences in the clinical characteristics of epilepsy in older people, particularly that seizure frequency appears to decline with increasing age.

ILAE Commission of European Affairs Subcommission on European Guidelines 1998-2001: The provision of epilepsy care across Europe

PURPOSE

To assess the needs and resources available in the provision of basic epilepsy care across Europe.

METHODS

A mailed questionnaire was used, the European Epilepsy Services inventory (EESI). The EESI was distributed to all 36 European chapters of the International League Against Epilepsy (ILAE), and answers were obtained from 32, a response rate of 89%. For the purpose of studying trends across Europe, the chapters were divided into a Western, an Eastern, a Central, and a Southern group.

RESULTS

The survey results showed that there was a wide range in the number of physicians and specialists involved in epilepsy care across Europe, with a trend toward higher numbers of neurologists, pediatricians, and pediatric neurologists in Eastern Europe. Many different specialties were involved in epilepsy care, and many chapters reported differences in the provision of care across their countries, with less possibility for patients to see a specialist in the least provided areas, where most epilepsy patients were cared for by general practitioners and internists. Problems with high costs of the newer antiepileptic drugs were most pronounced in Eastern Europe. Problems with lack of comprehensive care and of epilepsy specialists, with stigma and social problems, and with insufficient professional education and knowledge about epilepsy were reported all across Europe.

CONCLUSIONS

Knowledge about differences in the pattern of provision of epilepsy care and about the main problems encountered by the European ILAE chapters is of importance in the continuing efforts to improve management of epilepsy all over Europe.

Overtreatment in adults with epilepsy

Overtreatment of epilepsy patients is traditionally associated with the use of polytherapy, i.e. use of more than one antiepileptic drug (AED). Although monotherapy is now being used in 70% of patients with epilepsy, these patients are also at risk at being overtreated. Ten to 20% of patients withdraw from their first drug because of adverse effects. This is partly related to high starting dosages and fast titration rates. The conventional AEDs are still first choice monotherapy drugs, although they potentially have more adverse effects, especially in the elderly. Other problems are the random selection of second or third choice drugs and the uncertainty about when to switch to polytherapy. Several authors have suggested that patients with progressive forms of epilepsy, such as patients with mesiotemporal sclerosis, should be treated adequately as soon as possible and that epilepsy surgery should be considered for them in a much earlier stage. Overtreatment in polytherapy is still a large threat, due to several reasons: drug loads are much higher, and thus more adverse effects are likely to develop; drug combinations are selected randomly, as evidence about effective combinations has been scarce; the constant choice between continuing the existing treatment (which is suboptimal) and trying new drugs (which may disturb a patient's equilibrium); the long-term use of benzodiazepines.

Global Campaign Against Epilepsy:the treatment gap

A simple definition of the treatment gap is the number of people with a condition or disease who need treatment for it but who do not get it. It is an underutilised measure of health care. In epilepsy, it has been estimated by the direct method, during prevalence studies, and indirectly from the amount of antiepileptic drugs consumed in the country and the number of people with active epilepsy. The treatment gap in epilepsy is very high in the developing world. Possible causes of the treatment gap have been listed, but these have not been investigated.

Prevalence of childhood epilepsy in Kaunas, Lithuania

The prevalence of epilepsy in children aged 0-15 years of Kaunas city, Lithuania, was evaluated on 1 January 1995. Multiple sources for case identification were used, i.e. medical records at the university hospital, regional outpatient clinics and consultation centres, institutions, schools and kindergartens for the handicapped. Active epilepsy was defined as two or more unprovoked epileptic seizures with at least one seizure occurring within the previous 5 years, regardless of the antiepileptic drug treatment. Prevalence was found to be 4.25 (3.42, if age-standardized) in 1000. The highest rate was found in the 10-14 years age group. The male/female ratio was 1.29. No possible causes could be determined in 60.3% of cases. Congenital causes were diagnosed in 18.8% of cases, perinatal causes in 15.3%, traumatic causes in 2.6% and neuroinfectious causes in 2.4%. Classification of epilepsies and epileptic syndromes [Commission on Classification and Prognosis of the International League Against Epilepsy. Proposal for revised classification of epilepsies and epileptic syndromes. Epilepsia 1989; 30:389-399] revealed that 50% of cases were localization-related epilepsies, 29.9% were generalized epilepsies, 15.9% were undetermined whether partial or generalized and 4.2% were unclassifiable. Rates for idiopathic, symptomatic and cryptogenic cases are presented.

Dispensing epilepsy medication: a method of determining the frequency of symptomatic individuals with seizures

We estimated the prevalence and incidence of epilepsy in The Netherlands using drug-dispensing information from the PHARMO database, containing medication histories of nearly 300,000 individuals. An algorithm based on antiepileptic drug prescription records was used to identify patients with epilepsy requiring medication for seizure control. The algorithm was validated by comparing positive algorithm identifications to medical diagnoses from general practitioners and hospital records. In 1990-1991, the algorithm revealed 1158 patients with "certain" epilepsy, and 451 patients with "probable" epilepsy. Epilepsy was present in 93% of patients on polytherapy, and 58% on monotherapy. Clonazepam monotherapy was non-specific for epilepsy. The use of carbamazepine monotherapy for epilepsy was age-dependent. After correcting the algorithm for these drugs, and standardizing to the Dutch population, the point prevalence of epilepsy was 4.8/1000 (95% CI: 4.5-5.0). The incidence rate was 0.72/1000 person-years (95% CI: 0.65-0.79). Using drug-dispensing data for epilepsy medication, it is possible to make valid estimations of the number of epilepsy patients requiring drug therapy.

Usefulness of prolonged video-EEG monitoring in the elderly

The diagnosis of epilepsy in the elderly can be difficult. We sought to determine whether video-EEG monitoring (VEEG) is useful in the diagnosis and management of elderly patients with epilepsy. We reviewed the medical records of 20 consecutive patients, over 60 years of age, selected from a total of 1423 patients referred over a five year period for VEEG evaluation for epilepsy. The usefulness of VEEG was assessed by comparing changes in (a) the diagnosis and treatment of these patients before and after VEEG, and (b) the assessments made by an epileptologist who reviewed medical records before and after receiving results of VEEG. Compared to the initial diagnosis by the referring physician, VEEG resulted in changes in either the diagnosis or treatment in 11/20 patients based on the results of VEEG. The epileptologist was able to correctly assess the diagnosis and treatment of 16/20 patients without knowledge of the VEEG results. In 4/20 cases, the VEEG provided additional information to the epileptologist. In selected elderly patients, VEEG is useful in establishing the diagnosis of epilepsy, and may change the management of these patients.

Evaluation of epilepsy management in a developing country: a prospective study of 407 patients

407 patients (248 men, 159 women) of epilepsy attending the neurology clinic were evaluated to find out the profile of epilepsy, cost-effectiveness of various investigations, therapeutic regimens and efficacy of referring physicians in a developing country. At the time of onset of seizures 67.2% of patients were in the second and third decade. Generalised tonic clonic seizures were the commonest seizure type seen. Specific aetiology was established in 20.8% cases only. Neurocysticercosis was the commonest cause observed. The main source of referral (50.1%) was general practitioners. Referral diagnosis was incomplete in 52.8% of the cases. Investigations did not alter the diagnosis in 62.5% cases. The EEG was useful in the management of 15.1% cases of epilepsy. The skull x-ray and chest x-ray were abnormal in 1.7% and 2% cases respectively. CT scan revealed abnormality in 39.4% cases. Most of the patients were treated with monotherapy. Phenytoin, phenobarbitone and carbamazepine were the common drug used. Out of 246 cases who were started on anticonvulsant therapy prior to referral, the choice of drug was wrong in 78 (31.7%) cases and dose was inappropriate in 121 (49.2%) cases. It was concluded that most important factor for cost effective management of epilepsy is proper clinical evaluation and education of general physicians in this direction.

Prevalence and characteristics of epilepsy in children in northern Sweden

Active epilepsy was assessed in all children aged 0-16 years in an area of northern Sweden with about 250,000 inhabitants and around 50,000 children in the age group. One hundred and fifty-five children fulfilled the criteria of active epilepsy giving a prevalence rate of 4.2/1000. The proportion of boys to girls was 1:1.1. This dominance of girls had also been seen in a prospective study of incidence of epilepsy in the same area. Partial seizures were more common than generalized. Among the syndromes benign childhood epilepsy with centrotemporal spikes occurred in 17.4%, absence epilepsy in 6.5% and Lennox-Gastaut syndrome in 5.8%. Children with neurodeficit (ND) more often had generalized epileptic syndromes while the non-ND groups more often had localisation related syndromes. The aetiology was regarded to be remote symptomatic in 42%, idiopathic in 28% and cryptogenic in 30% of the children. Almost all children were on antiepileptic treatment, three quarters of them on monotherapy. Neurodeficit was noted in 42%. The prevalence of epilepsy and mental retardation was 1.7/1000. Relatively few children with neurodeficit had been seizure free during the last year, 43% had more than one seizures per month compared to 19% in the non-ND group.

Prevalence of epilepsy. A door-to-door survey in the Sicilian community of Riposto

In a door-to-door survey of common neurological disorders in Sicily (SNES Project), we administered a screening symptoms questionnaire and a brief neurological examination to detect epileptic patients. All of the subjects effectively resident in the community of Riposto on 1 November 1987 (prevalence day) were investigated (n = 9956). The subjects with a positive questionnaire or a previous diagnosis of epilepsy were extensively examined by a neurologist and then definitively classified for epilepsy by a panel of senior neurologists. The crude prevalence of active and non-active epilepsy was 3.21/1000; the prevalence of active epilepsy alone was 2.71/1000. Of the 27 active cases, sixteen were affected by generalized tonic-clonic seizures, four by absences and four by complex partial attacks. All except two were being treated with antiepileptic drugs, most with phenobarbital. Our prevalence rate is lower than that reported by most authors, but similar to the rates in other Sicilian communities.

Management and attitudes of epilepsy by a group of Sydney general practitioners

Previous surveys of general practitioners (GPs) have shown stereotypic attitudes and management of persons with epilepsy (PWE). We mailed a questionnaire to 107 GPs in the Sydney and Illawarra regions of Australia to evaluate changes in knowledge and management of epilepsy and attitudes of GPs toward PWE as compared with results of a similar study made 10 years previously. Most GPs referred patients with epilepsy to a neurologist for initial management in preference to initiating investigation and treatment themselves. GPs were very satisfied with their sharing of care with neurologists, but indicated their high level of dissatisfaction with other health care therapists because of impractical advice and lack of empathy. The GPs' objectives of continuing management were mainly to prevent seizures, monitor of medication and its effects, and reduce the impact of patients' epilepsy on their daily life. Although many GPs believed that PWE were more likely to have emotional and relationship problems, most also believed that such persons contribute equally to society and can have normal quality of life (QOL). Although the GPs prefer to use a neurologist for initial management of PWE, they see themselves as having a role in continuing care and providing psychosocial support. The stereotyped perceptions of GPs indicated in the previous study have improved, although in some respects they remain negative. This study offers an audit of the outcome of a decade of educational promotion regarding epilepsy.