Forgetting to take antiseizure medications is associated with focal to bilateral tonic-clonic seizures, as revealed by a cross-sectional study

Barriers to Medication Adherence in People Living With Epilepsy

Background and Objectives

Epilepsy affects approximately 1.2% of the US population, resulting in 3.4 million Americans with active epilepsy. Antiseizure medication (ASM) is considered the mainstay of treatment, effective for two-thirds of people with epilepsy (PWE), while at least one-third experience drug-resistant epilepsy. A significant percentage of PWE who are treated with ASMs report nonadherence to this type of medication, leading to potentially preventable seizures and the potential for being inappropriately classified as having drug-resistant epilepsy. Ongoing seizures are associated with increased morbidity, mortality, and health care costs, among other consequences. Recognizing when PWE struggle with ASM adherence is essential for creating effective interventions and prevention strategies to improve patient outcomes.

Methods

As part of the Epilepsy Learning Healthcare System Registry, we collected data from 2020 through 2023 from 4,917 individuals seen at 8 epilepsy clinics in the United States. In this cross-sectional study, we used logistic regression analysis to examine the relationship between patient-reported seizure control (or provider-reported seizure control for some sites) and endorsed barriers to medication adherence. In addition, we explored potential associations with demographic variables such as sex, race, and ethnicity. The data analysis was conducted using R version 2023.06.1 + 524.

Results

Overall, 18.4% (893/4,848) reported adherence barriers and 37.7% (1,447/3,834) reported seizure control, defined as no seizures for the preceding 12 months or longer. The most prevalent barriers were forgetting to take ASMs (48.2%), experiencing ASM side effects (29.2%), and feeling as if the ASMs were not helping in controlling seizures (21.3%). The PWE who reported adherence barriers had 0.6 lower odds of having seizure control compared with those who did not report barriers (95% CI 0.4-0.7) and 0.6 lower odds of having seizure control after adjusting for race, ethnicity, and sex (95% CI 0.5-0.7).

Discussion

We observed significant barriers to medication adherence and inadequate seizure control among adult PWE across 8 centers in the United States. This study suggests that PWE might benefit from standardized screening for adherence barriers with behavioral strategies to address these barriers offered during clinical encounters to personalize care.

Multicentric study of adherence to antiseizure medications among adults with epilepsy attended in neurology departments in Burkina Faso

OBJECTIVE

To study the adherence of antiseizures medication in neurology in the city of Ouagadougou.

PATIENTS AND METHODS

We conducted a multicentric cross-sectional study on adherence to antiseizure medications among adult patients with epilepsy followed by outpatient neurology consultations. The patients were recruited from November 22, 2021 to February 22, 2022 in four departments of neurology. Adherence to antiseizure medications (ASM) was measured using the Morisky Medication Adhesion Scale (MMAS). Logistic regression analysis was used to investigate factors associated with adherence.

RESULTS

One hundred and seven patients with a mean age of 38.92 ± 16.06 years were included in the study. Most of the patients were men (52.34%). Twenty-eight patients complied well with ASM (26.17%). The main causes of nonadherence to treatment were forgetfulness and lack of financial means. Factors associated with nonadherence were rural residence (p = 0.023), celibacy or divorce (p = 0.002), low level of education (p = 0.028), perception of stigma (p = 0.026), duration of epilepsy <5 years (p = 0.009).

CONCLUSIONS

Adherence to ASM is low in Burkina Faso. The main causes of nonadherence were forgetting and insufficiency of financial resources. Rural residence, celibacy, or divorce, low level of education, perception of stigmatization, and short duration of epilepsy were associated with non-adherence.

PLAIN LANGUAGE SUMMARY

Studies on adherence to antiseizure medications are rare in Africa while patients do not have access to adequate treatment. The aim of our study was to evaluate the adherence to antiseizure medications among patients with epilepsy followed by the neurology departments in the city of Ouagadougou. Forgetfulness and financial insufficiency were the main causes of treatment interruption. Our study showed that most of the patients were non adherent. Several factors such as place of residence, level of education, and duration of epilepsy influence the level of compliance.

The seizure severity score: a quantitative tool for comparing seizures and their response to therapy

Objective.Epilepsy is a neurological disorder characterized by recurrent seizures which vary widely in severity, from clinically silent to prolonged convulsions. Measuring severity is crucial for guiding therapy, particularly when complete control is not possible. Seizure diaries, the current standard for guiding therapy, are insensitive to the duration of events or the propagation of seizure activity across the brain. We present a quantitative seizure severity score that incorporates electroencephalography (EEG) and clinical data and demonstrate how it can guide epilepsy therapies.Approach.We collected intracranial EEG and clinical semiology data from 54 epilepsy patients who had 256 seizures during invasive, in-hospital presurgical evaluation. We applied an absolute slope algorithm to EEG recordings to identify seizing channels. From this data, we developed a seizure severity score that combines seizure duration, spread, and semiology using non-negative matrix factorization. For validation, we assessed its correlation with independent measures of epilepsy burden: seizure types, epilepsy duration, a pharmacokinetic model of medication load, and response to epilepsy surgery. We investigated the association between the seizure severity score and preictal network features.Main results.The seizure severity score augmented clinical classification by objectively delineating seizure duration and spread from recordings in available electrodes. Lower preictal medication loads were associated with higher seizure severity scores (p= 0.018, 97.5% confidence interval = [-1.242, -0.116]) and lower pre-surgical severity was associated with better surgical outcome (p= 0.042). In 85% of patients with multiple seizure types, greater preictal change from baseline was associated with higher severity.Significance.We present a quantitative measure of seizure severity that includes EEG and clinical features, validated on gold standard in-patient recordings. We provide a framework for extending our tool's utility to ambulatory EEG devices, for linking it to seizure semiology measured by wearable sensors, and as a tool to advance data-driven epilepsy care.

Detecting Reasons for Nonadherence to Medication in Adults with Epilepsy: A Review of Self-Report Measures and Key Predictors

This review presents individual reasons for self-reported nonadherence in people with epilepsy (PWE). A literature search was performed on the PubMed/Medline and Scopus databases for studies published up to March 2022. Thirty-six studies were included using the following inclusion criteria: original studies on adults with epilepsy, use of subjective self-report adherence measurement methods, and publication in English. Data were extracted using a standardized data extraction table, including the year of publication, authors, cohort size, study design, adherence measurement method, and self-reported reasons for nonadherence. Self-reported reasons for nonadherence were grouped following the WHO model with the five dimensions of nonadherence. In addition, study characteristics and sociodemographic information are reported. Of the 36 included studies, 81% were observational. The average nonadherence rate was nearly 50%. Across all studies, patient-associated, therapy-associated, and circumstance-related factors were the most frequently reported dimensions of nonadherence. These factors include forgetfulness, presence of side-effects, and history of seizures. Regarding healthcare system factors, financial problems were the most reported reason for nonadherence. Stigmatization and quality of life were the most frequently cited factors influencing nonadherence in the disease- and circumstance-related dimensions. The results suggest that interventions for improving adherence should incorporate all dimensions of nonadherence.

Current Status and Future Objectives of Surgical Therapies for Epilepsy in Japan

This study investigated the number of epilepsy surgeries performed over time in Japan, and conducted a questionnaire survey of the Japan Neurosurgical Society (JNS) training program core hospitals to determine the current status and future objectives of surgical therapies and epilepsy training programs for physicians in Japan. This article presents part of a presentation delivered as a presidential address at the 44th Annual Meeting of the Epilepsy Surgery Society of Japan held in January 2021. The number of epilepsy surgeries performed per year has increased in Japan since 2011 to around 1,200 annually between 2015 and 2018. The questionnaire survey showed that 50% of the responding hospitals performed epilepsy surgery and 29% had an epilepsy center, and that these hospitals provided senior residents with education regarding epilepsy surgery. The presence of an epilepsy center in a hospital was positively correlated with the availability of long-term video electroencephalography monitoring beds as well as the number of epilepsy surgeries performed at the hospital. In regions with no medical facilities offering specialized surgical therapies for epilepsy, the JNS training program core hospitals may help improve epilepsy diagnosis and treatment. They may also increase the number of safe and effective surgeries by establishing epilepsy centers that can perform long-term video electroencephalography monitoring, providing junior neurosurgeons with training regarding epilepsy, and playing a core role in surgical therapies for epilepsy in tertiary medical areas in close cooperation with neighboring medical facilities.

Perampanel as first add-on antiseizure medication: Italian consensus clinical practice statements

Background

When use of a single antiseizure medication (ASM) fails to induce seizure remission, add-on therapy is justified. Perampanel (PER) is approved in Europe as adjunctive therapy for focal, focal to bilateral tonic-clonic seizures and generalized tonic-clonic seizures. Aim of the study was to establish whether PER is suitable for first add-on use.

Methods

A Delphi methodology was adopted to assess consensus on a list of 39 statements produced by an Expert Board of 5 epileptologists. Using an iterative process, statements were finalized by a Delphi Panel of 84 Italian pediatric and adult neurologists. Each statement was rated anonymously to determine level of agreement on a 9-point Likert scale. Consensus was established as agreement by at least 80% of the panelists. The relevance of each statement was also assessed on a 3-point scale.

Results

Consensus was achieved for 37 statements. Characteristics of PER considered to justify its use as first add-on include evidence of a positive impact on quality of life based on long term retention data, efficacy, tolerability, and ease of use; no worsening of cognitive functions and sleep quality; a low potential for drug interactions; a unique mechanism of action. Potential unfavorable factors are the need for a relatively slow dose titration; the potential occurrence of behavioral adverse effects; lack of information on safety when used in pregnancy; limited access to plasma PER levels.

Conclusion

Perampanel has many features which justify its use as a first add-on. Choice of an ASM as first add-on should be tailored to individual characteristics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02450-y.

Selection of antiseizure medications for first add-on use: A consensus paper

INTRODUCTION

When monotherapy used alone or sequentially fails to achieve seizure control, a trial of combination therapy may be considered.

OBJECTIVE

To define optimal criteria to guide choice of an antiseizure medication (ASM) for use as first add-on.

METHODS

A standardized Delphi procedure was applied to produce a list of consensus statements. First, an Expert Board consisting of 5 epileptologists agreed on a set of 46 statements relevant to the objective. The statements were then finalized through an iterative process by a Delphi Panel of 84 Italian pediatric and adult neurologists with expertise in the management of epilepsy. Panel members provided anonymous ratings of their level of agreement with each statement on a 9-point Likert scale.

RESULTS

Consensus, defined as agreement by at least 80% of Panel members, was reached for 36 statements. Medication-related factors considered to be important for drug selection included efficacy, tolerability and safety, interaction potential, mechanism of action, and ease of use. The need to optimize adherence and to tailor drug selection to individual characteristics was emphasized.

CONCLUSIONS

Choice of an ASM for first add-on requires consideration of many factors, many of which also apply to choose initial treatment. Factors more specifically relevant to add-on use include drug interaction potential and the preference for an ASM with a different mechanism of action.

Exploring factors associated with interictal heart rate variability in patients with medically controlled focal epilepsy

PURPOSE

Heart rate variability (HRV) reflects the balance between the functional outputs of the sympathetic and parasympathetic nervous systems. It is lower in patients with epilepsy than in the healthy controls. However, HRV has been inadequately studied in different patient subgroups with medically controlled epilepsy. Hence, this study aimed to investigate factors associated with interictal HRV in patients with medically controlled epilepsy.

METHODS

This retrospective cohort study included 54 patients (24 males and 30 females) with medically controlled focal epilepsy who only received monotherapy to eliminate the confounding effect of different antiseizure medications (ASMs). Patients with major systemic or psychiatric disorder comorbidities were excluded. For HRV analysis, electroencephalography and 5-minute well-qualified electrocardiogram segment recording were conducted during stage N1 or N2 sleep. In addition, the association between age, gender, seizure onset type, ASMs, and the time domain and frequency-domain HRV measures was analyzed.

RESULTS

HRV negatively correlated with advanced age. Patients with focal to bilateral tonic-clonic seizure (FBTCS) had a significantly lower HRV than focal impaired awareness seizures (FIAS). HRV was not associated with any gender and ASMs.

CONCLUSIONS

HRV negatively correlated with age, and patients with FBTCS had a decreased HRV. Thus, these patients may have a declining autonomic function. Therefore, different seizure types may carry different risks of autonomic dysfunction in patients with medically controlled focal epilepsy.

Use of extended-release and immediate-release anti-seizure medications with a long half-life to improve adherence in epilepsy: A guide for clinicians

Poor adherence to anti-seizure medications (ASMs) is associated with breakthrough seizures and potentially increased toxicity in patients with epilepsy. Extended-release (ER) drugs and immediate-release (IR) drugs with a long half-life (t_1/2) that permit once-daily dosing (such as, perampanel, zonisamide, lamotrigine [IR, ER] and topiramate [ER]) have a number of advantages over short t_1/2 ASMs that require multiple daily dosing. These advantages include simplification of dosing regimens, reduction in pill burden, and a decrease in the peak-to-trough fluctuations in serum drug concentration that may be associated with a decreased risk of adverse effects and seizures. Such properties have wider implications in improving patient adherence to treatment. This article is intended as a practical guide for clinicians that provides an overview of the features of ER ASMs and long t_1/2 IR ASMs that are advantageous in the context of patient adherence and pharmacokinetic "forgiveness" (after missing a dose). In addition, we note that efforts to improve adherence should not depend solely on drug dosing regimens and drug pharmacokinetics, but should be part of a wider strategy that includes therapeutic drug monitoring, improved healthcare provider-patient dialogue, patient education, and the use of "reminder" technology.