The EpiPick algorithm to select appropriate antiseizure medications in patients with epilepsy: Validation studies and updates

The pharmacological treatment of epilepsy in adults

The pharmacological treatment of epilepsy entails several critical decisions that need to be based on an individual careful risk-benefit analysis. These include when to initiate treatment and with which antiseizure medication (ASM). With more than 25 ASMs on the market, physicians have opportunities to tailor the treatment to individual patients´ needs. ASM selection is primarily based on the patient's type of epilepsy and spectrum of ASM efficacy, but several other factors must be considered. These include age, sex, comorbidities, and concomitant medications to mention the most important. Individual susceptibility to adverse drug effects, ease of use, costs, and personal preferences should also be taken into account. Once an ASM has been selected, the next step is to decide on an individual target maintenance dose and a titration scheme to reach this dose. When the clinical circumstances permit, a slow titration is generally preferred since it is associated with improved tolerability. The maintenance dose is adjusted based on the clinical response aiming at the lowest effective dose. Therapeutic drug monitoring can be of value in efforts to establish the optimal dose. If the first monotherapy fails to control seizures without significant adverse effects, the next step will be to gradually switch to an alternative monotherapy, or sometimes to add another ASM. If an add-on is considered, combining ASMs with different modes of action is usually recommended. Misdiagnosis of epilepsy, non-adherence and suboptimal dosing are frequent causes of treatment failure and should be excluded before a patient is regarded as drug-resistant. Other treatment modalities, including epilepsy surgery, neuromodulation, and dietary therapies, should be considered for truly drug-resistant patients. After some years of seizure freedom, the question of ASM withdrawal often arises. Although successful in many, withdrawal is also associated with risks and the decision needs to be based on careful risk-benefit analysis.

Affordability of newer antiseizure medications in Asian resource-limited countries

OBJECTIVE

One of the objectives of the Intersectoral Global Action Plan on epilepsy and other neurological disorders for 2022 to 2031 is to ensure at least 80% of people with epilepsy (PWE) will have access to appropriate, affordable, and safe antiseizure medications (ASMs) by 2031. However, ASM affordability is a significant issue in low- and middle-income countries, preventing PWE from accessing optimal treatment. This study aimed to determine the affordability of the newer (second and third generation) ASMs in resource-limited countries in Asia.

METHODS

We conducted a cross-sectional survey by contacting country representatives in lower-middle-income countries (LMICs) in Asia, including Indonesia, Lao People's Democratic Republic (PDR), Myanmar, Philippines, Vietnam, India, Bangladesh, and Pakistan, and the upper-middle-income country Malaysia, from March 2022 to April 2022. The affordability of each ASM was calculated by dividing the 30-day ASM cost by the daily wage of the lowest paid unskilled laborers. Treatment costing 1 day's wage or less for a 30-day supply of chronic disease is considered affordable.

RESULTS

Eight LMICs and one upper-middle-income country were included in this study. Lao PDR had no newer ASM, and Vietnam had only three newer ASMs. The most frequently available ASMs were levetiracetam, topiramate, and lamotrigine, and the least frequently available was lacosamide. The majority of the newer ASMs were unaffordable, with the median number of days' wages for a 30-day supply ranging from 5.6 to 14.8 days.

SIGNIFICANCE

All new generation ASMs, whether original or generic brands, were unaffordable in most Asian LMICs.

Implementing WHO's Intersectoral Global Action Plan for epilepsy and other neurological disorders in Southeast Asia: a proposal

The World Health Assembly approved the Intersectoral Global Action Plan for epilepsy and neurological disorders. Member states, including those in Southeast Asia, must now prepare to achieve IGAP's strategic targets by embracing novel approaches and strengthening existing policies and practices. We propose and present evidence to support four such processes. The opening course should engage all stakeholders to develop people-centric instead of outcome-centric approaches. Rather than caring for convulsive epilepsy alone, as currently done, primary care providers should also be skilled in diagnosing and treating focal and non-motor seizures. This could reduce the diagnostic gap as over half of epilepsies present with focal seizures. Currently, primary care providers lack knowledge and skills to manage focal seizures. Technology-enabled aids can help overcome this limitation. Lastly, there is need to add newer "easy to use" epilepsy medicines to Essential Medicines lists in light of emerging evidence for better tolerability, safety and user-friendliness.

Big data analysis of ASM retention rates and expert ASM algorithm: a comparative study

Objective

Only 50% of patients with new‐onset epilepsy achieve seizure freedom with their first antiseizure medication (ASM). A growing body of data illustrates the complexity of predicting ASM response and tolerability, which is influenced by age, sex, and comorbidities. Randomized data with sufficient resolution for personalized medicine are unlikely to emerge. Two potential facilitators of ASM selection are big data using real‐world retention rates or algorithms based on expert opinion. We asked how these methods compare in adult‐onset focal epilepsy.

Methods

ASM retention rates were determined by cross‐referencing data from comprehensive Swedish registers for 37 643 individuals, with identified comorbidities. Eight fictive cases were created and expert advice was collected from the algorithm Epipick. We compared Epipick suggestions in representative patient subgroups, and determined whether ranking based on retention rate reflected expert advice.

Results

The Epipick algorithm suggested six ASM alternatives for younger patients and three ASM alternatives for older patients. In the real‐world data, retention rates for the ASMs ranked as best options by Epipick were high; 65%–72% for young patients and 71%–84% for older patients. The lowest retention rate for Epipick suggestions was 42%–56% in younger cases, and 70%–80% in older cases. The ASM with the best retention rate was generally recommended by Epipick.

Significance

We found a large overlap between expert advice and real‐world retention rates. Notably, Epipick did suggest some ASMs with more modest retention rates. Conversely, clearly inappropriate ASMs (not recommended by Epipick) had high retention rates in some cases, showing that decision systems should not rely indiscriminately on retention rates alone. In future clinical decision support systems, expert opinion and real‐world retention rates could work synergistically.