Epileptology最新文献

Epilepsy is one of the commonest neurological conditions, estimated to affect over 60 million people worldwide, the majority of whom live in low and middle-income countries where access to medical treatment is limited. We consider some of the aspects and factors that underlie the epilepsy treatment gap (ETG), which is defined as the percentage of people with active epilepsy who are not being appropriately treated (either as a result of lack of access to treatment or of being on inadequate treatment) in a given population at a given time.

We examine some of the evidence of the relative impact of various cultural, demographic economic and logistical factors that are believed to be at the origin of the ETG in resource-poor settings. We contend that the high cost and subsequent poor availability of first line anti-epileptic drugs including phenobarbital in low and low-middle income (compared to high income countries), is a major determinant of the ETG in these countries. Until this issue is tackled, little progress in reducing the global ETG is likely to be made.

Introduction

Epilepsy as a chronic neurological disease imposes a substantial burden on individuals and society through the considerable use of health-care resources and the loss of productivity. The aim of this cross-sectional study was to quantify epilepsy-related costs in Germany and to identify cost-driving factors. In addition, we reviewed recent studies on costs of epilepsy and put the present results in an international perspective.

Patients and methods

Adult patients with epilepsy from 32 general practitioners, 6 neurologists and an epilepsy center were enrolled for a three months observation period in 2008. Data on socioeconomic status, course of epilepsy as well as direct and indirect costs were recorded using validated patient questionnaires and evaluated from the societal perspective.

Results

We enrolled 494 patients (232 male, 46.9%) with a mean age of 46.3±17.1 years (range 18–89 years). We calculated epilepsy-specific direct costs of €599 per patient per three months in the primary care sector and €1354 at the epilepsy outpatient clinic. Direct medical costs were mainly due to hospitalization (29.7% in primary care sector and 40.7% at epilepsy outpatient clinic of total direct costs) and anticonvulsants (29.0% and 36.8%). Indirect costs were estimated at €1486 per patient per three months in the primary care sector and €1971 at the epilepsy outpatient clinic. Indirect costs were mainly due to early retirement (39.0% and 49.6% of total indirect costs), unemployment (29.3% and 28.3%) and days off due to seizures (31.7% and 21.2%). Direct costs for AEDs and hospital treatment but not indirect costs were significantly higher in patients treated at the epilepsy center as compared to the primary care sector. Predictors of higher medication and total direct costs were active epilepsy, focal epilepsy syndromes, worse prognostic groups and higher seizure frequency.

Conclusion

Indirect costs remained higher than direct costs in this study conducted in primary care sector and at an epilepsy center in Germany. Our study and other recent studies with a top-down approach demonstrated hospitalization beside AED costs as an important direct cost factor.

The informed decision to stop anticonvulsant treatment in patients with prolonged seizure remission requires assessing the risk of seizure relapse and predisposing factors. Although the probability of remaining seizure-free after treatment discontinuation is about 70%, patients at greater risk for relapse include those still presenting abnormal EEG and/or a documented etiology of epilepsy. In addition, seizure outcome depends on the syndromic pattern. Even though these indicators may be strongly influential, the decision to withdraw or withhold treatment must be still individualized. In any patient, the decision to discontinue treatment should also take into account social aspects like driving license, job and leisure activities, emotional and personal factors, and adverse effects or drug interactions. Patients and caregivers should be informed of the benefits and the risks associated with treatment discontinuation and should be actively involved in the decision process.

Epilepsy is one of the commonest neurological disorders, estimated to affect more than 60 million people worldwide. In the majority of these patients, seizures can be effectively suppressed with antiepileptic drugs (AEDs). Still, a significant percentage of patients (estimated to exceed 40% in some studies) exhibit pharmacoresistance during the course of their frequently lifelong condition.

We review our current understanding of some of the many missing pieces that constitute the puzzle of pharmacoresistant epilepsy (PRE), which can be practically defined as failure to achieve seizure freedom following adequate trials of two tolerated and appropriately chosen AEDs. The complexity of PRE reflects the dynamic nature of the underlying disease biology and the multiplicity of mechanisms of drug resistance.

We summarize some of the known clinical predictors, patterns and causes of treatment failure and examine potential underlying pathophysiological mechanisms and implications for the development of future therapies

The purpose of this article is to highlight and discuss why valproate should be used with great caution, or whenever possible be avoided, in the treatment of young women. Valproate has been shown to cause polycystic ovary syndrome in a substantial proportion of young women if treatment is initiated before the age of 26. Furthermore, use of valproate during pregnancy has been associated with major congenital malformations in the offspring that are higher than after exposure to other antiepileptic drugs. Recent data have also shown that exposure to valproate in utero can adversely affect the cognitive development of the child. For these reasons, valproate is best avoided in the treatment of young women with epilepsy when other alternatives are available.