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|NI FEATURE: THE EDITORIAL DEBATE-- PROS AND CONS
|Year : 2016 | Volume
| Issue : 6 | Page : 1143-1144
Nationwide survey of the antiepileptic used: A much needed study but is it truly representative?
Department of Neurology, Institute of Neurology, Dr. MGR Medical University, Chennai, Tamil Nadu, India
|Date of Web Publication||11-Nov-2016|
Department of Neurology, Institute of Neurology, Dr. MGR Medical University, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Arjundas G. Nationwide survey of the antiepileptic used: A much needed study but is it truly representative?. Neurol India 2016;64:1143-4
The authors of the study “Demographic characteristics of epilepsy patients and antiepileptic drug utilization in adult patients: Results of a cross-sectional survey” need to be lauded for their effort in conducting this nation-wide study for evaluating the anticonvulsant medications being used by neurologists and physicians. The study represents a long needed effort to rationalize antiepileptic treatment in India and to develop specific guidelines based on feedback from multiple departments from all over the country. The number of doctors recruited for the study is also commendable. It is also indisputable that the wide recruitment from multiple states of India and the numerous doctors involved added value to the study. To conduct a study of this size in a vast country like India is certainly not an easy task.
The results presented, however, appear too simplistic and may not be truly representative of the actual medical subscription of anti-epileptic medications in the country. The levels of awareness and knowledge regarding newer anticonvulsants differ vastly among doctors all over the country. The practice of administration of newer anticonvulsants also varies significantly between general and private institutions. A small change in the proportion of doctors recruited from either of these centers will significantly influence the results. If more doctors are recruited from the cohort (for example, large corporate hospitals or postgraduate institutes) that prescribe newer anticonvulsants, then the results will be skewed towards the latter medication; whereas, if more doctors (including senior residents) are recruited from those general hospitals that mainly cater to poor patients, then a predisposition towards older anticonvulsant medication will be evident. It may be true that levetiracetam may be the medication of choice in the economically enabled epileptics, but certainly in most of the poor patients, often with a poor drug compliance, the older anticonvulsants are still the treatment of choice. Moreover, in most of the states, including in Tamil Nadu, the state in which I have been working, many of the patients avail free government treatment due to their socioeconomic status being below the poverty line. The anticonvulsant medications given free of cost in most of the government medical colleges are still phenytoin, phenobarbitone, and sodium valproate. As the authors have not made any mention of the type of institutions that the recruited doctors were working in, it is possible that this population of patients receiving free antiepileptic medication may have been missed.
Another point worth mentioning is that this paper does not address the knowledge gap that exists between doctors in major hospitals of the country and the poorly informed medical practitioners, who prescribe medicines in the far flung areas. None of the doctors in the latter group would even remotely think of adding a newer anticonvulsant medication like levetiracetam to their treatment regimen. It is highly unlikely that any of them would have been consulted for assessing their choice of anticonvulsants.
Another important point was that the adverse effects noted in the study were only 0.1% among all the anticonvulsants. There may be several reasons for this low figure. Record keeping among doctors of the country is extremely dismal and many adverse events may not have been recorded. Moreover, patients in India have a tendency to change doctors as soon as they experience any discomfort with the treatment regimen prescribed by one doctor. Recruitment from several large states of India also is extremely poor in the study in focus. It is also noteworthy that several of these poorly represented states have a large population living in remote areas served by doctors who are not even aware of the newer anticonvulsants and would certainly not be accessible to be recruited in this study. The cross-sectional nature of the study has restricted the duration of follow up to only 6 months. The precipitation of adverse reactions of most anticonvulsants may often take a longer time to appear. No mention has been made of patients who received multiple anticonvulsants. The newer anticonvulsants often form a part of the adjuvant therapy along with the primary therapy that includes the older anticonvulsants. The duration of follow up and whether or not the person assessing the outcome was suitably blinded to the initial treatment will also influence results. The dropout rate at follow up and the reasons for lack of reporting of his/her status by the patient have also not been addressed.
By reading this study, however, one gets the erroneous impression that patients in this country are very well-off and receiving the best treatment possible!
Therefore, the study is commendable in its intent but more ground work is needed to maintain heterogeneity of the sample size to be truly representative of the socioeconomic status and knowledge of the population of India before the conclusions of the study may be unequivocally accepted.
| » References|| |
Newale S, Bachani DS. Demographic characteristics of epilepsy patients and antiepileptic drug utilization in adult patients: Results of a cross-sectional survey. Neurol India 2016;64:1180-6.