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Table of Contents    
COMMENTARY
Year : 2018  |  Volume : 66  |  Issue : 4  |  Page : 1060-1061

Epilepsy in India: Bridging the treatment gap


Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India

Date of Web Publication18-Jul-2018

Correspondence Address:
Malla Bhaskara Rao
Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.237003

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How to cite this article:
Rao MB. Epilepsy in India: Bridging the treatment gap. Neurol India 2018;66:1060-1

How to cite this URL:
Rao MB. Epilepsy in India: Bridging the treatment gap. Neurol India [serial online] 2018 [cited 2018 Nov 18];66:1060-1. Available from: http://www.neurologyindia.com/text.asp?2018/66/4/1060/237003




In order to cure or control epilepsy in a substantial number of people with epilepsy (PWE) in India, the following things need to be done; 1. An accurate estimate of the actual number of people with epilepsy (PWE), 2. Identification of the drug sensitive and drug resistant groups among the PWE, 3. Initiation and maintenance of monotherapy with first line anti-epileptic drugs, 4. Referral of people with drug resistant epilepsy (PWDRE) to comprehensive epilepsy care centres (CECC), 5. Initiation of life-style changes, rational poly-therapy as well as alternate methods, 6. Identification of people with surgically remediable lesional epilepsy syndromes by simple non-invasive evaluation and performing of standard surgical procedures, 7. Providing the necessary long-term support for prevention and management of comorbidities as well as improving the quality of life. Needless to emphasize that an enormous effort is required by the governmental as well as non-governmental agencies for educating PWE, general public and medical communities regarding the recent advances in the management of epilepsy.

There are, approximately six to seven million people with epilepsy (PWE),[1],[2],[3] over two million with drug resistant epilepsy (DRE) and half a million potential candidates for epilepsy surgery (ES) in India. DRE accounts for 80% of the health care costs for epilepsy. There will be a substantial decrease in the overall burden of epilepsy if these people with DRE can be identified early and referred to the CECC. Unfortunately, there is an enormous primary and secondary treatment gap in the medical management. Similarly, many suitable candidates are not undergoing epilepsy surgery because of illiteracy, ignorance and the wrongly perceived risks, costs and complications.

In this context, the article by Dr. Rawat et al., on the “Clinical predictors of treatment outcome in North Indian patients on antiepileptic drug therapy: A prospective observational study” is a welcome addition.[4] The authors highlighted the need to recognize simple and clinical predictive markers that are responsible for treatment failure. The study was performed to identify the clinical factors predictive of a poor prognosis in patients on AED therapy. The following three findings: an early disease onset, cryptogenic epilepsy, and a higher pre-treatment seizure frequency, were found to be related to a poor prognosis or poor remission in people with epilepsy (PW) on AED therapy. The authors have highlighted 'the intrinsic severity hypothesis', of Rogawski and Johnson [5] which suggests that neurobiological factors (such as frequent seizures at disease onset) that result in an increased disease severity lead to drug intractability. Routinely performing the assay of serum AED levels was not found to be essential.[6] These observations can be utilized in the early identification of children with drug resistant epilepsy, especially by the paediatricians as well as the paediatric neurologists. The data will also help in counselling and convincing parents of children with DRE for an early referral to the CECC.

The study was observational and carried out between 2005 and 2015. In the study, seizures have been classified into three groups; 1.idiopathic, 2.symptomatic, 3.cryptogenic. In the International League Against Epilepsy (ILAE) Proposal for Revised Terminology for Organization of Seizures and Epilepsies 2010, these terms have been clarified. In the genetic group, the gene defect directly contributes to epilepsy and seizures are the core symptoms of the disorder. In the idiopathic group, the aetiology is presumed to be genetic. In the structural and metabolic group, the cause is structural or metabolic disorder of the brain. The symptomatic group is secondary to a known or presumed disorder of the brain. In the unknown group, the cause is unknown and might be genetic, structural or metabolic. In the cryptogenic group, the aetiology is presumed to be symptomatic. Reclassifying these groups based upon the ILAE proposal of 2010 or the 2017 classification would have made the subject clearer to the practicing physician and paediatrician.

The following statement “Epilepsy being an incurable disease, it can only be treated by reducing the frequency of seizures using antiepileptic drugs (AEDs)”[7] undermines the tremendous progress being made in the management of people with drug resistant epilepsy in the recent years.[8],[9] Establishment of the National Epilepsy Control Programme in India hopefully will bring uniformity in the quality of clinical services, work force training and research. Efforts by the national institutions and motivated health care professionals will make a significant contribution.[10] Networking of CECC in the public and private sector as well as collaborations between national and international institutions will minimize the inequity.



 
  References Top

1.
Rao MB. Addressing the burden of epilepsy in India…. Neurol India 2017;65, Suppl S1:4-5.  Back to cited text no. 1
    
2.
Rathore C, Radhakrishnan K. Epidemiology of epilepsy surgery in India. Neurol India 2017;65, Suppl S1:52-9.  Back to cited text no. 2
    
3.
Gourie-Devi M. Epidemiology of neurological disorders in India: Review of background, prevalence and incidence of epilepsy, stroke, Parkinson's disease and tremors. Neurol India 2014; 62:588-98.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Rawat C, Guin D, Talwar P, Grover S, Baghel R, Kushwaha S, et al. Clinical predictors of treatment outcome in North Indian patients on antiepileptic drug therapy: A prospective observational study. Neurol India 2018;66:1052-9.  Back to cited text no. 4
  [Full text]  
5.
Rogawski MA, Johnson MR. Intrinsic severity as a determinant of antiepileptic drug refractoriness. Epilepsy Curr 2008;8:127-30.  Back to cited text no. 5
    
6.
St Louis EK. Monitoring antiepileptic drugs: A level-headed approach. Curr Neuropharmacol 2009;7:115-9.  Back to cited text no. 6
    
7.
Eadie MJ. Shortcomings in the current treatment of epilepsy. Expert Rev Neurother 2012;12:1419-27.  Back to cited text no. 7
    
8.
Vakharia VN, Duncan JS, Witt JA, Elger CE, Staba R, Engel Jr J, et al., Getting the best outcomes from epilepsy surgery. Ann Neurol 2018;83:676-90.  Back to cited text no. 8
    
9.
Berg AT, Langfitt JT, Cascino GD. The changing landscape of epilepsy surgery: No longer the “last resort.” Neurology 2018; DOI: 10.1212/WNL.0000000000005764.  Back to cited text no. 9
    
10.
Rathore C, Rao MB, Radhakrishnan K. National epilepsy surgery program: Realistic goals and pragmatic solutions. Neurol India 2014;62:124-9.  Back to cited text no. 10
[PUBMED]  [Full text]  




 

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