Pharmacoepidemiology of epilepsy in a paediatric neurology clinic.

Abstract

Pharmacoepiemiology is the use of epidemiological methods to study the use of drugs and their effect on populations. Thus far, no pharmacoepidemiological studies regarding epilepsy have been carried out in Malta. Epilepsy is a common neurological condition and research initiatives have been promoted by the WHO's 2013 report on 'Priority Medicines for Europe and the World', emphasising the importance of addressing chronic non-communicable diseases which are characterised by high morbidity and mortality. This same document includes children among 'special groups' whose needs need to be addressed and in whom the management of illnesses needs to be prioritised since children are a vulnerable population with unique health needs. This study aimed to investigate pharmacoepidemiological aspects of epilepsy in population of Maltese children presenting to a paediatric epilepsy clinic by establishing whether local practices followed principles of rational prescribing and whether Maltese children with epilepsy had access to the best available care. In order to determine whether the care of children with epilepsy presenting to a specialist clinical followed principles of best prescribing practice, the clinical records of 76 children were reviewed retrospectively from the 31st December 2013 to the date of first presentation of each patient to hospital services for the management of epilepsy. Data collected was input into a spreadsheet and statistical data analysis was carried out. In order to determine whether Maltese children with epilepsy were able to access the best locally available care, pharmacy records were consulted in order to determine how many Maltese children with epilepsy were receiving free antiepileptic drug therapy in accordance with local the policy of providing free drug therapy for patients with specific chronic diseases in accordance with the fifth schedule of the Maltese legal code. In the paediatric epilepsy clinic, valproate was the most commonly prescribed AED overall (40.8%), possibly due to its good efficacy and wide spectrum of action. Lamotrigine was the most commonly prescribed newer AED (19.7%), as in other countries. The use of older AEDs exceeded that of newer ones, suggesting clinician confidence with working with time-tested drugs. The most commonly prescribed AED was combination was that of valproate with lamotrigine, which have a well known synergastic interaction. 48.7% of children were receiving AEDs as monotherapy, similar to studies from other countries. Around a third of the children (35.5%) were off AED therapy on the 31st December 2013 since they were in seizure remission. In 55.3% of cases the first AED started at diagnosis remained unchanged. AED selection was not affected by gender or comorbidity. It was also noted that lowest prevalence of children with epilepsy were living in Gozo. This could be due to travel issues since patients need to cross the Maltese channel by ferry in order to access the educated service at Mater Dei hospital, educational issues or issues of social stigma. The highest prevalence of children with epilepsy was found to be living in the South Harbour district of the Maltese Islands, an area which the latest concensus revealed to be at highest risk of poverty.

This study identified that although the care available at the paediatic epilepsy clinic follows latest evidence and best practice principles, this care is not available to all Maltese children with epilepsy. A substantial number of children with epilepsy receive care from the generalist paediatricians. Hence the way forward would be to broaden the function of the clinic, provide more clinican training, design clinical practice guidelines and protocols, which could be extended to generalist paediatric teams and also community general practice teams. It was also found that an increasing duration of epilepsy did not lead to a decrease in the number of presentations to accident and emergency in view of seizure events, although children were receiving the best available care, even in terms of the selection of antiepileptic drugs used in clinical management. This calls for providing further education to children, parents, teachers, healthcare professionals and the general public in order to empower them in their role as part of the multidisciplinary management of the child with epilepsy, as well as minimising stigma. Results regarding demographic findings and selection of drug therapy are comparable to findings from studies from other countries but those regarding seizure semiology and aetiology differ between published studies. Despite its limitation of small numbers, selection bias and lack of computerised records as a data source, it may serve as a basis for further pharmacoepidemiological, qualitative and pharmacoeconomic studies which could guide local drug-related policy and facilitate access to care, providing equity for all citizens.