A one year-review of anti-epileptic drug monitoring in Trinidad

OBJECTIVE: To audit anti-epileptic drug monitoring in tertiary hospitals in Trinidad. METHODS: Epileptic patients, from hospital clinics, who were receiving maintenance therapy and were referred for plasma drug level monitoring, gave informed consent and were enrolled. Blood collection was at trough levels of drug and coded plasma samples were analysed by competitive immunoassay on the TDx Monitoring system. RESULTS: All 93 patients consented to participate. Phenytoin and carbamazepine were the two major drugs prescribed. The use of multiple drugs did not influence the occurrence of seizures in the patients; (31 percent) receiving polytherapy. Phenobarbital was the most frequent agent added to the drug regime in 24/9 patients (83 percent). Low plasma levels of drugs were detected in 58 percent and 36 percent of patients receiving polytherapy with phenytoin and carbamazepine respectively; but an association was not found between the range of drug levels and the frequency of seizures. Seventy-seven (83 percent) patients reported good compliance. Plasma drug levels were significantly below normal (p=0.004) in patients who reported poor compliance. CONCLUSIONS: Multiple drug therapy did not influence the prognosis of seizure control in this study. Suspected non-compliance, drug toxicity and failure to individualize dosing are considerations for plasma level drug monitoring in the protocol for management of epilepsy.(Au)

Epilepsy in Latin America and the Caribbean: a survey on needs and resources

A survey was done on the needs and resources available to control epilspsy in the countries of Latin America and the Caribbean. Responses came from ministries of health, prominent neurologists, and epilepsy advocacy organizations. A mailed questionnaire was used, and the response rate was excellent, 89 percent. The survey results showed that the private sector, in terms of both specialized personnel and access to a variety of drugs. Public policies are lacking, and linkages between medical personnel and social workers are almost nonexistent. Primary care doctors and nurses are somewhat able to diagnose some types of epilepsy but do less well with other types of the disorder. There is a strong justification for the new "Out of the Shadows" initiative, in which the International League Against Epilepsy, the International Bureau for Epilepsy, the World Health Organization, and the Pan American Health Organization are working to improve epilepsy health-care services, treatment, and social acceptance (AU)

Estimates of the prevalence of childhood seizure disorders in communities where professional resources are scarce: results from Bangladesh, Jamaica and Pakistan

Although numerous estimates of the prevalence of seizure disorders in populations in the less developed world have now been published, these estimates are difficult to interpret due to lack of comparability of study methods and criteria for case definition. The results reported in this paper are from a large, collaborative study of disabilities in 2- to 9-year-old children in which standard research procedures and case definitions were used in three diverse populations (located in Bangladesh, Jamaica and Pakistan). A two-phase study design (screening followed by professional evaluations) was used in this study allowing for the professional evaluation to serve as the criterion in the estimation of prevalence, even for rare disorders. As a result, the prevalence estimates reported here have a high degree of comparability across populations and exhibit unusually strong validity for population surveys. Febrile seizures were the most common type of seizure history in all three populations, with point estimates of lifetime prevalence rates of epilepsy (recurrent unprovoked seizures) ranged from 5.8 to 15.5 per 1000. Lifetime prevalence rates of neonatal, all provoked and all unprovoked seizures, as well as estimates of the prevalence of active epilepsy, are also reported.(AU)

Service needs of disabled children in Jamaica - abstract

Parents of children presenting for a medical assessment as part of a two-stage survey of 2 to 9-year-old children in mid and south Clarendon were asked about symptoms relating to six different disabilities: visual, hearing, speech, motor, cognitive and fits and whether they had sought treatment for these symptoms. Their responses were compared with those who were diagnosed as disabled by the professional team. The frequencies of five possible types of intervention for children with disabilities recommended by the physician were analysed and related to the estimated prevalence of the six disabilities in the parish, to estimate the needs of Jamaican children for the various types of services. These were then compared with existing services. For all disabilities, except fits, the percentage of children that received treatment for symptoms was low, ranging from 5 percent for cognitive to 33 percent for motor symptoms. For children found to be disabled, the rates were a little higher except for treatment of fits which was 87 percent and cognitive disability at 5.6 percent. Awareness of the disability was also poor in cognitive, visual and speech disabilities. Fifty-six percent of disabled children needed special education, 29.5 percent needed community-based services, 21 percent needed spectacles, 21 percent needed specialist referral and 6 percent required medical treatment. The vast majority of the estimated needs for Jamaica as a whole are unmet (AU)

Epilepsy: disappearing lesions appearing in the United Kingdom

Objective: - Investigation of spontaneously resolving lesions associated with epilepsy. Design:- Observational study during one year. Setting:- One neurology department. Patients:- 4 cases in patients (one of Indian parents, one African, one white English, and one Afro-Caribbean) resident in the United Kingdom, who presented with transient epilepsy. Main outcome measures:- Findings on computed tomography and on screening for infections. Results:- In all four cases a small mass lesion in one cerebral hemisphere was observed on computed tomography, which resolved after 9, 4, 3 and 1.5 months respectively without surgery. Conclusions:- The number of cases seen in one year suggests that the lesions may be more common in the United Kingdom than previously recognised and that research into their cause is warranted. (AU)

Epilepsy at the General Hospital, Port-of-Spain - abstract

In 1987, the discharge diagnosis on 264 patients admitted to 5 medical wards at the General Hospital, Port-of Spain was fits/epilepsy/seizures. This prompted us to review the cases of epilepsy attending the Neurology Clinic at the institution over a 3-month period, May-August, 1988. There were 182 cases aged 8 to 80 years. Common seizure patterns were tonic/clonic 124 (685), and complex partial become generalized 37 (21 percent). Monotherapy was used in 117 (64 percent), 2 drugs in 51 (28 percent), and 3 drugs in 6 (3 percent) patients. The most commonly used drug was dilantin, drugs included phenobarbitone in 49 cases, mostly in combination and tegretol in 42 cases (21 cases each, singly and in combination). The commonest combination was dilantin and phenobarbitone in 31 cases (17 percent). Antiepileptic drug (AED) levels were done on 297 Specimens from 107 patients and, overall, 117 (39 percent) were in the therapeutic range. Only 59 patients (32 percent) were in good control, i.e. there were no seizures in the 6 months prior to the visit. Epilepsy is not satisfactorily controlled in these patients. This partly reflects lack of compliance, lack of regular supplies of medication, supervision by staff not well-informed in the management of epilepsy, frequent change of clinic staff and lack of awareness of the nature of the illness by patients (AU)

A survey of epilepsy management and control in a hospital out-patient setting - abstract

The majority of patients with a diagnosis of epilepsy, attending the medical or paediatric outpatient clinics or the Casualty Department of the QEH in the three months, August 5 to November 5, 1987, were identified and interviewed by a research nurse. Data were collected on employment, diagnosis, fit frequency, drug regime, and alcohol use. A venous plasma sample was taken for anti-epileptic drug analysis. Two hundred and seventy-nine patients were seen (54 percent male and 46 percent female) aged 26ñ12 years meanñSD). Sixty-two per cent of adults were unemployed, nearly four times the national figure of 18 percent. There had been no attempt to qualify or label the type of epilepsy in 61 percent of patients. Specific diagrams of grand mal, complex partial and focal seizures were made in 19 percent, 18 percent and 4 percent respectively. Petit mal (1 case) appeared to be grossly under-diagnosed. Twenty-nine per cent of patients had had their last fit in the previous week, 20 percent between one week and one month, 25 percent between one and six months, and 22 percent more than six months before. Thus, half were unsatisfactorily and half well controlled. Phenytoin was the most frequently prescribed drug (in 44 percent alone, plus 13 percent in combination) followed by carbamazepine (30 percent and 13 percent) and phenobarbitone (8 percent and 6 percent). Eighty-two per cent of patients were treated with one drug, 17 percent with two and only 1 percent with three. There was a clear positive correlation between drug dose and plasma concentration for phenobarbitone, a less good one for carbamazepine and a poor one for phenytoin. Concentrations fell at high doses, showing poor compliance. More careful dose titration is necessary, using plasma monitoring. This is essential for good epilepsy control. Both doctor and public re-education is needed if patients with epilepsy are to be given a "fair deal" in health-care and employment (AU)

Drug assay services and management of epilepsy in Barbados a one year review - abstract

Therapeutic drug monitoring with a clinical pharmacology consultative service has been available in Barbados for one year. Its use is reiewed in 143 epileptic patients, from whom 239 blood samples were drawn. Three hundred and eleven assays were performed by Enzyme Mediated Immunoassay [EMIT] (phenytoin 179, phenobarbitone 85 and carbamzepine 47). Efficiency of prescribing was assessed by comparing plasma levels with Recomended Therapeutic Ranges (RTR). Sixty-eight per cent of all assays were outside the RTR (47 percent below and 21 percent above). Only 24 percent of phenytoin levels were in the RTR, compared with 39 percent for carbamzepine and 49 percent for phenobarbitone. Ten per cent of all assays showed insignificant drug concentrations, indicating severe non-compliance. Assay reports included suggestions for dose adjustments were made in 38 percent. Non-compliance or"on-off" compliance was the major therapeutic problem and was identified in 48 percent, but the clinician recorded compliance counselling in only 27 percent. Reports were frequently not noted, drugs changed instead of doses, or inappropriate dose blood test and tests and (ii) different doctors reviewing. These results demonstrate unsatifactory mangement of epilepsy. Mean annual drug cost for these patients was 10 time the cost of one assay. Improved fit control and projected savings from reduced doses and reduced drug wastage more than justify costs of therapeutic drug monitoring in the Caribbean, when linked with consultative services and education in drug use (AU)

Epidemic nephritis in South Trinidad

Over a period of 6 months a remarkable increase was seen in the incidence of acute nephritis among children in South Trinidad, and 263 cases were admitted to a general hospital. The patients were found to differ in their age, sex, and geographic distribution. The disease was associated with respiratory infection rather than skin infection, the form usually seen here, and the appearance of desquamation in many of the children suggested that the underlying organism was one capable of producing scarlet fever. The disease was mild. Only five children (1.9 percent) died, all from cardiac failure. Recovery appears so far to be complete in all but one of the survivors. (Summary)

Therapeutic drug monitoring in the Caribbean - abstract

For many drugs there is a close relationship between plasma concentration and biological/therapeutic effects. Laboratory services for estimating plasma drug concentrations (Therapeutic Drug Monitoring or TDM) are now provided in most major hospitals of the developing world, including most of the Caribbean, for three major reasons: 1) the variable but generally long lag period in the transfer of new technology, 2) the perceived cost of the new technology, 3) the dearth of clinical pharmacologists, the specialists most closely involved in the provision and interpretation of plasma drug levels. A TDM service was set up in Barbados in 1982, in the Clinical Pharmacology Laboratory at the Queen Elizabeth Hospital using the Syva Enzyme Mediated Immuno Assay/spectophotometric system. Eight drugs are now routinely assayed, using (since January 1987) a flourescence polarisation immuno assay (Abbott), which permits rapid estimation and a same day service, facilitating immediate feedback of emergency and out-patient results. Drugs assayed include the top four anti-epileptics (phenytoin, phenobarbitone, carbamazepine and valproate), two cardiac drugs (digoxin and quinidine), theophylline and gentamycin. Assay services (including pharmacokinetic interpretation and advice on dose regimes) are provided for hospital in-and out-patients, private and polyclinic patients and, on request, to other Caribbean countries, i.e. countries of the Organisation of Eastern Caribbean States (OECS) and occasionally Jamaica. In Trinidad TDM services are provided for anti-epileptics at the Port-of-Spain General Hospital. Review of anti-epileptic TDM in Barbados indicates that drug management is usually far less than optimal. Because of its saturation kinetics, phenytoin is particularly difficult to achieve correct therapeutic levels and good results with, only 25 percent of assays falling in the recommended therapeutic range. Improved patient compliance and doctor education both require the concerted attention of the health services if the present poor epilepsy management is to be improved. TDM is less costly than perceived if the service: 1) uses a system where equipment is provided by the Company, with a contract for purchase of a minimal number of kits, rather than purchase of equipment, at high capital costs, and having to pay for service; 2) is centralised, providing large runs and minimising cost of controls, etc. Current costs per test for anti-epileptics to our lab (e.g. carbamazepine US$3.50) are comparable with basic cost to QEH of hormone assays (e.g. prolactin US$2.50, testosterone US$3.50, cortisol US$2.30). These costs are, however, multiplied by about four for private patients, or six or more by the commercial labs, where routine assays, e.g. amylase and blood count costs US$6.00 and $15.00 respectively. Since most other lab test costing must include capital equipment and service costs, the comparisons become even more favourable. Finally, assay costs are negligible compared to annual Drug costs for all relevant drugs except phenobarbitone. A select number of drug assays provide invaluable guidance in treating difficult patients with drugs which have a narrow therapeutic/toxic ratio. Anti-epileptic assays in particular are increasingly recognised to be as valuable in treating epilepsy as blood sugars in treating diabetics. No major hospital in the Caribbean or elsewhere should be without a Clinical Pharmacologist or a TDM service, providing assays for anti-epileptics, gentamycin and digoxin at least (AU)