SummaryEpilepsy is characterised by a tendency to experience unprovoked seizures and is one of the most common neurological disorders. Over 2% of the population will experience a seizure at some time in their life, and recurrent unprovoked seizures will require treatment in approximately one-in-200 people at any given time. Treatment of epilepsy remains important in helping to reduce the psychological and social sequelae which follow on from uncontrolled seizures.
Epilepsy is characterised by a tendency to experience unprovoked seizures and is one of the most common neurological disorders. Over 2% of the population will experience a seizure at some time in their life, and recurrent unprovoked seizures will require treatment in approximately one-in-200 people at any given time. Treatment of epilepsy remains important in helping to reduce the psychological and social sequelae which follow on from uncontrolled seizures.
The relative paucity of neurologists in the UK has meant that historically the burden of epilepsy care has fallen not on those with relevant expertise, but on those with responsibility for acute care (usually physicians working in primary care and general medicine). The legacy of this is that there has been a long period of misdiagnosis and misclassification, with misuse of investigations and under use of optimal diagnostic tools, surgical resources and newer drugs.
However, over the last decade, significant strides have been made to improve the approach to epilepsy care. This legacy has been addressed by the guidelines produced to help direct best practice in epilepsy in Scotland (Scottish Intercollegiate Guidelines Network [SIGN], Guideline No 70, April 2003; www.sign.ac.uk) and England and Wales (National Institute for Health and Clinical Excellence [NICE] 2004; www.nice.org.uk). These guidelines have been motivated by both the medical profession and central government, and acknowledge specific difficulties and challenges required in the course of managing this long-term disorder. These include the occasional difficulties in diagnosis, the need for use of appropriate treatment and the need to address specific individual patient concerns. Further, inclusion of epilepsy as one of the key disease activity markers in the 2004 General Medical Services (GMS) GP contract may prove to be a powerful motivator for primary care to improve the lot of epilepsy patients in the community.
Increasing general expertise in epilepsy management has become more important with the evolution in antiepileptic drug treatments over the last two decades. By the late 1980s, a sustained period of intensive research had resulted in the introduction of a number of new antiepileptic drugs. Vigabatrin, lamotrigine, gabapentin, topiramate, tiagabine, oxcarbazepine and levetiracetam were respectively introduced into widespread use in the UK, with a further anticonvulsant recently launched in 2005 (zonisamide). In total, the last 20 years have seen more anticonvulsant compounds developed than were discovered in the previous century and a half. Of the newer drugs, lamotrigine, topiramate and levetiracetam have become commonly used compounds with proven efficacy, fewer pharmacokinetic interactions and more favourable tolerability profiles than the older agents.
An additional bonus of the increasing interest from the pharmaceutical industry has been a blossoming of research into the causes, effects and treatment of the disorder. The increasing drive towards improving epilepsy management amongst the medical profession has been mirrored by a marked sea change in the character of the voluntary sector concerned with epilepsy care. Since the early 1990s, the voluntary sector has moved away from being a group of organisations concerned with improving care and providing help for affected individuals. Instead, under the umbrella of the Joint Epilepsy Council, these groups (National Society for Epilepsy, Epilepsy Action, Epilepsy Scotland and Epilepsy Wales) have maintained their role in helping individuals whilst additionally developing their skills in lobbying politicians and effecting changes in national policy.
As a profession and as a society, we have made some important first steps in improving epilepsy care in the UK. Guidelines and incentives should prove to be both carrot and stick for the health services persuading primary, secondary and tertiary care to improve provision of care for all patients with epilepsy.
In the earliest years of the twenty-first century, the drug treatment of epilepsy has never been so promising or so potentially complex. We may be nearer reaching our goal of maximising both the efficacy and tolerability of antiepileptic drug treatment. Whilst newer drugs will always be welcome, we should be careful to ensure that we make good use of those compounds already available. Allied to a coherent response from our health services and our politicians, we can only hope that such improvements are only the start of a new phase of epilepsy management in the UK.
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This Editorial has been written by the specialist opinion leader, Dr John Paul Leach
Consultant, Department of Neurology, Southern General Hospital, Glasgow and published in the latest issue of the serial publication, Drugs in Context.
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