Indian Write- Ups

Epilepsy describes a condition in which a person has recurrent seizures due to a chronic underlying process and thus refers to a clinical phenomenon rather than a single disease entity since there are many causes and forms of epilepsy.

The incidence of epilepsy is about 4-6 per 1000 population all over the world, whereas in developing countries it may be up to 6-10 per 1000 population. Hence, the first step in cost-effective management of epilepsy would be to reduce the incidence of epilepsy itself. This could be achieved by the following measures:

• Better antenatal and perinatal care. The higher incidence of epilepsy is due to poor health care facilities, poor antenatal and perinatal care leading to a higher incidence of birth hypoxia, and consequently a higher incidence of epilepsy later on in life.
• Improvement of hygiene and sanitation.Cysticercosis is an important cause of epilepsy and hence the need for maintenance of proper sanitary measures at piggeries and cattle sheds as pigs and cattle are the carriers of cysticercosis.
• Proper road and traffic management.These are an important cause of post-traumatic epilepsy.
• Correct and early diagnosis with appropriate medical management is the next step to reduce the overall suffering and cost of management. This is imperative and the shortage of neurologists in developing countries could be compensated for by training physicians and paediatricians in electroencephalography (EEG). This will enable over 70% of epileptic patients to lead a normal life with a functional role in society and a secure personal family life.

Pertinent Investigations

Any epileptic where an absence, myoclonic or complex partial seizure is suspected should undergo an EEG.

Any epileptic where seizures are not getting controlled in spite of good therapeutic doses and regular treatment should undergo an EEG and CT scan.

MRI should be reserved for epileptics where the CT scan is negative, yet seizures persist.

Any epileptic with progressive neurological deficit, focal neurological deficit, papilloedema, or persistent headache should undergo at least a CT scan, if not a MRI.

Serum drug levels are done routinely for antiepileptic medications in ideal settings. This is not always possible in developing countries due to cost consideration; hence serum antiepileptic drug levels should be reserved for uncontrolled epilepsy, difficult-to-treat epilepsy, where polytherapy is administered, or other situations which a neurologist may deem correct.

Cost-effective Therapy

In order to ensure compliance, the prescribing doctor should issue only a drug that the patient can afford on a regular long-term basis.

• Cheap antiepileptic drugs such as Phenobarbitone, Phenytoin and Ethosuximide.
• Moderately priced antiepileptic drugs such as Carbamazepine, Valproate, Primidone, Clonazepam, Lamotrigene, Clobazam and Nitrazepam.
• Costly antiepileptic drugs such as Gabapentin, ACTH, and other drugs not easily available such as Vigabatrin, Tiagabine, Felbamate etc.
  

Epilepsy – A Social Stigma

Epilepsy encompasses every walk of life and every social strata. The psychosocial impact it causes is tremendous.

• Children in school are discriminated against, peer's scoff at them and insensitive teachers have a difficult and sometimes even hostile attitude towards them. On the other hand, some parents may be over-protective and stifle their growth.
• Adults have difficulty in getting suitable jobs or may lose the same on discovery of epilepsy by their employers.
• Young females have difficulty in getting married. If epilepsy is not revealed before marriage, on discovery of epilepsy, divorce may result and remarriage is also very difficult. Laws regarding marriage and epilepsy are outdated.
• Driving and epilepsy are always a problem. The rules are not fair and many times outdated.

Summary

Government and non-government agencies can do a lot for epilepsy, such as cost subsidization of antiepileptic drugs, free drug supply in government hospital, regular supply of drugs, availability of doctors trained in managing epilepsy, and facilities such as EEG, CT Scan and MRI in government hospitals would go a long way in reducing the burden of epilepsy. Epilepsy by itself is a disease that causes a tremendous amount of suffering, both physical and mental, and the above recommendations will go a long way to lessen the same.