Reasons for uncontrolled seizures in adults; the impact of pseudointractability

Asadi‐Pooya, Ali A.; Emami, Mehrdad; Ashjazadeh, Nahid; Nikseresht, Alireza; Shariat, Abdolhamid; Petramfar, Peyman; Yousefipour, Gholamali; Borhani‐Haghighi, Afshin; Izadi, Sadegh; Jaberi, Abbas Rahimi

doi:10.1016/j.seizure.2013.01.010

Cited by 48 publications

(36 citation statements)

References 13 publications

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“…Choosing an optimal ASM is not an exact science and requires training and extensive experience, which may not always be available. Suboptimal ASM selection is common, at least in some settings, and may cause harm 6‐11 . Whether experts weigh critical factors in a similar way is not known, and inter‐rater agreement in selecting currently available ASMs for individuals with a wide range of clinical variables has not been investigated before.…”

Section: Introductionmentioning

confidence: 99%

Optimal choice of antiseizure medication: Agreement among experts and validation of a web‐based decision support application

et al. 2020

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ObjectiveOptimal choice of antiseizure medication (ASM) depends on seizure type, syndrome, age, gender, comorbidities and co‐medications. There are no fixed rules on how to weigh these factors; choices are subjective and experience‐driven. We investigated agreement among experts in selecting ASM as monotherapy and used their prevailing choices to validate a web‐based decision‐support application.MethodsTwenty‐four international experts, blinded to the app, selected the optimal ASM for 25 individual patient‐cases covering a wide variation of seizure types and other factors influencing ASM selection. The app ranked ASMs in order of likely appropriateness for each case. In a second step, experts rated anonymously the choices of the app.ResultsOf the 25 patient‐cases (age 13‐74 years), 13 were female, 18 (72%) had comorbidities, six (24%) were on contraceptives, and 13 (52%) had other co‐medications. The median number of experts who selected the same ASM for a given case was 15 (62.5%) and interquartile range (IQR) 13‐18 (54%‐75%). Gwet's agreement coefficient among experts was 0.38 (95% confidence interval [CI] 0.32‐0.44), corresponding to a "fair" agreement. Agreement between the app and the prevailing expert choice for each case was 0.48 (95% CI 0.29‐0.67), corresponding to a “moderate” beyond chance agreement. The percent agreement between the highest ranked selections of the app and the expert selections was 73% (95% CI 64%‐82%). Ninety‐five percent of the experts considered that no incorrect or potentially harmful ASMs were ranked highest by the app, and most experts strongly agreed with the app's selections.SignificanceThis app, now validated by experts, provides an objective, reproducible method for selecting ASM that accounts for relevant clinical features. It is freely available at: https://epipick.org.

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Section: Introductionmentioning

confidence: 99%

Optimal choice of antiseizure medication: Agreement among experts and validation of a web‐based decision support application

et al. 2020

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“…Identifying epilepsy syndrome and seizure type(s) correctly is a necessary first step in clinical practice, but it may not necessarily lead to choice of an appropriate treatment. Evidence of incorrect or suboptimal drug selection in patients with epilepsy has been documented by many studies done in different settings 9,32,33 . Our instrument has the potential to reduce inappropriate prescribing, as it provides advice not only on drug choice but also on dosage and titration schedules.…”

Section: Discussionmentioning

confidence: 99%

“…This risk is compounded by a scarcity of neurologists and epilepsy specialists in many places, particularly in low‐ and middle‐income countries, but also in wealthier countries 8 . Moreover, misdiagnosis and misclassification of seizures are common, and can lead to selection of either ineffective or potentially seizure‐aggravating treatments 9 . In one study of 350 adults with uncontrolled seizures, 29% were found to have been prescribed an inappropriate ASM and 18% were taking suboptimal ASM doses 9 .…”

Section: Introductionmentioning

confidence: 99%

“…Moreover, misdiagnosis and misclassification of seizures are common, and can lead to selection of either ineffective or potentially seizure‐aggravating treatments 9 . In one study of 350 adults with uncontrolled seizures, 29% were found to have been prescribed an inappropriate ASM and 18% were taking suboptimal ASM doses 9 . Inappropriate drug choice can also adversely affect comorbidities and diminish the efficacy of other drugs 10,11 …”

Section: Introductionmentioning

confidence: 99%

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A pragmatic algorithm to select appropriate antiseizure medications in patients with epilepsy

et al. 2020

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Objective: Antiseizure medications (ASMs) are the first-line treatment for epilepsy. Many ASMs are available; this offers the opportunity to improve therapy by tailoring it to individual characteristics, but also increases the possibility of healthcare professionals making inappropriate treatment choices. To assist healthcare professionals, we developed a pragmatic algorithm aimed at facilitating medication selection for individuals whose epilepsy begins at age 10 years and older. Methods: Utilizing available evidence and a Delphi panel−based consensus process, a group of epilepsy experts developed an algorithm for selection of ASMs, depending on the seizure type(s) and the presence of relevant clinical variables (age, gender, comorbidities, and comedications). The algorithm was implemented into a web-based application that was tested and improved in an iterative process. Results: The algorithm categorizes ASMs deemed to be appropriate for each seizure type or combination of seizure types into three groups, with group 1 ASMs considered preferred, group 2 considered second line, and group 3 considered third line. Depending on the presence of relevant clinical variables, the ranking of individual ASMs is adjusted in the prioritization scheme to tailor recommendations to the characteristics of the individual. The algorithm is available on a web-based application

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“…2 Juvenile myoclonic epilepsy is often characterized by excellent response to treatment, 3 but delay to a correct diagnosis and consequently, choosing an inappropriate or suboptimal agent may result in uncontrolled seizures in many patients. 6 Besides, even a correct diagnosis does not guarantee an optimal response to therapy and many patients suffer from ongoing Table 1 Comparison of demographic and clinical characteristics of patients with JME, with or without seizures in their follow-up. seizures despite an appropriate treatment plan.…”

Section: Discussionmentioning

confidence: 99%

Predictors of seizure control in patients with juvenile myoclonic epilepsy (JME)

Asadi‐Pooya

Hashemzehi

Emami

2014

Seizure

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A correct diagnosis of JME does not guarantee an optimal response to therapy. Poorer drug adherence might result in more seizures; this should be highlighted for patients in every single visit. Longer follow-up gives the treating physician more time to adjust the drug(s) and formulate a plan that is appropriate for patients with difficult to treat seizures. We recommend valproate if seizure control is the main objective.

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Reasons for uncontrolled seizures in adults; the impact of pseudointractability

Abstract: Uncontrolled seizures are a commonly encountered problem, especially at epilepsy clinics and one should consider all possible reasons for these uncontrolled seizures. The mainstay for making a correct diagnosis is a detailed clinical history.

Cited by 48 publications

References 13 publications

Optimal choice of antiseizure medication: Agreement among experts and validation of a web‐based decision support application

Optimal choice of antiseizure medication: Agreement among experts and validation of a web‐based decision support application

A pragmatic algorithm to select appropriate antiseizure medications in patients with epilepsy

Predictors of seizure control in patients with juvenile myoclonic epilepsy (JME)

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