A new study published in Epilepsia1 found that although most newly diagnosed cases of epilepsy in older adults are treated appropriately with monotherapy, only half of those patients receive treatment within the recommended time frame, and a substantial portion were prescribed older antiepileptic drugs (AEDs) despite recommendations to use newer AEDs in this population.
Investigators from the University of Birmingham in Alabama and Emory University in Atlanta, Georgia, conducted a retrospective analysis of Medicare claims filed in 2009 to assemble a cohort of 3706 probable cases of epilepsy in 3 age categories: 67 to 74 years (34.9%), 75 to 84 years (37.3%), and 85 years and older (27.8%). The majority of patients were female (64.9%) and from the south (49.2%). The original random 5% sample of the Medicare database was racially enhanced (61.2% African American, 18.0% white, 12.3% Hispanic, 6.6% Asian, and 2.0% American Indian/Alaskan Native) to evaluate treatment patterns across minority groups.
The vast majority of the Medicare sample (95%) was given monotherapy in accordance with Quality Indicators for Epilepsy Treatment 6 (QUIET 6) recommendations.2 Divergence from recommendations occurred, however, in the choice of first-line therapy. Although levetiracetam was appropriately chosen for initial monotherapy in 45.5% of the cohort, older, less desirable agents such as phenytoin, divalproex, and carbamazepine were prescribed for 30.6%, 9.5%, and 2.4% of patients, respectively. Gabapentin, which was recommended in previous studies3,4 for older patients because of a more favorable adverse effect profile and reduced interactions with other drugs, was only prescribed to 6.1% of the total Medicare cohort.
Variations by race in choice of AEDs were observed in the study. Levetiracetam was the most commonly prescribed agent for Asian, white, African American, and Hispanic patients (55.0%, 48.8%, 45.6%, and 38.8%, respectively). Phenytoin was the most commonly prescribed agent among American Indian/Alaskan Native patients (43.1%) and the second most common among all other groups.
In cases in which patients received 2 agents, Asian and white patients (37.0% and 35.4%) were most likely to receive levetiracetam first, whereas African American and Hispanic patients (40.4% and 32.5%) were most likely to receive phenytoin as the first agent. Levetiracetam was the most common second AED in all groups receiving 2 or more drugs, chosen twice as often as phenytoin, divalproex, and gabapentin in all groups except for American Indian/Alaskan Native patients, where it was chosen equally as often as phenytoin (29.6%). Lamotrigine was the least-chosen agent overall (chosen by 3.4% as a first agent and 7.0% as a second), although its use also varied by race.
The data also revealed a delay in the initiation of treatment in this population. The investigators reported that only 50% of the patients evaluated filled an AED prescription within 30 days of diagnosis, with of the average being 60.1 days. Although African American and white patients had the longest time to initiation of therapy compared with American Indian/Alaskan Native patients, who had the least (61.3, 60.2, and 56.8 days, respectively), differences among the groups were not considered statistically significant.
- Martin RC, Faught E, Szaflarski JP, et al. What does the U.S. Medicare administrative claims database tell us about initial antiepileptic drug treatment for older adults with new-onset epilepsy? [published online February 7, 2017]. Epilepsia. doi: 10.1111/epi.13675
- Pugh MJ, Berlowitz DR, Montouris G, et al. What constitutes high quality of care for adults with epilepsy? Neurology. 2007;69:2020-2027. doi: 10.1212/01.WNL.0000291947.29643.9f
- Pugh MJ, Foreman PJ, Berlowitz DR. Prescribing antiepileptics for the elderly: differences between guideline recommendations and clinical practice. Drugs Aging. 2006;23:861-875.
- Pugh MJ, Cramer JA, Knoefel J, et al. Potentially inappropriate antiepileptic drugs for elderly patients with epilepsy. J Am Geriatr Soc. 2004;52:417-422. doi: 10.1111/j.1532-5415.2004.52115.x