Epilepsy Medication Audit at QECH OPC Dr Chipiliro kadzongwe MMed Psych Trainee, CoM, UNIMA

Outline Introduction Methodology – Design – Sample size – Standards – Data collection Data analysis – Results Conclusions Recommendations

Introduction Epilepsy is a chronic neurological disorder characterized by recurrent unprovoked seizures The majority of the seizures can be controlled with appropriate medications with patients able to return to function

Introduction Different causes – Genetic – past history of birth trauma – brain infections – head injury – in some cases, no specific cause can be identified

Introduction Classification of epileptic seizures – Clinical type Partial Generalized – Epilepsy syndromes

Introduction Malawi epidemiology (Amos A & Wapling L, 2011) – Prevalence 2.8% – 55 % males – 45 % females

Introduction Queen Elizabeth Central Hospital (QECH) tertiary hospital in Blantyre Care for patients with epilepsy shared between departments of internal medicine and psychiatry Initial assessment and diagnosis conducted by department of internal medicine – Neurologist available occasionally

Introduction Follow up care is provided psychiatry nursing staff In 2012 the clinic had – an average of 51 patients per week – 240 patients per month – total of 2,875 visits

Introduction Main challenges – Irregular availability of AEDs – Staff availability

Introduction This was a baseline assessment for the existing prescribing practices

Methods Prospective follow up audit on adult epilepsy patients; at least 100 patients Assessment of health passport books Inclusion criteria – Patients with an established diagnosis of epilepsy

Methods Exclusion criteria – Patients attending clinic for the first time – Children Data collected between March & April 2013

Methods Compared available standards – Local Malawi standard treatment guidelines (MSGT) 2008 – International mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings: 2010 Guidance on epilepsy in adults and children produced by the National Institute for Health an Clinical Excellence (NICE); 2004

Methods Standards – Record show seizure type has been classified – Records show that combination anti-epileptic drug therapy, if prescribed, followed an adequate trial of monotherapy

Methods Standards – The prescribed AEDs are within the recommended maintenance dose ranges – Records show that all patients have had a review in the previous 12 months – Record shows that seizure frequency has been documented in the past 12 months

Maintenance dose ranges for AEDs

Data collection The following documentation was sought – a description of the seizures (ictal phenomenology) – seizure type – reference to prescribed AEDs patient is taking, where more than one drug was being taken, documentation of at least two periods of monotherapy that failed to gain adequate results

Data collection – reference to the dosage of AED patient taking – review of seizure frequency at least every 12 months

Results Baseline Characteristics – 65 patient were included – 65 % (42) of the patients were males – 35 % (23) were females

Results Baseline characteristics – Mean age of the patients is 30 years within the range of 15 to 67 years – The mean age of seizure onset was 18 years within the range of 6 months to 65 years

Results Current Treatment – AEDs currently being used in then clinic are Sodium valproate (VPA) Carbamazepine (CBZ) Phenobarbital (PHB) Phenytoin (PHY)

Results 69 % (45) of the clinic attendees were on monotherapy while 31 % (20) were on combination therapy

Results Seizure type – 53 (82 %) did not have their seizure type documented and classified – 12 (18%) had seizures classified

Results Seizure frequency – All patients had their seizure frequency recorded in the last 12 month – 65 % (42) of the patients had their seizures well controlled

Results Seizure frequency – 35% (23) had poor seizure control – 48% (11) of the patients with poor seizure control had no change in their medication – With 2 (18%) patients only having a reason indicated for not changing their medication

Results Commonly prescribed AEDs AEDsNumberPercentage (%) PHB3351 PHY812 VPA35 CBZ12 PHB & CBZ1219 PHB & PHY35 PHB & VPA23 PHY & CBZ12 VPA & CBZ12 PHB/PHY/CBZ12

Results Starting therapy TherapyPercentage (n) No documentation49 % (32) Single drug49% (32) Combined2 % (1)

Results Minimum and maximum dose ranges for each AEDs AEDsMinimum doseMaximum dose PHB60mg210mg (3) PHY100mg (7 ) 400mg VPA200mg (1)1600mg CBZ200mg (7)1400mg

Results In 28% (18) of the patients, the AEDs were not in maintenance treatment range

Results Number of reviews in last 12 months – No clear indication of review patients seizures – 52% have 5 reviews in 12 months

Results HIV Status

Limitations Lack of documentation on when the patients started treatment Medication collected by family member on review Limited time for data collection

Conclusion Lack of documentation on seizure type Lack of justification for combination therapy 28 % of AEDs doses not within the maintenance treatment ranges Lacks regular reviews Good documentation of seizure frequency

Recommendations Importance classification of epileptic seizures Recording the justification for combination therapy Improved record keeping At least 2 reviews of seizures and medications in 12 months Continue documentation on seizure frequency

Recommendations Training of nursing staff Institute standard prescribing guideline for the epilepsy clinic Re-audit

Recommendations Other standards that could be audited – Side-effects – Drug interactions HAART – Safety of daily activities – Risks in pregnancy – Prognosis

Acknowledgement Dr J. Ahrens, HoD, Department of Mental Health, CoM Ms M. Kumwenda, psychiatric nurse, QECH Mr S. Maida

References 1. Stokes T, Shaw EJ, Juarez-Garcia A, Camosso- Stefinovic J, Baker R. Clinical Guidelines and Evidence Review for the Epilepsies: diagnosis and management of the epilepsies in adults and children in primary and secondary care. London; Available at: /29533.pdf. 2. Oakley C, Coccia F, Masson N, McKinnon I, Simmons M eds. 101 Receips for Audit in Psychiatry. London: RCPsych; 2011:47–48.

References World Health Organisation Health. mhGAP Intervention Guide. Geneva; Available at: MoH. Malawi Standard Treatment Guidelines. Fourth. Lilongwe; 2008:25–27. Amos A, Wapling L. Epilepsy in Malawi

Education never % primary % seconda ry % Total %

Age of onset by age group Age groupn% < >6411.5