Bad medicine: epilepsyBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3396 (Published 28 May 2013) Cite this as: BMJ 2013;346:f3396
- Des Spence, general practitioner, Glasgow
Money is the great motivator. The anticonvulsant drug phenytoin was recently replaced by a generic, in exploitation of a loophole in UK policy and increasing the cost to the NHS by £40m (€46.8m; $60.3m).1 Epilepsy is profitable, with lifelong multiple medication, so a huge range of putatively new drugs have been developed to seek a slice of the profits. These are all pitched at the same price, in the drug industry’s traditionally sham competition. Anticonvulsants have an additional big business bonus, as well. The industry has been fined billions for promoting anticonvulsants off licence in pain and psychiatry specialties.2 3 4 5 6 ⇑
Antiepileptic prescriptions in England rose from seven to 17 million in a decade, with annual costs near tripling to £389m.7 These large increases are attributable to the new antiepileptics, despite these having no proved benefit over older drugs such as valproate and lamotrigine.8 9 There is also emerging evidence that new drugs are being used inappropriately.10 These prescribing patterns must also reflect increasing polypharmacy in epilepsy. Yet monotherapy is the treatment goal, and polypharmacy adds little to seizure control.11 12
Rapid, unexplained increases in prescribing are a hallmark of overdiagnosis. So is this happening in epilepsy, especially partial or focal epilepsy? In partial epilepsy, unlike generalised tonic-clonic seizures, the diagnosis is often only clinical,13 with defining symptoms such as déjà vu, detachment, feeling frightened, memory problems, tingling, and many more subjective effects. All diagnoses based on self reporting and clinical judgment are open to overdiagnosis phenomena.
Yet there is scant epidemiological data on changes in the prevalence of epilepsy in adults, and concerns about overdiagnosis are merely anecdotal. Paradoxically, in children, for whom a diagnosis of epilepsy is less subjective, incidence has halved since the mid-1990s.14 Accurate diagnosis is fundamental in epilepsy because treatment is life long, although epilepsy often spontaneously resolves.15 There are, however, no national initiatives to withdraw anticonvulsant drugs.
Some of the rationale for more prescribing in epilepsy is to protect against the rare but devastating SUDEP (sudden unexpected death in epilepsy). SUDEP is most commonly associated with people with tonic-clonic epilepsy activity, not partial non-generalised epilepsy.16 Although undoubtedly seizure control reduces SUDEP,17 there is no evidence that this massive increase in antiepileptic treatment has had an impact on SUDEP. Lastly, predictably, and depressingly, the educational agenda of epilepsy is a gravy train of international conferences and drug industry sponsorship.18 The numbers for antiepileptic prescribing just don’t stack up clinically, demand research, and risk overtreatment. This is bad medicine.
Cite this as: BMJ 2013;346:f3396
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; externally peer reviewed.
Follow Des Spence on Twitter @des_spence1