Keywords
Epilepsy - Primary Health Care - Health Centers - Drug Resistance
Palavras-chave
Epilepsia - Atenção Primária à Saúde - Centros de Saúde - Resistência a Medicamentos
INTRODUCTION
Epilepsy poses a global health challenge, affecting a staggering 50 million individuals
across the world. A significant majority of these cases, in low-middle income countries.[1]
[2]
[3]
[4] This glaring inequality highlights the pressing need for improved epilepsy care
and management in regions that often face resource limitations and healthcare disparities.
In the context of Brazil, the landscape of epilepsy is no less intricate. The prevalent
population of 1.8 million actively epileptic patients and nearly 340 thousand new
cases estimated per year demonstrates the importance of this condition in the country.[3] Epilepsy represents a significant burden on morbidity and mortality rates, with
outcomes intertwined with the often-challenging nature of managing the condition.
Around 2/3 of cases can attain such control through a single medication regimen; however,
the remaining 33% becomes pharmacoresistant. Because of this subset of patients, management
requires not only medical attention but also the expertise of a specialized multidisciplinary
epilepsy team.[5]
[6]
In regions where economic disparities and healthcare infrastructure gaps persist,
such as in less developed nations, the scarcity of neurologists and epileptologists
compared with the number of individuals afflicted by epilepsy creates a dissonance.
This dissonance, prominently evident within the framework of public health, underscores
the need for strategic resource allocation and priority setting. This decision-making
process dictates who should be granted access to specialized interventions and when
such interventions are warranted. The gateway to the public healthcare system, in
many instances, is the primary care unit, which facilitate referrals to tertiary reference
centers.[7] Consequently, the competence of these primary care practitioners takes on importance,
spanning a spectrum from accurate comorbidity diagnosis, adept management of controllable
cases, mitigation of treatment-induced effects, and identification of patients who
require specialized care.[8]
[9]
The mentioned study aimed to assess the knowledge of primary care medical professionals
in the state of Rio de Janeiro regarding a range of topics associated with epilepsy.
The initiative sought to contribute to the planning of educational intervention measures
that could enhance the understanding and treatment of epilepsy by these professionals.
METHODS
Specialists in the field of epilepsy at Instituto Estadual do Cérebro Paulo Niemeyer
(in Rio de Janeiro/RJ) developed a course covering critical concepts related to epilepsy.
The course had a total duration of 8 hours and addressed essential topics, including:
epidemiology, diagnosis, classification, treatment modalities, prognosis, pertinent
societal matters, and the evolving landscape of epilepsy policies as exemplified in
[Table 1].
Table 1
Course schedule
|
Week one: Introductory class part I: Basic concepts in epilepsy
|
ILAE's semiology classification and Amaneses
|
|
Week two: Introductory class part II: Basic concepts in epilepsy
|
Differential diagnosis, PNES, and epilepsy pharmacoresistance
|
|
Week three: When to refer?
|
When to refer patients to a tertiary center? Which exams are necessary?
|
|
Week four: Pharmacology part I
|
What do primary care physicians need to know?
|
|
Week five: Pharmacology part II
|
Adverse effects and main interactions
|
|
Week six: Special populations
|
Pregnancy, elderly and when to think about “unprescribing” medications
|
|
Week seven: Pharmacology part III
|
Psychiatric disorders and convulsive initial management
|
|
Week eight: Non-pharmacological treatments
|
Surgery, VNS, DBS, ketogenic diet, and cannabidiol
|
Abbreviations: DBS, deep brain stimulation; ILAE, International League Against Epilepsy;
PNES, psychogenic nonepileptic seizures; VNS, vagus nerve stimulation.
The methodology employed in the course entailed the distribution of questionnaires
that delved into the specified topics, aiming not only to evaluate participants' knowledge
levels but also to discern the characteristics of the population they served. Through
their answers in a precourse questionnaire, we summarized the main points involving
the reality of caring for patients with epilepsy in primary centers, from concepts
about the disease, reasoning for therapeutic decisions and the difficulties in managing
these patients in the public health context. The questionnaire is described in [Supplementary Material S1] (https://www.arquivosdeneuropsiquiatria.org/wp-content/uploads/2024/04/ANP-2023.0259-Supplementary-Material.docx).
RESULTS
The course engaged a total of 66 participants, with an impressive completion rate
of 92.4% (61 individuals). Within this cohort, 54.5% (36) were engaged in the pursuit
of studies or were undergoing residency in family medicine, while 45.5% (30) were
general physicians serving within basic health units (UBSs). The profile from years
of practice is resumed in [Figure 1]. The participants' epilepsy-related knowledge had primarily been acquired through
their graduation for 41 individuals (62.1%), residency for 19 (28.8%), and self-guided
learning for 6 (9.1%).
Figure 1 Profile of professionals by time of clinical practice.
In exploring epidemiological aspects concerning their patients with epilepsy, the
predominant age group was adults (78.8%), trailed by adolescents (27.3%), children
(21.2%), the elderly (10.6%), and infants (3%). Among these age groups, a proportion
of patients remained under seizure control for more than 6 months (39/59.1%) or were
seizure-free for more than 2 years (15/22.7%).
The survey uncovered that 16 participants (24.2%) had pregnant patients, all of whom
expressed a lack of confidence in managing such cases. Additionally, 28 participants
(42.4%) attended to elderly patients, out of which 75% expressed discomfort treating
them without specialist follow-up.
Addressing therapeutic adherence barriers, participants highlighted limited medication
availability through the public system (50/75.8%), patients' financial constraints
(34/51.5%), challenges in comprehending dosage instructions (31/47%), concerns about
drug interactions (14/21.2%), and reservations surrounding controlled medications
(4/6.1%).
When confronted with a report of a single suspicious event with negative investigation
outcomes and no initial anti-epileptic drug use, or the use of a single medication
without seizure control, 43 participants (65%) referred their patients to a tertiary
service. Among the physicians, 30 (45.5%) requested specialized assessments without
the preliminary test results due to regulatory delays. Among those who initiated the
regulation process, a substantial 86.4% (57) reported a lack of feedback from subsequent
neurological follow-ups.
Participants identified key diagnostic tests, as electroencephalogram (EEG) (49/74.2%),
serum laboratory tests (53/80.3%), and cranial tomography (CT; 39/59.1%). Only 3 (4.5%)
indicated that they would request a brain magnetic resonance imaging (MRI).
Turning to general epilepsy concepts, 51 participants (78%) struggled to accurately
classify seizure semiology and types and 13 (19.6%) were proficient in defining the
concept of pharmacoresistance. A consensus emerged that normal electroencephalogram
(EEG) and computed tomography (CT) scans do not rule out epilepsy, yet half of the
participants equated an altered EEG with epilepsy.
Their treatment preferences are summarized in [Figure 2]. No professional reported prescribing levetiracetam, despite its availability in
the public health system.
Figure. 2 Treatment preferences per participant.
In addition, 15 participants (22.7%) did not consider seizure type a determining factor
in therapeutic decisions. Their main considerations for treatment choice are described
in [Figure 3].
Figure 3 Main considerations for treatment choice in percentage.
Regarding non-pharmacological therapies, a significant proportion of participants
were aware of the potential use of cannabidiol (50/75.8%), followed by surgical options
(27/40.9%), the utility of the ketogenic diet (15/22.7%), and neuromodulation methods
(deep brain stimulation/vagus nerve stimulation, DBS/VNS; 15/22.7%).
DISCUSSION
Epilepsy ranks as the second most burdensome neurological disorder.[10] Its trajectory hinges on the effective control of seizures through diverse interventions,
ranging from medications to surgical procedures. The condition also has a social stigma
reverberating into different areas of an individual's life, thereby incurring indirect
costs for society.[11]
[12]
In Brazil, the primary care interface enables the assessment of referral necessity
to tertiary and quaternary centers.[13]
[14] However, these higher-tier centers remain scarce, giving rise to a dearth of available
slots relative to population demand. Consequently, stringent criteria become imperative
to discern cases warranting specialized attention from those feasibly managed within
primary care.[15]
[16]
[17]
[18]
[19]
[20]
This situation stems from issues spanning not only the capabilities of family and
community medicine (FCM) units but also the professionals' unease in managing epilepsy
comorbidities.[21]
[22]
Our study, involving FMC professionals in Rio de Janeiro, highlights gaps in management:
as outdated concepts about epilepsy due to the greater proportion of education on
the topic coming only from undergraduate level. This training also impacts the choice
of therapy, as despite newer, and more tolerable medications are provided by public
health, there is a persistence toward first and second-generation drugs, misunderstanding
around newer drugs, like levetiracetam, and the idea that gender and comorbidities
do not have much impact on the choice of medication.
It was noted that referral to tertiary centers occurs even in cases of pharmacosensitive
monotherapy and are referred even without the necessary mandatory exams due to the
delay in carrying them out by the SUS. This highlights challenges linked to the availability
of the necessary exams and with the absence of a coherent referral pathway for tertiary
centers.
In summary, our study illuminates the pressing requirement for sustained education
in epilepsy care for primary care professionals aiming to provide better patient care
and optimize the resources of the public health system.
Bibliographical Record
Vanessa Cristina Colares Lessa, Marília Bezerra Magalhães Martins, Alexandra Seide
Cardoso Vidal, Leonardo Alves Araujo, Isabella D'Andrea Meira. The reality of epilepsy
in primary care in Rio de Janeiro: the importance of educational projects for better
patient care. Arq Neuropsiquiatr 2024; 82: s00441787796.
DOI: 10.1055/s-0044-1787796
