Strategies for improving adherence to antiepileptic drug treatment in people with epilepsy
Abstract
Background
Poor adherence to antiepileptic medication is associated with increased mortality, morbidity and healthcare costs. In this review, we focus on interventions designed and tested in randomised controlled trials and quasi‐randomised controlled trials to assist people with adherence to antiepileptic medication. This is an updated version of the original Cochrane review published in the Cochrane Library, Issue 1, 2010.
Objectives
To determine the effectiveness of interventions aimed at improving adherence to antiepileptic medication in adults and children with epilepsy.
Search methods
For the latest update, on 4 February 2016 we searched the Cochrane Epilepsy Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO), MEDLINE (Ovid 1946 to 4 February 2016), CINAHL Plus (EBSCOhost 1937 to 4 February 2016), PsycINFO (EBSCOhost 1887 to 4 February 2016), ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform. We also searched the reference lists of relevant articles.
Selection criteria
Randomised and quasi‐randomised controlled trials of adherence‐enhancing interventions aimed at people with a clinical diagnosis of epilepsy (as defined in individual studies), of any age and treated with antiepileptic drugs in a primary care, outpatient or other community setting.
Data collection and analysis
All review authors independently assessed lists of potentially relevant citations and abstracts. At least two review authors independently extracted data and performed quality assessment of each study according to the Cochrane tool for assessing risk of bias. We graded the level of evidence for each outcome according to the GRADE working group scale.The studies differed widely according to the type of intervention and measures of adherence; therefore combining data was not appropriate.
Main results
We included 12 studies reporting data on 1642 participants (intervention = 833, control = 809). Eight studies targeted adults with epilepsy, one study included participants of all ages, one study included participants older than two years, one study targeted caregivers of children with epilepsy, and one study targeted families of children with epilepsy. We identified six ongoing trials. Follow‐up time was generally short in most trials, ranging from one to 12 months. The trials examined three main types of interventions: educational interventions, behavioural interventions and mixed interventions. All studies compared treatment versus usual care or 'no intervention', except for two studies. Due to heterogeneity between studies in terms of interventions, methods used to measure adherence and the way the studies were reported, we did not pool the results and these findings were inappropriate to be included in a meta‐analysis. Education and counselling of participants with epilepsy resulted in mixed success (moderate‐quality evidence). Behavioural interventions such as use of intensive reminders provided more favourable effects on adherence (moderate‐quality evidence). The effect on adherence to antiepileptic drugs described by studies of mixed interventions showed improved adherence in the intervention groups compared to the control groups (high‐quality evidence).
Authors' conclusions
Behavioural interventions such as intensive reminders and the use of mixed interventions demonstrate some positive results; however, we need more reliable evidence on their efficacy, derived from carefully‐designed randomised controlled trials before we can draw a firm conclusion. Since the last version of this review, none of the new relevant studies have provided additional information that would lead to significant changes in our conclusions. This current update includes 12 studies, of which six came from the latest searches.
PICOs
Plain language summary
Strategies for improving how people with epilepsy take their medication
Background
People with epilepsy can find it difficult to take their medicines as prescribed, and this is thought to be a reason for poor control of seizures. This review of trials reports on ways of improving how they take their antiepileptic medication.
Study characteristics
We searched scientific databases for clinical trials looking at ways of improving adherence to drug treatment in people with epilepsy. We limited our search to randomised controlled trials involving people with a clinical diagnosis of epilepsy of any age and treated with antiepileptic drugs in a primary care, outpatient or other community setting. The results are up‐to‐date to February 2016.
Key results
We identified twelve trials (1642 participants). The trials were conducted in different countries with the majority from the United States. The trials examined three main types of interventions: i) education and counselling of participants about topics such as epilepsy and medication used to control epilepsy, ii) behavioural interventions such as asking epileptic patients to link the intention of taking their medication with a particular time, place and other routine activity and iii) the use of more than one intervention (mixed interventions). Behavioural interventions and mixed interventions resulted in an improved adherence in the intervention groups compared to the control groups. Four trials showed that when adherence improved in the intervention groups, seizure frequency or seizure severity was decreased.
Many of the included trials are of moderate quality and have limitations in the design. Therefore, it is difficult to draw firm conclusions. We need carefully‐designed randomised controlled trials involving more people with longer follow‐up periods to identify the best intervention to improve adherence to antiepileptic medication.
