Therapeutic drug monitoring in epilepsy clinic: a multi-disciplinary approach.

Epilepsy is a common public health problem and needs multi-disciplinary treatment. Therapeutic drug monitoring (TDM) is one of step of the multi-disciplinary treatment in epilepsy at Epilepsy clinic, Khon Kaen University (Thailand). The TDM service has been established since 2008. Here, we aimed to study the roles of TDM order and epilepsy control. This is a prospective descriptive study in which data collection was done from January 1 to December 31, 2010, the period when pharmacists took part in assessing the appropriateness in measurement and interpretation of TDM in order to provide suggestions for physicians. The 112 patients under study had an average age of 38.21±15.36 years; 254 samples were collected for therapeutic drug monitoring; phenytoin was submitted mostly for drug monitoring at 46.46%; 44.49% of submissions for drug level monitoring were made owing to a suspected sub-therapeutic level. Associations were found between reasons of sending samples for drug level monitoring and the measured drug levels, i.e., 66.67% of drug levels found was so low that they were undetectable in sample for patients' compliance investigation and 38.94% of the drug levels were found to be sub-therapeutic as for the case where submission of samples was done because of suspected sub-therapeutic level, 40% of the cases were found to be in toxicity range in the cases with suspected over-therapeutic levels and monitoring levels, 58.25% were found to be within the therapeutic range. Pharmacists used the interpreted results in patients' care by recommending physicians to monitor therapeutic drug closely, to adjust the dosage of drugs, and to recommend checking patients' compliance in their use of drugs at 56.5, 38.9, and 4.3%, respectively. Physicians' responses were found to be absolute follow, partial follow and not follow at 77.95, 11.03, and 7.48%, respectively. In conclusion, associations were found between reasons of TDM order and measured drug level. Therapeutic drug monitoring services at the Epilepsy Clinic was useful in supporting clinical information queries. Pharmacists could make use of interpreted drug level information by recommending physicians to monitor drug levels and adjust individual dosage regimen accordingly. It should be noted that physicians accepted pharmacists' recommendation, denoting multi-disciplinary care team that would lead to greater efficiency.

Adherence to mineral and bone disorder clinical practice guidelines in chronic kidney disease.

BACKGROUND: Mineral and bone disorders (MBD) in patients with chronic kidney disease (CKD) are cardiovascular risk factors. Clinical practice guidelines were developed to prevent MBD and to decrease cardiovascular events in CKD patients. OBJECTIVE: To determine adherence to mineral and bone disorder clinical practice guidelines (MBD-CPG) in chronic kidney disease patients. MATERIAL AND METHOD: A retrospective, observational study was performed on 206 patients with CKD stage 3, 4, and 5 that were followed-up at pre-dialysis and dialysis clinic, Nephrology Unit, Srinagarind Hospital between July and September 2007. RESULTS: The mean percentages of adherence in each patient were 89.5% for calcium monitoring, 88.6% for phosphate monitoring and 17.1% for PTH monitoring. The mean percentage of adherence to using of phosphate binder in each patient was 84.6%. The mean percentage of adherence to using of vitamin D3 was 72.2% in patients who had all three clinical parameters monitoring. The K/DOQI 2003 target recommendation achievements at the end of study were 73.7% for serum calcium, 76.1% for serum phosphate, 94.6% for calculated CaxP product, and 23.7% for serum PTH. The mean percentage of K/DOQI 2003 target recommendation achievement, in each patient during 12 months of postindex period, were: 79.3% for serum calcium, 78.1% for serum phosphate, 95.8% for serum CaxP product and 26.3% for serum PTH. The 100% achievement of target recommendations for serum calcium, serum phosphate and serum CaxP product were statistically, significant different, when compared between the group of 100% and 75.0-99.9% adherence to using phosphate binder, with the odd ratio 5.43 (95% CI 2.43-12.11) for serum calcium achievement, 11.33 (95% CI 4.63-27.72) for serum phosphate achievement and 11.75 (95% CI 2.92-47.24) for CaxP product achievement. CONCLUSION: The use of vitamin D3, monitoring of serum PTH and achieving of PTH target level, are still far from recommendations. Therapeutic end point for cardiovascular and bone diseases should be investigated in long-term studies.

Patient self-reporting of potential adverse drug reactions to non-steroidal anti-inflammatory drugs in Thailand.

OBJECTIVES: To validate and pilot in Thailand a questionnaire to enable patients to identify and report symptoms perceived as potential ADRs from NSAIDs. To determine the questionnaire's usefulness in enabling Thai out-patients to report potential ADRs. To determine the frequency with which symptoms patients reported were recorded by health professionals and the frequency of ADRs to these drugs reported to the APRM Centre. To assess whether patients reported symptoms from non COX-selective inhibitors and COX-2 selective NSAIDs with different frequencies. SETTING: Out-patient departments (OPD) of a University teaching hospital in North-East Thailand. METHOD: A questionnaire which incorporated an extensive symptoms checklist, developed and validated in English, was translated, piloted and validated in Thai. This was distributed to patients receiving one of five NSAIDs. Causality assessment of the symptoms reported was undertaken by a pharmacist, using data on concomitant medicines and disease states from OPD records. OUTCOME MEASURES: Frequency and type of symptoms reported by patients, recording of these in OPD records, reports sent to APRM Centre. RESULTS: Piloting found that patients were able to understand the questionnaire, but were unaware of drug names. A response rate of 42% was obtained: 694 usable questionnaires were returned out of 1,654 distributed. Overall 73% of respondents reported at least one symptom perceived to be an ADR. Sixty percent of symptoms reported were classed as probably or possibly an ADR. Fewer symptoms per patient were reported by those taking COX-2 selective inhibitors (3.5) than those taking non-selective NSAIDs (5.5), although there were no differences in the frequency of GI symptoms reported between these two sub-classes, which may relate to other factors, such as age, previous GI problems and prescription of protective ulcer-healing therapy. Only 5% of symptoms were recorded in OPD records and reporting of ADRs to these drugs to the APRM Centre of the Thai FDA during the study was very limited. CONCLUSION: Thai out-patients were willing and able to complete questionnaires regarding potential ADRs. The questionnaire could form part of routine out-patient monitoring, aiding identification of ADRs, and may help to increase ADR reporting in Thailand.

Predictive risk factors of seizure-related injury in persons with epilepsy.

OBJECTIVE: The clinical risk factors for seizure-related injuries (SRI) in adult persons with epilepsy (PWE) were studied and analyzed to develop a predictive model. METHODS: We enrolled 300 consecutive cases from three epilepsy clinics in Northeast, Thailand. Subjects were eligible if reported to have at least one seizure attack during the past 12 months. Face-to-face questionnaire was used to evaluate SRI, baseline characteristics and other seizure-related variables. RESULTS: There were 247 and 91 PWE who met a criterion and had SRI, respectively. By multivariate logistic regression method, GTC seizure type, having history of seizure attacks at least 12 times/year, and daytime seizure were significant risk factors of having SRI with odds ratio of 2.376, 2.460, and 3.562, respectively. We developed the predictive model for having SRI in PWE and it gave 90.3% sensitivity and 46.7% specificity on the occurrence of SRI. The estimated probability of SRI can be found online at http://sribykku.webs.com/. CONCLUSIONS: The significant predictive factors for SRI in PWE were the occurrence of GTCs, seizures at least 12 times/year or daytime seizures. Clinicians or PWE can easily evaluate the risk of having SRI in individuals by the online predictive model.

Basic knowledge of epilepsy among medical students.

BACKGROUND: The medical students' knowledge about basic medical neuroscience in the preclinical level may be fragmented and incomplete. OBJECTIVE: Evaluate the knowledge of students prior to a lecture on epilepsy in clinical level. MATERIAL AND METHOD: One hundred ten fourth-year medical students' knowledge was accessed by a self-administered questionnaire. RESULTS: The presented results revealed that 91.8% of respondents knew that epilepsy arose from a transient dysfunction in the brain. Generalized tonic-clonic seizures (GTCs) were the most common type (91.5%) they knew and absence seizures were the least common type (33.6%) they knew. All of them knew that eating pork and punishment of gods did not cause epilepsy. However 50% thought that genetics was a cause and 80.3% did not know that stroke and sleep deprivation (92.7%) cause epilepsy. About treatment and prognosis, only 28.2% of respondents thought epilepsy can be cured and patients should take antiepileptic drugs (AEDs) for seizure free 2-5 years (48.2%), life long (33.6%). They knew that the patients should be prohibited from driving (80%), working on machinery (74.5%), and (27.3%) avoid drinking. However, they knew that the patients could marry (100%), get pregnant (98.2%), and lactate (91.9%). Regarding the first aid management, 50.9% of them recommended that placing a piece of wood between the teeth during a seizure and perform chest compressions (20.0%). Means knowledge scores is about 60%, the highest score is the definition of epilepsy (90.2%) and the lowest is type of seizure (43%). CONCLUSION: The findings indicated that lecturers should review aspects ofpathophysiology and emphasize on type of seizure, cause, consequences, and prognosis including first-aid management.

Very high dose phenobarbital for refractory status epilepticus.

BACKGROUND: Refractory status epilepticus (RSE), defined as status epilepticus that fails to respond to first, second and third-line therapy. The RSE is associated with high morbidity and mortality. Treatment guidelines of RSE give a spectrum of options, such as, continuous intravenous (i.v.) midazolam (MDL), or continuous i.v. propofol (PRO) as alternatives to phenobarbital (PB) or continuous i.v. pentobarbital (PTB). OBJECTIVE: To study the efficacy of very-high-dose phenobarbital (VHDPB) for treatment RSE. STUDY DESIGN: Retrospective study MATERIAL AND METHOD: The authors collected and analyzed data from adult patients who were diagnosed with RSE. RESULTS: The authors present 10 patients with RSE who were treated with VHDPB. All of them were generalized convulsive status epilepticus (GCSE). Ages ranged from 16-86 years old (mean.: 43 years). PB dosage ranged 40-140 mg/kg/day (mean: 70 mg/kg/day). The duration of status epilepticus (SE) varied widely, ranged 1-44 days (mean: 7 days). PB level ranged 35.29-218.34 ug/mL (mean 88.1 ug/mL). RSE was controlled by VHDPB 70%, 30% were not controlled. CONCLUSION: VHDPB were considered as alternative treatment for RSE.

Knowledge of epilepsy among teachers in Khon Kaen Province, Thailand.

INTRODUCTION: Epileptic patients face social stigmatization due to negative attitudes and incorrect knowledge on epilepsy. OBJECTIVES: To evaluate knowledge of epilepsy among teachers in Khon Kaen province. MATERIAL AND METHOD: A self-administered questionnaire distributed to 102 teachers who attended the training lectures on epilepsy. The number of correct responses for each item were collected. The statistical analysis included the percentage of correct response and the means of the total scores. RESULTS: Most (78.4%) respondents understood that a seizure is an abnormal electrical discharge in the brain, while 54.9% thought it included a form of abnormal movement and 1% demonic possession. The generalized tonic-clonic seizure (GTCs) was the type of seizure with which most respondents were familiar (90.2%), while 23.5% had knowledge of absence seizures. The respondents identified the following as causes for epilepsy: 1) head injury (84%); 2) genetic disease (74.5%); 3) high fever (68%); and, 4) brain tumor (57%). A small minority associated epilepsy with eating pork (11%) and even fewer (2%) with a non-organic/non-physical cause. Only 16% of respondents thought epilepsy was incurable, and a quarter (27%) of the teachers thought epileptics required anti-epileptic drugs (AEDs) life long, while 20 and 9 percent believed patients would take AEDs for 3-6 months and only for episodes, respectively. About 57% of the teachers thought epileptics needed AEDs for 2-5 years. Most (77-79%) respondents thought epileptics were prohibited from using machinery or driving, and 63% thought alcohol would be prohibited. Almost two-thirds of the teachers (64%) thought they should try to place an object between the teeth of a person having an episode in order to prevent a biting injury to the tongue and 27% would restrain the person and perform chest compressions (CPR). The average total score for correct answers on the questionnaire was about 60% (29.26/50). Respondents generally understood that epilepsy is controllable (82%) and were able to identify a seizure (78.4%). The lowest scores were found in the section on identifying the types of seizures (37.8%). CONCLUSION: Teachers' knowledge of epilepsy was incomplete; thus, an epilepsy education campaign is needed and should emphasize the types of seizures, the causes of epilepsy, and management.