Interventional programs to improve therapeutic management of people with epilepsy in low- and middle-income countries
Résumé
Objective: To assess the current status of initiatives carried out in developing countries to improve therapeutic
management of people with epilepsy.
Methods: A literature review was performed in 2015 to identify and analyze interventional programs carried out
in countrieswith low- and middle-income economies. Electronic databases were reviewedwith no time restriction.
Each intervention was categorized according to the level of evidence achieved (A: blind randomized controlled
trial, B: randomized controlled trial, C1: randomized trial, C2: controlled trial, D: prospective cohort, E:
retrospective evaluation).
Results: A total of 46 intervention projects were identified, 13with no quantitative assessment. The 31 remaining
projectswere carried out in 18 countries, 52% (16) in Africa, 42% (13) in Asia, and 6% (2) in Latin America. Among
those, 13% (4) were level B, 3% (1) C1, 6% (2) C2, 74% (23) D, and 3% (1) were level E. The effectiveness of the
intervention, assessed by the efficacy of antiepileptic drugs, was the primary objective in 81% (25). People
with epilepsy were on average seizure-free in 44.6% ± 14.4% of cases at one year, ranging from 25.0% to 78.4%.
At two years, on average 50.9% ± 29.7% are seizure-free, ranging from 4.6 to 92.7%. The median compliance
was 79.3% with a minimum of 21.6% and a maximum of 100.0%.
Discussion: No blind randomized controlled trial has been used to assess the efficacy of a programto improve access
to antiepileptic drugs (AEDs) in developing countries, and the level of evidence was globally low. Phenobarbital
remains the AED predominantly used in programs. Adherence to treatment management has been pointed
out to be a key element in the success of a program, sometimes not sufficiently considered. Monthly supply of
AEDs, at specific and community level, reducing the costs and time spent traveling, appeared to be the most effective
strategies. Homogenization and standardization of evaluation practices of programs to improve themanagement
of epilepsy in resource-limited settings would lead to comparison and meta-analysis which would
ultimately improve strategies of support for not only epilepsy but also other noncommunicable diseases in developing
countries.