Wide Variety Exists for First Antiseizure Medication Prescriptions in Children With Epilepsy

Alan Wu, MS

New data from an analysis of prescribing patterns for young children with epilepsy suggest that there is little standardization in first antiseizure medication (ASM) selection for this population, with drivers of the decision influenced by age, physician preference, insurance status, and race/ethnicity.¹

Collected via the Pediatric Epilepsy Learning Healthcare System (PELHS), the data include electronic health record information from 17 centers from 2017 to 2020. The patient population consisted of children with a first prescription of an ASM and a diagnosis of epilepsy before the age of 5 years.

The data were presented in a poster by Alan Wu, MS, a research biostatistician in the Division of Biostatistics and Epidemiology at Weill Cornell Medicine, at the 2022 American Epilepsy Society Annual Meeting, held December 2 to 6, in Nashville, Tennessee. “These data highlight the need for comparative effectiveness research to understand if variations in prescribing practices are linked to variations in outcomes,” Wu and colleagues concluded. They noted that additional efforts are underway currently to incorporate clinical drivers of ASM selection into the model, including seizure type, seizure burden, etiology, and comorbidity profile.

All told, the top 4 medicines that were prescribed as first ASMs were levetiracetam (n = 5358; median age, 2.6 years [IQR, 1.4-3.8]; 43% girls), clobazam (n = 496; median age, 2.9 years [IQR, 1.7-3.9]; 47% girls), oxcarbazepine (n = 1458; median age, 3.3 years [IQR, 2.2-4.2]; 44% girls), and phenobarbital (n = 5358; median age, 2.6 years [IQR, 0.1-1.2]; 42% girls). The remaining 1663 individuals (median age, 3.4 years [IQR, 1.8-4.3]; 43% girls) were treated with other medications, which included zonisamide, topiramate, and valproate, among others.

Levetiracetam was notably more commonly prescribed for children with public only insurance (odds ratio [OR], 1.16; 95% CI, 1.01-1.34) and less commonly prescribed with mixed insurance (OR, 0.88; 95% CI, 0.77-1.0) compared with those with private insurance. Clobazam, on the other hand, was more commonly prescribed for those with mixed insurance (OR, 1.59; 95% CI, 1.19-2.14), as was phenobarbital (OR, 1.75; 95% CI, 1.23-2.51), compared with those with private insurance.

Regarding race and ethnicity, associations were observed with the selection of levetiracetam, with Black patients being more likely to be prescribed the ASM than White non-Hispanic patients (OR, 1.26; 95% CI, 1.1-1.44). Similar associations were observed for clobazam, which was less commonly prescribed for Black patients than White non-Hispanic patients (OR, 0.63; 95% CI, 0.45-0.86).

“Understanding variations in health care delivered to children with epilepsy is foundational to design comparative effectiveness studies and to develop initiatives to improve health equity,” Wu and colleagues wrote.

Zachary Grinspan, MD, MS, a pediatric epilepsy specialist at Weill Cornell Medicine, in New York City, and a coauthor on the study alongside Wu et al, presented data from the PELHS earlier in the year which showed that the Pediatric Epilepsy Learning Healthcare System Quality of Life (PELHS-QOL-2) prompt is a valid HRQOL prompt for children with epilepsy, and can be used in clinical care as a way to consistently start conversations about quality of life with caregivers on the children with epilepsy.²

At the annual meeting, Grinspan told NeurologyLive^® more about the creation of PELHS, saying, “Several of my colleagues and I realized that every time we see a patient with epilepsy, a child with epilepsy, there's an ocean of data that's created. We see the patient in the clinic, we write our notes, and we draw labs. Sometimes they come to the hospital, we get EEGs on them, we do MRIs, we get genetic testing. They go for surgery, etc, etc. And all that data is sitting in all of our centers isolated just for clinical care.”

“Clinical care is important, but we want to learn, we want to do better. We want to give the best possible care to our children, for every child that comes through the door. We realized that we should use this ocean [of data] to learn,” Grinspan said. “What we did is we founded the Pediatric Epilepsy Learning Healthcare System, with generous donations grants from the Pediatric Epilepsy Research Foundation, from our centers, and from some other sources. We now have a data coordinating center at Weill Cornell Medicine, in New York City. We have data from 18 centers around the country. They ship us these huge datasets with raw electronic health record data that we then ingest into our data coordinating center, process it, standardize it, and then use it to learn.”

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REFERENCE
1. Wu A, Axeen EJT, Bhalla S, et al. Variations in prescribing practices for early life epilepsy: A Pediatric Epilepsy Learning Healthcare System study. Presented at: AES Annual Meeting; December 2-6, 2022; Nashville, TN, and virtual.
2. Shah PD, Yun M, Wu A, et al. Pediatric Epilepsy Learning Healthcare System Quality of Life (PELHS-QOL-2): A novel health-related quality of life prompt for children with epilepsy. Epilepsia. 2022;63(3):672-685. doi:10.1111/epi.17156