According to the WHO, there are nearly 50 million people with epilepsy (PWE) worldwide and 80% of them reside in developing countries. Among them, nearly 12 million reside in India, amounting to nearly one-fifth of the global burden. The estimated proportion of the worldwide general population with active epilepsy [defined as “the affected person has had at least one seizure in the previous 5 years, regardless of the antiepileptic drugs (AEDs) used] at a given time is between 4 and 10 per 1000 people; however, in low and middle-income countries, the proportion is much higher, ranging between 7 and 14 per 1000 people. The treatment gap in epilepsy (i.e., the percentage of people with untreated epilepsy) in India ranges from 22% in the urban setting to as high as 90% in villages. In a recent population-based prospective study on epilepsy conducted over 5 years (2003–2008) in Kolkata, India, on randomly selected 100,802 participants (males 53209, females 47593), there were 476 participants with active epilepsy and the age-adjusted prevalence rate was 4.71 per 1000. Over 5 years, there were 197 incident cases of epilepsy, of whom 26 died. The age-adjusted annual incidence rate of epilepsy was 38.3 per 100,000, and the all-cause standardized mortality rate of epilepsy was 2.4. The burden of epilepsy during the years 2007–2008 revealed that the overall years of life lost (YLL) were 755 per 100,000 general population, and the overall years of lives lived with disability (YLD) ranged from 14.45 to 31.0 per 100,000 persons, depending on the clinical severity of epilepsy. Both YLL and YLD values were higher in male than in female patients.
There is a differential distribution of epilepsy among various demographic and economic strata with higher rates reported in the male gender, rural population, and those hailing from a low socioeconomic status. In our country, central nervous system infections, neurocysticercosis, head trauma, and birth injuries have emerged as major risk factors for secondary epilepsy. Despite these grim statistics, majority of epilepsies and epilepsy syndromes are treatable, especially with the emerging knowledge regarding each of them, and better treatment options available, both medical and surgical. In almost all of the studies done at any point of time in India, the prevalence of epilepsy was found to be more in the rural than in the urban population. In a population-based neuroepidemiologic survey among 102,557 individuals in urban and rural Bengaluru in Southern India, the prevalence of epilepsy was reported to be nearly two times higher in rural areas as compared to urban areas.
Regarding treatment of epilepsy, with more than a minimum of 20 AEDs available in the market at a given point of time, at least 200 dual therapies and more than 1000 combinations with three AEDs are possible. However, it is impossible to try every permutation of these in a single life time. PWE dwelling in rural areas cannot afford the annual price of newer AEDs. Moreover, in patients who are on AED polytherapy, the majority of seizures are precipitated by drug default. Most of the primary health centers provide drugs such as carbamazepine (CBZ), phenytoin (PHT), phenobarbitone (PB), and valproate (VPA) free of cost. Moreover, drugs such as CBZ and PHT still remain the first-line AEDs for treatment of focal epilepsy. VPA is the drug of choice for generalized epilepsy syndromes such as juvenile myoclonic epilepsy. PB likewise is a boon for poor patients, where the choice has to be made between PB versus “no-treatment,” rather than between PB versus “newer AEDs.”Neurocognitive deficits, which have been feared, are far and few and the efficacy of the primary anticonvulsants far outweigh the problems of the toxic reactions that occasionally occur.
The appropriate use of AEDs results in adequate seizure control in approximately 50–60% of PWE. Among the remaining people, usually in the context of an idiopathic focal epilepsy syndrome, 20% continue to experience a few seizures before spontaneous remission occurs. However, the remaining 20% continue having refractory seizures despite the use of AEDs, either as monotherapy or polytherapy. The pharmacological treatment of epilepsy has been extensively studied primarily in high income countries. In view of the refractory epilepsy, newer AEDs are constantly being developed with the precise aim to tackle epilepsy through different mechanisms of action, while ensuring better safety profile and fewer drug interactions. In addition, cognitive, psychosocial and gender issues have gained more attention, with the result that quality of life has become the central focus of epilepsy care. However, no AED has a perfect combination of high efficacy, low toxicity and cost, and a good pharmacologic profile. Moreover, in conditions such as temporal lobe epilepsy (TLE), it is well-known that people who undergo early epilepsy surgery have a better quality of life in terms of reduced seizure frequency, better neuropsychological outcome, and even a life free from AEDs.
Progress in epilepsy care has inevitably escalated its cost as well. There has been much debate on the economic aspects of newer AEDs used in the treatment of epilepsy. Most clinicians have little exposure to health economics because it is a relatively new discipline in health sciences. The International League Against Epilepsy