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Patients with epilepsy at increased risk for unnatural death
Patients with epilepsy were at a higher risk for unnatural death than those without epilepsy, according to findings recently published in JAMA Neurology.
“Though it is already known that patients with epilepsy are at a higher risk for death, we don’t know much about the risks of different types of death,” Hayley Gorton, PhD, MRPharmS, MPharm, FHEA, of the Centre for Pharmacoepidemiology and Drug Safety at the University of Manchester in England told Healio Family Medicine. “There has been a ‘call to action’ to encourage research to improve the understanding of risks of specific types of death. We addressed this call by using linked-primary care datasets so that we could understand risks involved with people with epilepsy in the general community.”
Researchers analyzed data from two prevalent epilepsy cohorts (CPRD: 44,678; SAIL Databank; 14,051) and matched comparison cohorts (CPRD: 891,429; SAIL Databank: 279,365). Fifty-one percent of the participants in both data sets were male, and the interquartile age range of all participants was 24 to 64 years.
Gorton and colleagues found patients with epilepsy were significantly more likely to die of unnatural causes (HR = 2.77; 95% CI, 2.43-3.16), unintentional injury or poisoning (HR = 2.97; 95% CI, 2.54-3.48), or suicide (HR = 2.15; 95% CI, 1.51-3.07) vs. those in the comparison cohort.
In addition, researchers noted “particularly large” risk increases in the patients with epilepsy for intentional self-poisoning with medication (HR = 3.55; 95% CI, 1.01-12.53) and unintentional medication poisoning (HR = 4.99; 95% CI, 3.22-7.74). Psychotropic medications were involved in 32.3% (95% CI, 20.9-45.3) of poisoning deaths and opioids were involved in 56.5% (95% CI, 43.3-69) of poisoning deaths in patients with epilepsy, while antiepileptic drugs were responsible for 9.7% (95% CI, 3.6-19.9) of such deaths.
“At this stage, it seems sensible to suggest that physicians should talk to people with epilepsy about how to reduce their risk of accident and to ask them about any suicidal thoughts or actions. Prescribers should also be aware of the toxicity of concomitantly prescribed medications for other conditions in people with epilepsy in light of the increased poisoning risk,” Gorton said in the interview.
“Future research that helps us fully understand what causes these increased risks that apply different designs and methods to the routinely collected databases that we utilized to conduct this study, would be needed before developing, evaluating and implementing interventions to reduce these risks,” she continued.
In a related editorial, Orrin Devinsky, MD, of the department of neurology at the New York University Langone Center, and colleagues wrote that though the study findings support previous research on the same topic, Gorton and colleagues’ findings still “shed light on an enormous problem hiding in plain sight.”
They also wrote the current health care system does not treat all patients equally and suggested increasing availability to care, better comprehending of patients with epilepsy experiences and providing better education to medical students and trainees would end the discontinuity.
Devinsky and colleagues also wrote that additional studies on this subject matter would narrow the health care bridge.
“Our basic science, epidemiologic, and clinical researchers need to explore the tangled thicket where neurology and psychiatry meet,” they wrote. “The National Institutes of Mental Health and Neurological Disorders and Stroke should encourage researchers to explore this overlap and develop effective therapies.” – by Janel Miller
Disclosure: Devinsky reports receiving grant support paid to New York University Langone Medical Center from GW Pharmaceuticals. No other relevant financial disclosures were reported.
Perspective
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The findings by Gorton and colleagues do not surprise me. There has always been a big emphasis on telling people about sudden death in patients with epilepsy, but we have known this is only one danger that people with epilepsy face. The results of their research complement those from a recent article in Neurology that showed the link between pedestrian accidents and patients with epilepsy. Based on these multiple findings, neurologists and primary care physicians alike need to caution their patients with epilepsy about how to keep themselves safe. Perhaps the one that Gorton and colleagues found that is most surprising is the accidental poisonings, in the sense of what that means and who that is relevant for.
Many researchers, including Gorton and colleagues, trade off data quality for large numbers when they cite ‘big data’ — they know something is going on, but they do not have enough detail to say who it is happening to. This can sometimes hinder the ability to determine which subsets of the population the findings are relevant for. Thus, there is not enough information to make recommendations on changing the clinical practice based on the JAMA Neurology authors’ findings. We need to do more digging to know the population most at risk and by how much.
Reference:
Sundelin HEK, et al. Neurology. 2018;doi:10.1212/WNL.0000000000005210.