Use of Newer Antiseizure Meds for Epilepsy Differ by Race, Ethnicity

Racial and ethnic minority groups are less likely to be taking newer-generation antiseizure medications (ASMs) for their epilepsy, an analysis of Medicaid data showed.

Compared with white patients, Black (adjusted OR 0.71, 95% CI 0.68-0.75), Hispanic (aOR 0.93, 95% CI 0.88-0.99), and Native Hawaiian/Pacific Islander (aOR 0.77, 95% CI 0.67-0.88) patients had lower odds of being on newer ASMs, reported Wyatt Bensken, PhD, of Case Western Reserve University in Cleveland, and co-authors.

Of note, taking a second-generation ASM was associated with better treatment adherence (aOR 1.17, 95% CI 1.11-1.23), and those seeing a neurologist had higher odds of being on newer ASMs (aOR 3.26, 95% CI 3.13-3.41), the researchers detailed in Neurology Clinical Practice.

“Being on a newer, second-, and third-generation ASM may represent an important marker of quality of care for people with epilepsy,” Bensken and team wrote, citing evidence that newer ASMs are associated with fewer side effects and more effective seizure control.

“From the patterns we observed, there is the potential that a sizeable proportion of people with epilepsy may not be on an optimal ASM regimen, and the differences appear to reflect clear racial and ethnic inequities in epilepsy care,” they added.

Supplemental analyses showed that a slightly higher percentage of Black patients saw a neurologist compared with white patients, yet both Black and Hispanic people had lower odds of being on a newer ASM whether they saw a neurologist or not, according to the study.

Odds of being on a newer-generation ASM were higher among those who were newly diagnosed (aOR 1.29, 95% CI 1.16-1.42), as well as women, younger patients, and high utilizers.

“Even after adjusting for these inequities in generation, there were persistent racial/ethnic adherence differences in Black, Asian, and Hispanic individuals; all had lower odds of adherence compared with white individuals,” Bensken and colleagues wrote.

“This underscores that factors affecting adherence are complex and vary greatly across patients,” they continued. “For example, factors such as social support, education level, seizure control, and ASM toxicity should be evaluated to further understand the causes of these differences.”

They added that “adverse reactions may be more common in some people due to their genetic constitutions and the ability to process specific drugs. Alleles that affect drug metabolism may differ among the racial groups we assessed and hence may affect adherence and the need to switch generations.”

Medical mistrust may also play a role in lower adherence, Bensken and colleagues pointed out. It has been shown that “complaints and treatment of pain are taken less seriously for Black patients, and racial concordance between a patient and their care provider influences communication and engenders trust.”

Nassim Zecavati, MD, MPH, director of epilepsy at Children’s Hospital of Richmond in Virginia, told MedPage Today that “this study highlights the fact that significant barriers remain for people of color in accessing epilepsy care and that even when they reach our clinics, the medications they are prescribed are typically an older generation of drugs with potentially greater side effects.”

“As a profession, we need to better understand how systemic racism and implicit bias impact the care of epilepsy patients,” added Zecavati, who was not involved in this study. “The first step in providing optimal care to our patients is recognizing our own biases and those inherent in our healthcare system. This study is eye-opening and demonstrates the need for further studies to better understand these disparities and how to overcome them.”

For this study, Bensken and team used Medicaid claims data for 78,534 adults (56.9% women) with epilepsy from 2010 to 2014, of which 87.4% had a blind or disabled Medicaid eligibility status. Just over half were white, 22.6% were Black, 11.9% were Hispanic, and 1.5% were Native Hawaiian/Pacific Islander.

Overall, 25.6% were taking older first-generation ASMs, 65.1% were taking second-generation ASMs, and 9.3% were on third-generation ASMs.

Bensken and colleagues noted that their analysis lacked data on untreated patients, and they were unable to determine patients’ reasons for using or switching ASMs.