Mapping the availability, price, and affordability of antiepileptic drugs in 46 countries

Department of Essential Medicines and Pharmaceutical Policies, World Health Organization, Geneva, Switzerland.
Epilepsia (Impact Factor: 4.57). 03/2012; 53(6):962-9. DOI: 10.1111/j.1528-1167.2012.03446.x
Source: PubMed


In low- and middle-income countries (LMICs), a large proportion of people with epilepsy do not receive treatment. An analysis of the availability, price, and affordability of antiepileptic drugs (AEDs) was conducted to evaluate whether these factors contribute to the treatment gap.
Data for five AEDs (phenytoin, carbamazepine, valproic acid, phenobarbital, and diazepam) were obtained from facility-based surveys conducted in 46 countries using the World Health Organization/Health Action International (WHO/HAI) methodology. Outcome measures were percentage availability, ratios of local prices to international reference prices, and number of days' wages needed by the lowest-paid unskilled government worker to purchase treatment. Prices were adjusted for inflation/deflation and purchasing power parity.
The average availability of generic AEDs in the public sector was <50% for all medicines except diazepam injection. Private sector availability of generic oral AEDs ranged from 42.2% for phenytoin to 69.6% for phenobarbital. Public sector patient prices for generic carbamazepine and phenytoin were 4.95 and 17.50 times higher than international reference prices, respectively, whereas private sector patient prices were 11.27 and 24.77 times higher, respectively. For both medicines, originator brand prices were about 30 times higher. The highest prices were observed in the lowest income countries. The lowest-paid government worker would need wages from 1-2.6 days' to purchase a month's supply of phenytoin, whereas carbamazepine would cost 2.7-16.2 days' wages. Despite its widespread use in LMICs, WHO/HAI survey data for phenobarbital was only available from a small number of countries.
In LMICs, availability and affordability of AEDs are poor and may be acting as a barrier to accessing treatment for epilepsy. Ensuring a consistent supply of AEDs at an affordable price should be a priority.

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    • "Nevertheless, it seems that a major contributing factor driving the ETG in low and LM income countries is the poor availability of AEDs. While this is certainly, in part due to the low priority accorded to epilepsy by governments with limited resources, the most significant factor is the very high cost of first line AEDs (often 5–10 times that of HIC) (Cameron et al., 2012; Chivorakoun et al., 2012). The WHO has recommended that PB be considered a first line treatment for people with focal and generalised seizures in low and middle income countries primarily because of its cost relative to the other AEDs. "
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    ABSTRACT: Epilepsy is one of the commonest neurological conditions, estimated to affect over 60 million people worldwide, the majority of whom live in low and middle-income countries where access to medical treatment is limited. We consider some of the aspects and factors that underlie the epilepsy treatment gap (ETG), which is defined as the percentage of people with active epilepsy who are not being appropriately treated (either as a result of lack of access to treatment or of being on inadequate treatment) in a given population at a given time.We examine some of the evidence of the relative impact of various cultural, demographic economic and logistical factors that are believed to be at the origin of the ETG in resource-poor settings. We contend that the high cost and subsequent poor availability of first line anti-epileptic drugs including phenobarbital in low and low-middle income (compared to high income countries), is a major determinant of the ETG in these countries. Until this issue is tackled, little progress in reducing the global ETG is likely to be made.
    Full-text · Article · Mar 2013 · Epileptology
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    • "The lowest price quoted by the WHO is $0.008 per 100-mg tablet. However, in a recent study it was not possible to obtain appropriate information of the availability and price of PB in 46 countries (Cameron et al., 2012). A pragmatic response to this dilemma would be to conduct a modern, comprehensive, prospective evaluation program with the primary goal of optimizing phenobarbital use as monotherapy for untreated epilepsy. "
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    ABSTRACT: This article reviews the current position of phenobarbital using articles published since 2000 and speculates on its likely future contribution to epilepsy care. Over the last decade there have been no major double-blind randomized placebo-controlled or comparative trials with phenobarbital. Previous studies have suggested that phenobarbital is as effective in monotherapy as phenytoin and carbamazepine. Several observational studies undertaken in developing countries over the last decade have confirmed its efficacy and safety for the common epilepsies. This was particularly so in the substantial demonstration project undertaken in rural China under the auspices of the World Health Organization in partnership with the International League Against Epilepsy and International Bureau for Epilepsy. Phenobarbital is still widely used for neonatal and childhood seizures and for drug-resistant convulsive and nonconvulsive status epilepticus. Recent data have confirmed in a prospective cohort of women taking phenobarbital as monotherapy that the drug can be associated with a range of congenital defects in exposed infants. Much effort has gone into exploring the apparent contradiction of higher withdrawal rates due to cognitive and behavioral side effects in studies undertaken in developed countries but not in those sited in the developing world. A raft of data over the last 10 years, including a systematic review, showed no important differences between the tolerability of phenobarbital compared to that with other antiepileptic drugs. Finally, cognitive test scores and mood ratings in 136 people with epilepsy receiving phenobarbital for a year were similar to those in 137 age-, sex-, and education-matched controls in a number of Chinese villages. Indeed, there were some cognitive gains in the patients possibly due to improved seizure control. Phenobarbital is still the most cost-effective pharmacologic treatment for epilepsy. All these data predict a healthy future for phenobarbital, particularly in helping to close the treatment gap in low- and middle-income countries during its second century of clinical use.
    Preview · Article · Dec 2012 · Epilepsia
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    ABSTRACT: Epilepsy is a common disorder, particularly in poor areas of the world, and can have a devastating effect on people with the disorder and their families. The burden of epilepsy in low-income countries is more than twice that found in high-income countries, probably because the incidence of risk factors is higher. Many of these risk factors can be prevented with inexpensive interventions, but there are only a few studies that have assessed the effect of reducing risk factors on the burden of epilepsy. The mortality associated with epilepsy in low-income countries is substantially higher than in less impoverished countries and most deaths seem to be related to untreated epilepsy (eg, as a result of falls or status epilepticus), but the risk factors for death have not been adequately examined. Epilepsy is associated with substantial stigma in low-income countries, which acts as a barrier to patients accessing biomedical treatment and becoming integrated within society. Seizures can be controlled by inexpensive antiepileptic drugs, but the supply and quality of these drugs can be erratic in poor areas. The treatment gap for epilepsy is high (>60%) in deprived areas, but this could be reduced with low-cost interventions. The substantial burden of epilepsy in poor regions of the world can be reduced by preventing the risk factors, reducing stigma, improving access to biomedical diagnosis and treatment, and ensuring that there is a continuous supply of good quality antiepileptic drugs.
    Full-text · Article · Sep 2012 · The Lancet
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