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People of color with epilepsy, including Black, Hispanic and Native Hawaiian and Other Pacific Islander patients, are significantly less likely to be prescribed the latest antiseizure medications (ASMs) compared with their White counterparts, a new research shows.
Even after controlling for epilepsy severity, comorbid conditions and other factors that might affect medication choice, researchers found that newer medication use was 29% less likely in Black patients, paxil induced akathisia 23% less likely in Native Hawaiian and Other Pacific Islander patients, and 7% less likely in Hispanic patients, compared with White individuals.
Dr Wyatt Bensken
“I hope that clinicians will see from our findings that minoritized patients with epilepsy face a myriad of barriers in receiving the highest quality of care, including ASM use,” lead investigator Wyatt P. Bensken, PhD, adjunct assistant professor of Population and Quantitative Health Sciences at Case Western Reserve University, Cleveland, Ohio, told Medscape Medical News. “Considering your patients’ barriers, and how that influences their care including ASM selection, will be critical to helping reduce these population-level inequities.”
The study was published online January 11 in Neurology.
A Prompt for Practice Change
For the study, researchers used Medicaid claims for more than 78,000 people who had filled at least two prescriptions for an ASM between 2010-2014.
Most patients were White (53.4%); 22.6% were Black; 11.9% were Hispanic; 1.6% were Asian; 1.5% were Native Hawaiian or Other Pacific Islander; 0.6% American Indian or Alaskan Native; and 8.3% were classified as “other.”
One quarter of participants were taking an older ASM, such as carbamazepine, phenytoin, and valproate. About 65% were taking second-generation ASMs, including gabapentin, levetiracetam, and zonisamide. A little less than 10% were taking lacosamide, perampanel, or another third- generation ASM.
Compared to White patients, newer medication prescriptions were significantly less likely in Black individuals (adjusted odds ratio [aOR], 0.71; 95% CI, 0.68 – 0.75), Native Hawaiian or Other Pacific Islanders (aOR, 0.77; 95% CI, 0.67 – 0.88), and Hispanic patients (aOR, 0.93; 95% CI, 0.88 – 0.99).
Third-generation ASMs were used by 10.7% of White patients vs 6% of Black individuals and 5.1% of American Indian or Alaskan Native patients.
Researchers also found that taking a second-generation ASM was associated with better treatment adherence (aOR, 1.17; 95% CI, 1.11 – 1.23) and that patients on newer ASMs were more than three times as likely to be under the care of a neurologist (aOR, 3.26; 95% CI, 3.13 – 3.41).
The findings draw attention to racial inequities surrounding access to medication and specialists and subspecialists, Bensken said. Identifying specific barriers and developing solutions is the long-range goal, he added.
“In the interim, increasing the attention to these inequities will, we hope, prompt changes across practices,” Bensken said.
A “Wake-Up Call”
Commenting on the findings for Medscape Medical News, Joseph Sirven, MD, professor of neurology at the Mayo Clinic Florida in Jacksonville, said the results were “striking” because newer ASMs are generally the go-to for most physicians who treat epilepsy.
“Use of first generation ASMs is typically reserved if one runs out of options,” Sirven said.
This study and others like it should serve as a “wake-up call” for clinicians, Sirven added.
“This study is important because it shows that whether we realize it or not, race and ethnicities are playing a role in ASM and this is related to financial access to newer-generation drugs,” he said. “Similar findings are seen in impoverished countries where first-generation ASM drugs are routinely used because of drug pricing.”
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Also commenting for Medscape Medical News, Scott Mintzer, MD, a professor and director of the Epilepsy Monitoring Unit at Thomas Jefferson University in Philadelphia, said using first-generation ASMs as a proxy for quality of care is “a very innovative concept.”
“From that perspective, the finding that racial minority patients are more likely to be on a first-generation drug is not surprising. But after that it gets far more complicated to interpret,” he added.
Neither adherence nor care by a neurologist was different in a consistent direction within the various minority populations, Mintzer noted. In addition, Black patients were as likely to see a neurologist as White patients, but still more likely to be on a first-generation drug.
There are also a few caveats to the findings that should be considered, Mintzer added. First, the sample included only Medicaid recipients, nearly 35% of whom had a comorbid psychosis. Those and other characteristics of the study pool suggest participants aren’t representative of the US population as a whole. Second, significant shifts in ASM use have occurred since the study data cutoff in 2014, none of which are reflected in these findings.
“So, I don’t think we can really say how to address this yet,” Mintzer said. “There’s a lot to explore about whether this is still occurring, how generalizable these findings are, and what they might be due to, as there are a host of potential explanations, which the authors themselves acknowledge.”
The study was funded by the US Centers for Disease Control and Prevention and the National Institute on Minority Health and Health Disparities (NIMHD). Bensken has received support for this work from NIMHD and serves on the Editorial Board of the journal Neurology. Sirven and Mintzer report no relevant financial relationships.
Neurology. Published online January 11, 2023. Full text
Kelli Whitlock Burton is a reporter for Medscape Medical News covering neurology and psychiatry.
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