Bone Risks of Older Antiepileptics Sometimes Unaddressed

SAN DIEGO – The women who were most likely to be on older antiepileptic drugs were the least likely to be counseled about the dangers those drugs pose to bone health in a retrospective study of 756 women with epilepsy.

Being uninsured or having Medicaid coverage was associated with about 50% lower odds for receiving counseling for bone health among women on phenytoin, carbamazepine, or phenobarbital – older antiepileptic drugs that are known to increase bone turnover and cause other bone issues that are especially problematic for women – investigator and second-year medical student Katie Paniszyn reported at the annual meeting of the American Epilepsy Society.

"This is a big problem. You have this huge discrepancy between who’s being prescribed these medications and who’s being counseled. Privately insured patients were less likely to be on these drugs, but more likely to get proper counseling when they were," said Ms. Paniszyn of Brown University, Providence, R.I.

She and her colleagues identified 756 female patients with epilepsy aged 11-60 years who were seen in 2010 at the outpatient academic neurology clinics affiliated with Hasbro Children’s Hospital and Rhode Island Hospital. They analyzed the patients’ clinical notes from 2005 to 2010.

The older antiepileptic drugs were more commonly used in uninsured patients (39 of 59, 66%) and those on Medicaid (52 of 103, 50%) and Medicare (42 of 85, 49%), compared with privately insured women (147 of 509, 29%). That’s not surprising because, as generics, they are more affordable to people with limited income.

What was surprising, however, was that uninsured and Medicaid patients were about half as likely to be encouraged to do weight-bearing exercises, have regular bone density scans, and take vitamin D and calcium supplements while taking the drugs. Bone health counseling was noted in the charts of 64% of Medicare (27 of 42) and 62% of privately insured patients (91 of 147), but in only 31% of Medicaid (16 of 52) and 36% of uninsured patients (14 of 39) (P less than .001). Epilepsy specialists were more likely to provide bone-health counseling than were general neurologists.

The reason for the discrepancy isn’t clear, but could have something to do with the fact that uninsured and Medicaid patients made fewer visits to the neurology clinic so that there were fewer opportunities to counsel them. Advice about compliance and more immediate side effects may have taken precedence, she said.

Whatever the reason is for the discrepancy, the investigators plan to add a flag to their electronic medical record system to remind clinicians about bone health counseling when they prescribe phenytoin, carbamazepine, or phenobarbital. Even "if someone only comes in once or twice, hopefully that will trigger counseling," she said.

While more than half of the women in the study spoke English, many spoke other languages. Because of that, the investigators also plan to print bone health brochures for epilepsy patients in several languages.

Ms. Paniszyn said she had no relevant financial disclosures.

SAN DIEGO – The women who were most likely to be on older antiepileptic drugs were the least likely to be counseled about the dangers those drugs pose to bone health in a retrospective study of 756 women with epilepsy.

Being uninsured or having Medicaid coverage was associated with about 50% lower odds for receiving counseling for bone health among women on phenytoin, carbamazepine, or phenobarbital – older antiepileptic drugs that are known to increase bone turnover and cause other bone issues that are especially problematic for women – investigator and second-year medical student Katie Paniszyn reported at the annual meeting of the American Epilepsy Society.

"This is a big problem. You have this huge discrepancy between who’s being prescribed these medications and who’s being counseled. Privately insured patients were less likely to be on these drugs, but more likely to get proper counseling when they were," said Ms. Paniszyn of Brown University, Providence, R.I.

She and her colleagues identified 756 female patients with epilepsy aged 11-60 years who were seen in 2010 at the outpatient academic neurology clinics affiliated with Hasbro Children’s Hospital and Rhode Island Hospital. They analyzed the patients’ clinical notes from 2005 to 2010.

The older antiepileptic drugs were more commonly used in uninsured patients (39 of 59, 66%) and those on Medicaid (52 of 103, 50%) and Medicare (42 of 85, 49%), compared with privately insured women (147 of 509, 29%). That’s not surprising because, as generics, they are more affordable to people with limited income.

What was surprising, however, was that uninsured and Medicaid patients were about half as likely to be encouraged to do weight-bearing exercises, have regular bone density scans, and take vitamin D and calcium supplements while taking the drugs. Bone health counseling was noted in the charts of 64% of Medicare (27 of 42) and 62% of privately insured patients (91 of 147), but in only 31% of Medicaid (16 of 52) and 36% of uninsured patients (14 of 39) (P less than .001). Epilepsy specialists were more likely to provide bone-health counseling than were general neurologists.

The reason for the discrepancy isn’t clear, but could have something to do with the fact that uninsured and Medicaid patients made fewer visits to the neurology clinic so that there were fewer opportunities to counsel them. Advice about compliance and more immediate side effects may have taken precedence, she said.

Whatever the reason is for the discrepancy, the investigators plan to add a flag to their electronic medical record system to remind clinicians about bone health counseling when they prescribe phenytoin, carbamazepine, or phenobarbital. Even "if someone only comes in once or twice, hopefully that will trigger counseling," she said.

While more than half of the women in the study spoke English, many spoke other languages. Because of that, the investigators also plan to print bone health brochures for epilepsy patients in several languages.

Ms. Paniszyn said she had no relevant financial disclosures.

SAN DIEGO – The women who were most likely to be on older antiepileptic drugs were the least likely to be counseled about the dangers those drugs pose to bone health in a retrospective study of 756 women with epilepsy.

Being uninsured or having Medicaid coverage was associated with about 50% lower odds for receiving counseling for bone health among women on phenytoin, carbamazepine, or phenobarbital – older antiepileptic drugs that are known to increase bone turnover and cause other bone issues that are especially problematic for women – investigator and second-year medical student Katie Paniszyn reported at the annual meeting of the American Epilepsy Society.

"This is a big problem. You have this huge discrepancy between who’s being prescribed these medications and who’s being counseled. Privately insured patients were less likely to be on these drugs, but more likely to get proper counseling when they were," said Ms. Paniszyn of Brown University, Providence, R.I.

She and her colleagues identified 756 female patients with epilepsy aged 11-60 years who were seen in 2010 at the outpatient academic neurology clinics affiliated with Hasbro Children’s Hospital and Rhode Island Hospital. They analyzed the patients’ clinical notes from 2005 to 2010.

The older antiepileptic drugs were more commonly used in uninsured patients (39 of 59, 66%) and those on Medicaid (52 of 103, 50%) and Medicare (42 of 85, 49%), compared with privately insured women (147 of 509, 29%). That’s not surprising because, as generics, they are more affordable to people with limited income.

What was surprising, however, was that uninsured and Medicaid patients were about half as likely to be encouraged to do weight-bearing exercises, have regular bone density scans, and take vitamin D and calcium supplements while taking the drugs. Bone health counseling was noted in the charts of 64% of Medicare (27 of 42) and 62% of privately insured patients (91 of 147), but in only 31% of Medicaid (16 of 52) and 36% of uninsured patients (14 of 39) (P less than .001). Epilepsy specialists were more likely to provide bone-health counseling than were general neurologists.

The reason for the discrepancy isn’t clear, but could have something to do with the fact that uninsured and Medicaid patients made fewer visits to the neurology clinic so that there were fewer opportunities to counsel them. Advice about compliance and more immediate side effects may have taken precedence, she said.

Whatever the reason is for the discrepancy, the investigators plan to add a flag to their electronic medical record system to remind clinicians about bone health counseling when they prescribe phenytoin, carbamazepine, or phenobarbital. Even "if someone only comes in once or twice, hopefully that will trigger counseling," she said.

While more than half of the women in the study spoke English, many spoke other languages. Because of that, the investigators also plan to print bone health brochures for epilepsy patients in several languages.

Ms. Paniszyn said she had no relevant financial disclosures.