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\def\citeauthor{~Dinesh~Kumar~Kukunuri,
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              ~Sugreev~Dwivedi~Anuj,
              ~Sasi~Karnati}
\def\citetitle{Prescribing Patterns of Anticonvulsant Drugs in Epilepsy in a Tertiary care Hospital: An Observational Prospective Study}
\def\copyrightstmt{This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial- ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.}
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\def\RunningAuthor{Dinesh Kumar Kukunuri et al.}
\firstPage{54}
\articleType{Original Article}
\receivedDate{02 Jun 2021}
\acceptedDate{14 Jun 2021}
\revisedDate{12 Jun 2021}
\journalVolume{1}
\journalIssue{2}
\copyrightYear{2021}
\eISSN{2583-0953}
\journalDoi{10.26452/ijcpms.v1i2.198}
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\title{Prescribing Patterns of Anticonvulsant Drugs in Epilepsy in a Tertiary care Hospital: An Observational Prospective Study}
\author{Dinesh~Kumar~Kukunuri\textsuperscript{*}\textsuperscript{1},  
            Richard~Noah\textsuperscript{1},  
            Sugreev~Dwivedi~Anuj\textsuperscript{2}, 
            Sasi~Karnati\textsuperscript{3}~\\[5pt]{\textsuperscript{1}H.K.E.S.S Mathosree Taradevi Rampure Institute of Pharmaceutical Sciences, Gulbarga-585105, Karnataka, India}~\\{\textsuperscript{2}Parul Institute of Pharmacy and Research, Vadodara-391760, Gujarat, India}~\\{\textsuperscript{3}Anesthesiology Department, Medicover Hospitals, Nellore-524003, Andhra Pradesh, India}}

\begin{abstract}
There is a testimonial of various patterns of drug prescription of anticonvulsant drugs in India. The latest upcoming drugs are extensively available at present and the way of these newer drugs are prescribed is quite interesting to see. Complications in antiepileptic therapy such as the use of poly-therapy, adverse drug reactions, drug interactions, lack of medication adherence and so on, can be point out and cleared up by clinical pharmacist. On considering all these points, this study was commenced with the title: A study on prescribing patterns of anticonvulsant drugs in epilepsy in a tertiary care hospital. Prospective observational study of 6 months duration was carried out. Patients prescribed with anti-epileptic drugs in General Medicine and Neurology out-clinic department were selected according to inclusion criteria. Data were collected in the pre-prepared data collection form after obtaining the patient consent and verified the patient case sheets/ prescriptions. Morisky Medication Adherence Scale-8 (MMAS-8) was utilized to assess the medication adherence at baseline. Microsoft excel was used to summarize the analysis of data. Data were measured in percentage and frequency using descriptive statistics. For testing significant associations, Chi-square test was performed, where P{\textless}0.05 was considered as statistically significant. Usage of newer antiepileptic drugs was very less, with high evidence of polytherapy in the prescriptions for treating epilepsy. Clobazam was the most commonly prescribed drug. Medication adherence among these patients was less.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Antiepileptic Drug,\newline Prescribing Pattern,\newline Polytherapy,\newline Medication Adherence
\end{keywords}
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\makeatletter{\raggedright{\Large$^\ast$}Corresponding Author\par Name:\ Dinesh~Kumar~Kukunuri~\\ Phone:\ 9100554988~\\  Email:\ dineshalliswell1998@gmail.com
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\section{Introduction}
Seizure is a clinical incident occurs because of the abnormal electrical discharge in the brain. While, epilepsy is the proneness to have recurrent seizures \unskip~\cite{1116687:22341510}. Epilepsy is a clinical manifestation of a brain disorder rather than a disease itself \unskip~\cite{1116687:22341510}. An epileptic seizure is a short-term paroxysm of unrestrained discharge of neurons that bring about an event that is not noticeable by the person who having the seizure but can be detected by an observer. The inclination to have recurrent attacks is known as epilepsy \unskip~\cite{1116687:22341505}.

Epileptic seizures or attacks are the symptoms of many other diseases.\ensuremath{^{}} There are many causes for seizures or epilepsy. Further epilepsy is classified into many categories.\ensuremath{^{}} Recurrence is common with seizures. The recurrence rate after first seizure approaches 70\% during first year, most of the recurrent attacks occur within a month or two following the first attack. The recurrent attacks can be avoided if triggering factor is identified.\ensuremath{^{}} The seizures that are prolonged or repetitive are associated with considerable morbidity and mortality. Patients with epilepsy experience other co-morbidities including depression, anxiety, neuro-endocrine disturbance, also may display neuro-developmental delay, memory issues and cognitive impairment \unskip~\cite{1116687:22341532}.

\textbf{Incidence and prevalence}

Epilepsy is a common disorder. The incidence has been in the range of 20 - 70 cases per 100000 persons approximately, and the cumulative incidence at 2 -5\%. The second raise is majorly due to cerebro-vascular diseases. Most of the studies show that prevalence of active epilepsy between 4 -8 per thousand1000 \unskip~\cite{1116687:22341505}. The prevalence of epilepsy in European countries is about 0.5\%. Prevalence is almost 5 times higher in the developing countries than in developed countries \unskip~\cite{1116687:22341510}.

\textbf{Classification}

There are two types of seizures

\textbf{Generalized onset seizures}

These seizures influence the dual sides of the brain or groups of cells on dual sides of the brain at the exact timing. This term comprises seizures types like tonic-clonic, absence, or atonic and others \unskip~\cite{1116687:22341509}.

\textbf{Tonic-Clonic}

Usually called grand mal attacks, these are the most common one of all epileptic seizures, without warns the patient and then suddenly goes stiff, falls and convulses along with salivation, cyanosis incontinence and tongue biting \unskip~\cite{1116687:22341510}.\ensuremath{^{}}

\textbf{Absence\ensuremath{^{}}}

Usually called petit-mal, these are the rare one among generalized seizure, they occurs extensively in childhood and early adolescence, the child goes blank and stares, and flopping of the head occurs. This attack lasts only for a few seconds and then gone unnoticeable \unskip~\cite{1116687:22341504}.\ensuremath{^{}}

\textbf{Myoclonic\ensuremath{^{}}}

These are abrupt, involuntary shock like jerks, which may involve the whole body or the arms or the head. They usually occur in the morning, shortly after waking.  It is vital to know that there are other non-epileptic myoclonic jerks that occur in other diseases \unskip~\cite{1116687:22341517}.\ensuremath{^{}}

\textbf{Atonic}

These seizures are connected with the sudden loss of muscle tone, and then the person would collapse to the earth. They are rare, accounting for less than 1\% of the epileptic seizures \unskip~\cite{1116687:22341510}.\ensuremath{^{}}

\textbf{Focal onset seizures}

The idiom focal is used preferably of incomplete to be more precise when speaking about where seizures can start. Focal seizures can begin in one place or group of cells in one side of the brain \unskip~\cite{1116687:22341530}.\ensuremath{^{}}


  
  \begin{enumerate}
  \item \relax Focal Onset Aware Seizures
  \item \relax Focal Onset Impaired Awareness\ensuremath{^{}}
  \end{enumerate}
  \textbf{Unknown onset seizures\ensuremath{^{}}}

When the origination of a seizure is not well-known, it's referred as an unknown onset seizure. A seizure could also be known an unknown onset if it's not observed or seen by anyone, for instance when seizures occurs at night or in a person who lives alone. When more information is collected, later an unknown onset seizure may be diagnosed as a focal or generalized seizure \unskip~\cite{1116687:22341530}.\ensuremath{^{}}

\textbf{Etiology }

The seizures are occurred due to the abnormal discharge of neurons that may be because of any pathological process which affects the brain. The idiopathic epilepsies are those in which there is a clear genetic component, and they probably account for a thread of all new cases of epilepsy. The term symptomatic epilepsy indicates that a probable cause has been identified \unskip~\cite{1116687:22341509}.\ensuremath{^{}}

\ensuremath{^{}}\ensuremath{^{}}The etiology of epilepsy based upon the age of the patient and the type of seizures. The most common causes in young infants are low o\ensuremath{_{2}} levels or birth asphyxia, intracranial trauma during birth, metabolic disturbance and congenital malformation of brain or infection \unskip~\cite{1116687:22341509}.\ensuremath{^{}}

In young children and adolescents, idiopathic seizures accounts for the majority of the epilepsies, although trauma and infection also play an important role \unskip~\cite{1116687:22341509}. In children aged between6 months and 5 years, seizures may occur along with febrile illness \unskip~\cite{1116687:22341509}.\ensuremath{^{}}

\textbf{Path-physiology}

Normally brain electrical pursuit is non-synchronous \unskip~\cite{1116687:22341535} its activity is controlled by various factors both within the neuron and the cellular environment. Factors within the neuron comprises the type, number and distribution of ion channels, changes to receptors and changes of gene expression \unskip~\cite{1116687:22341520}. Factors around the neuron comprise ion concentrations, synaptic plasticity and synchronize of transmitter breakdown by glial cells \unskip~\cite{1116687:22341520,1116687:22341526}. Chronic inflammation also seems to play a role \unskip~\cite{1116687:22341538}. The exact procedure of epilepsy is unknown \unskip~\cite{1116687:22341529} and only little is known about its cellular and network mechanisms. However, it is unknown under which circumstances the brain transfers into the activity of a seizure with its excessive regulation \unskip~\cite{1116687:22341501,1116687:22341525}. In epilepsy, the objection of excitatory neurons to fire during this period is reduced \unskip~\cite{1116687:22341535}. This evolve in a specific area from which seizures may develop is known as a "seizure focus" \unskip~\cite{1116687:22341535}. Another mechanism of epilepsy may be the up-regulation of excitatory circuits or down-regulation of inhibitory circuits following an injury to the brain \unskip~\cite{1116687:22341535,1116687:22341528}. These secondary epilepsies occur through processes known as epileptogenesis \unskip~\cite{1116687:22341537,1116687:22341540} . Failure of the blood{\textendash}brain barrier may also be a causal procedure as it would permit substances in the blood to enter the brain \unskip~\cite{1116687:22341511}.

\textbf{Seizures}

There is corroboration that epileptic seizures are often not an unplanned event. Seizures are usually brought on by factors like stress, alcohol abuse, flickering light, or a lack of sleep, among others. The idiom seizure threshold is generally employed to indicate the amount of stimulus needed to bring about a seizure. Seizure threshold is reduced in epilepsy \unskip~\cite{1116687:22341501}.\ensuremath{^{}}

In epileptic seizures a group of neurons start firing in an abnormal, excessive,\ensuremath{^{}} and synchronized manner \unskip~\cite{1116687:22341535}. This result in a wave of depolarization called as a paroxysmal depolarizing shift \unskip~\cite{1116687:22341502}. Commonly, after an excitatory neuron fires it becomes more resistant to firing for a period of time.\ensuremath{^{}} This is because of in part to the effect of inhibitory neurons, electrical changes within the excitatory neuron, and the negative effects of adenosine\unskip~\cite{1116687:22341535}.\ensuremath{^{}}

Focal seizures start in one hemisphere of the brain while generalized seizures begin in dual hemispheres \unskip~\cite{1116687:22341540}.\ensuremath{^{}} Some types of seizures may alter the brain structure, while others seem to have a little effect \unskip~\cite{1116687:22341503}. Gliosis, neuronal loss, and atrophy of specific areas of the brain are connected to epilepsy but it is not clear if epilepsy results these alterations or if these changes will occurs in epilepsy \unskip~\cite{1116687:22341503}.

\textbf{Signs and symptoms}

Several various symptoms can be seen during a seizure. These new classifications distinguish them simply into groups that imply the movement.

\textbf{For generalized onset seizures}

Motor symptoms may comprises sustained rhythmical jerking movements  (clonic), muscles becoming weak or limp (atonic), muscles becoming tense or rigid (tonic), brief muscle twitching (myoclonus), or epileptic spasms (body flexes and extends repeatedly) \unskip~\cite{1116687:22341530}.\ensuremath{^{}}

Non-motor symptoms are often called absence seizures. These can be typical or atypical absence seizures (staring spells). 

\textbf{For focal onset seizures}

Motor symptoms may also include jerking (clonic), muscles becoming limp or weak (atonic), tense or rigid muscles (tonic), brief muscle twitching (myoclonus), or epileptic spasms. There may be repeated automatic movements, like clapping or rubbing of hands, lip smacking or chewing, or running \unskip~\cite{1116687:22341530}.

Non-motor symptoms include Examples of symptoms that don't affect movement could be seen such as changes in sensation, emotions, thinking or cognition, autonomic functions (such as gastrointestinal sensations, waves of heat or cold, goose bumps, heart racing, etc.), or lack of movement (called behavior arrest) \unskip~\cite{1116687:22341530}.

\textbf{For unknown onset seizures}

Motor seizures are described as either tonic-clonic or epileptic spasms.

Non-motor seizures often comprises of a behavior arrest. This means that movement stops {\textendash} the person may just stare and not make any other movements \unskip~\cite{1116687:22341530}.

\textbf{Diagnosis}

Determining a right and precise diagnosis is needed prior to any confirmation of pharmacotherapy. When a patient complains of paroxysmal stereotypical spells that may be seizures, it must be obstinate if the spells are really seizures \unskip~\cite{1116687:22341531}.

A proper diagnostic plan of a patient having with seizures should include:


  
  \begin{enumerate}
  \item \relax Thorough neurologic examination
  \item \relax Electroencephalogram
  \item \relax Laboratory tests (CBC, LFT, Serum chemistry )
  \item \relax Neuro-imaging (preferably magnetic resonance imaging )
  \end{enumerate}
  Patients with epilepsy may have totally normal results in their assessment. Many of tests are done to find the other causes of seizures. (eg: infection or electrolyte imbalance ) \unskip~\cite{1116687:22341531}.

Usually the EEG appears normal between seizures several manipulation can be done in a try to express seizure or seizure like activity on the EEG \unskip~\cite{1116687:22341531}.


\begin{table*}[!htbp]
\caption{\boldmath {Age wise distribution of the study participants} }
\label{tw-f4eea0d7294b}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1632\linewidth-2\tabcolsep}p{\dimexpr.15680000000000001\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor} &  & \multicolumn{2}{p{\dimexpr(.32\linewidth-2\tabcolsep)}}{\cAlignHack Gender} &  & \\
\rowcolor{kwdboxcolor}\cAlignHack S. No & \cAlignHack Age & \cAlignHack Male & \cAlignHack Female & \cAlignHack Total & \cAlignHack \textit{P }value\\
\tblmidrule 
\cAlignHack 1 &
  \cAlignHack 15-19 &
  \cAlignHack 17 (54.8\%) &
  \cAlignHack 14 (45.2\%) &
  \cAlignHack 31 (100\%) &
  \cAlignHack \\
\cAlignHack 2 &
  \cAlignHack 20-29 &
  \cAlignHack 19 (61.3\%) &
  \cAlignHack 12 (38.7\%) &
  \cAlignHack 31 (100\%) &
  \cAlignHack \\
\cAlignHack 3 &
  \cAlignHack 30-39 &
  \cAlignHack 7 (38.9\%) &
  \cAlignHack 11 (61.1\%) &
  \cAlignHack 18 (100\%) &
  \cAlignHack \\
\cAlignHack 4 &
  \cAlignHack 40-49 &
  \cAlignHack 6 (42.9) &
  \cAlignHack 8 (57.1\%) &
  \cAlignHack 14 (100\%) &
  \cAlignHack 0.0318*\\
\cAlignHack 5 &
  \cAlignHack 50-59 &
  \cAlignHack 1 (20\%) &
  \cAlignHack 4 (80\%) &
  \cAlignHack 5 (100\%) &
  \cAlignHack \\
\cAlignHack 6 &
  \cAlignHack 60-69 &
  \cAlignHack 1 (100\%) &
  \cAlignHack 0 (0\%) &
  \cAlignHack 1 (100\%) &
  \cAlignHack \\
\multicolumn{2}{p{\dimexpr(.32\linewidth-2\tabcolsep)}}{\cAlignHack Total} &
  \cAlignHack 51 (51\%) &
  \cAlignHack 49 (49\%) &
  \cAlignHack 100 (100\%) &
  \cAlignHack \\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{(*p{\textless}0.05 is statistically significant)}
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Types of prescribed therapy among the study participants} }
\label{tw-41bd2b8ee0be}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.3862\linewidth-2\tabcolsep}p{\dimexpr.3129\linewidth-2\tabcolsep}p{\dimexpr.30090000000000003\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Type of Therapy & \cAlignHack No. of Subjects & \cAlignHack Percentage\\
\tblmidrule 
\cAlignHack Single Therapy &
  \cAlignHack 44 &
  \cAlignHack 44\\
\cAlignHack Double Therapy &
  \cAlignHack 35 &
  \cAlignHack 35\\
\cAlignHack Triple Therapy &
  \cAlignHack 17 &
  \cAlignHack 17\\
\cAlignHack Quadruple Therapy &
  \cAlignHack 3 &
  \cAlignHack 3\\
\cAlignHack Quintuple Therapy &
  \cAlignHack 1 &
  \cAlignHack 1\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Single drug therapy pattern of AED's prescription} }
\label{tw-ef99c51d5f15}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1668\linewidth-2\tabcolsep}p{\dimexpr.3528\linewidth-2\tabcolsep}p{\dimexpr.31109999999999996\linewidth-2\tabcolsep}p{\dimexpr.1693\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack S. No & \cAlignHack Drug Prescribed & \cAlignHack No. Sub (N=44) & \cAlignHack \%\\
\tblmidrule 
\cAlignHack 1 &
  \cAlignHack Clobazam &
  \cAlignHack 0 &
  \cAlignHack 0\\
\cAlignHack 2 &
  \cAlignHack Phenobarbitone &
  \cAlignHack 1 &
  \cAlignHack 2.3\\
\cAlignHack 3 &
  \cAlignHack Carbamazepine &
  \cAlignHack 11 &
  \cAlignHack 25.0\\
\cAlignHack 4 &
  \cAlignHack Divalproex Sodium &
  \cAlignHack 12 &
  \cAlignHack 27.3\\
\cAlignHack 5 &
  \cAlignHack Phenytoin &
  \cAlignHack 7 &
  \cAlignHack 15.9\\
\cAlignHack 6 &
  \cAlignHack Oxcarbazepine &
  \cAlignHack 4 &
  \cAlignHack 9.1\\
\cAlignHack 7 &
  \cAlignHack Leviteracetam &
  \cAlignHack 9 &
  \cAlignHack 20.4\\
\cAlignHack 8 &
  \cAlignHack Topiramate &
  \cAlignHack 0 &
  \cAlignHack 0\\
\cAlignHack 9 &
  \cAlignHack Clonazepam &
  \cAlignHack 0 &
  \cAlignHack 0\\
\cAlignHack  &
  \cAlignHack Total &
  \cAlignHack 44 &
  \cAlignHack 100\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
This comprises sleep deprivation, photic stimulations, prolonged (more than 20 mins) EEG recording and 24 hours EEG monitoring with video correlation.

\textbf{Key points on diagnosis}

1. Diagnosis to be made immediately by a specialist with an interest in epilepsy. EEG to be used to support diagnosis \unskip~\cite{1116687:22341505}; 2. MRI to be used in people to evolve epilepsy as adults, in whom focal onset is doubtful, or whom seizure persist \unskip~\cite{1116687:22341505}.

\textbf{Management}

\textbf{Pharmacological management}

Barbiturates: Phenobarbital; Hydantoins: Phenytoin, Fosphenytoin; Iminostilbenes: Carbamazepine, Oxcarbazepine; Succinimides: Ethosuximide; Aliphatic Carboxylic Acids: Valproic Acid, Divalproex; Benzodiazepines: Clonazepam, Lorazepam, Diazepam, Clobazepam; Phenyltriazene: Lamotrigine; Cyclic GABA Analogue: Gabapentin, Pregabalin; 

Newer Drugs: Vigabatrin, Topiramate, Leviteracetam, Tiagabin, Zonisamide

\textbf{Non - Pharmacological management}

Ketogenic diet and modified Atkins diet

Vagal nerve stimulation 

Implantable neurostimulator

\textbf{Aim of the Study}

To Study the Prescribing Patterns of Anti - Convulsants in Epilepsy

\textbf{Objectives}


  
  \begin{enumerate}
  \item \relax To study the trends in prescribing patterns of Anti - Convulsants in epilepsy.  
  \item \relax To study the medication adherence.  
  \item \relax To study the clinical profile.
  \end{enumerate}
  \textbf{Need of the Study}
  
  \begin{enumerate}
  \item \relax Epilepsy is the most common disease worldwide.
  \item \relax In U.S. 3.4 million number of patients and in India more than 12 million people are suffering from epilepsy.
  \item \relax AEDs are the Prescribing agents used in epilepsy  
  \item \relax Now a days, a wide variety of AEDs are available in the market. So we are conducted a study on the current trends of prescribing patterns of AEDs.
  \end{enumerate}
  
    
\section{METHODOLOGY}
Study design: A prospective observational study; Study site: Department of Neurology/ Medicine of  Medicover hospital, Nellore; Study duration:  6 months; Study size: 100 Epilepsy Patients

\textbf{Inclusion Criteria}


  
  \begin{enumerate}
  \item \relax Patients above age group of 15 years. 
  \item \relax All the patients of both genders with confirmed diagnosis of Epilepsy. 
  \item \relax Patient who willing to participate in the study.
  \end{enumerate}
  \textbf{Exclusion Criteria}


  
  \begin{enumerate}
  \item \relax Patients above age group of 15 years. 
  \item \relax All the patients of both genders with confirmed diagnosis of Epilepsy. 
  \item \relax Patient who willing to participate in the study.
  \end{enumerate}
  \textbf{Study Materials}


  
  \begin{enumerate}
  \item \relax Patient data collection proforma 
  \item \relax Patient informed consent form
  \end{enumerate}
  \textbf{Method of the Study}

On daily basis patients who were came to Neurology department with the epilepsy complaints were screened as per the study eligibility criteria and eligible patients were recruited after getting the consent through written, signed ICF from the subjects/care takers. After identifying the subjects the eligible subjects, their complaints and severity and study the prescriptions based type of epilepsy and severity, prescribing various therapies, Such as Double drug therapy, triple drug therapy quadrant drug therapy and penta drug therapy. Patients were monitored for the prognosis through interview, monitoring vitals and to assess the adherence of patients. Patients' details along with outcomes of the treatment were observed and noted in a standard self designed data collection form. All the patients and their care takers were educated/ regarding lifestyle modifications to be followed.

\textbf{Statistical Analysis}

Data was analyzed by using Graph Pad Prism software to find out. P-value with 95\% CI. Percentage, Average and SD was assessed by using Microsoft 2007 Excel data sheet.


\begin{table*}[!htbp]
\caption{\boldmath {Dual drug therapy pattern of AED's prescription} }
\label{tw-faf703084293}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.4009\linewidth-2\tabcolsep}p{\dimexpr.40339999999999996\linewidth-2\tabcolsep}p{\dimexpr.1957\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Drugs Prescribed & \cAlignHack No. Sub (N=35) & \cAlignHack \%\\
\tblmidrule 
\cAlignHack CLO+D &
  \cAlignHack 6 &
  \cAlignHack 17.2\\
\cAlignHack CLO+P &
  \cAlignHack 7 &
  \cAlignHack 20.0\\
\cAlignHack CLO+L &
  \cAlignHack 2 &
  \cAlignHack 5.72\\
\cAlignHack CLO+C &
  \cAlignHack 2 &
  \cAlignHack 5.7\\
\cAlignHack CLO+O &
  \cAlignHack 1 &
  \cAlignHack 2.8\\
\cAlignHack PB+D &
  \cAlignHack 4 &
  \cAlignHack 11.4\\
\cAlignHack PB+P &
  \cAlignHack 1 &
  \cAlignHack 2.8\\
\cAlignHack PB+C &
  \cAlignHack 1 &
  \cAlignHack 2.8\\
\cAlignHack C+L &
  \cAlignHack 1 &
  \cAlignHack 2.8\\
\cAlignHack C+D &
  \cAlignHack 2 &
  \cAlignHack 5.7\\
\cAlignHack C+P &
  \cAlignHack 1 &
  \cAlignHack 2.8\\
\cAlignHack D+L &
  \cAlignHack 2 &
  \cAlignHack 5.7\\
\cAlignHack D+P &
  \cAlignHack 1 &
  \cAlignHack 2.8\\
\cAlignHack D+CN &
  \cAlignHack 1 &
  \cAlignHack 2.8\\
\cAlignHack O+T &
  \cAlignHack 1 &
  \cAlignHack 2.8\\
\cAlignHack O+L &
  \cAlignHack 2 &
  \cAlignHack 5.7\\
\cAlignHack Total &
  \cAlignHack 35 &
  \cAlignHack 100\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Triple drug therapy pattern of AED's prescription} }
\label{tw-6bfa46c5d441}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.38870000000000005\linewidth-2\tabcolsep}p{\dimexpr.3544\linewidth-2\tabcolsep}p{\dimexpr.25689999999999998\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Drugs Prescribed & \cAlignHack No. Sub (N=17) & \cAlignHack \%\\
\tblmidrule 
\cAlignHack CLO+C+P &
  \cAlignHack 4 &
  \cAlignHack 23.5\\
\cAlignHack CLO+O+L &
  \cAlignHack 1 &
  \cAlignHack 5.9\\
\cAlignHack CLO+C+T &
  \cAlignHack 1 &
  \cAlignHack 5.9\\
\cAlignHack CLO+PB+C &
  \cAlignHack 2 &
  \cAlignHack 11.7\\
\cAlignHack CLO+PB+D &
  \cAlignHack 2 &
  \cAlignHack 11.7\\
\cAlignHack CLO+C+D &
  \cAlignHack 1 &
  \cAlignHack 5.9\\
\cAlignHack P+O+L &
  \cAlignHack 1 &
  \cAlignHack 5.9\\
\cAlignHack CLO+C+L &
  \cAlignHack 1 &
  \cAlignHack 5.9\\
\cAlignHack CLO+PB+O &
  \cAlignHack 2 &
  \cAlignHack 11.7\\
\cAlignHack PB+C+L &
  \cAlignHack 1 &
  \cAlignHack 5.9\\
\cAlignHack PB+C+P &
  \cAlignHack 1 &
  \cAlignHack 5.9\\
\cAlignHack Total &
  \cAlignHack 17 &
  \cAlignHack 100\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Quadruple drug therapy pattern of AED's prescription} }
\label{tw-c50e95b1d7b7}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.33\linewidth-2\tabcolsep}p{\dimexpr.33\linewidth-2\tabcolsep}p{\dimexpr.34\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Drugs Prescribed & \cAlignHack No. Sub (N=3) & \cAlignHack \%\\
\tblmidrule 
\cAlignHack CLO+C+D+P &
  \cAlignHack 1 &
  \cAlignHack 33.3\\
\cAlignHack CLO+PB+C+D &
  \cAlignHack 1 &
  \cAlignHack 33.3\\
\cAlignHack CLO+C+P+L &
  \cAlignHack 1 &
  \cAlignHack 33.3\\
\cAlignHack Total &
  \cAlignHack 3 &
  \cAlignHack 100\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Drug compliance among the study participants} }
\label{tw-537e7d428062}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1628\linewidth-2\tabcolsep}p{\dimexpr.1572\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Age Group & \cAlignHack High & \cAlignHack Medium & \cAlignHack Low & \cAlignHack Total & \cAlignHack P value \\
\tblmidrule 
\cAlignHack 15-19 &
  \cAlignHack 14 &
  \cAlignHack 9 &
  \cAlignHack 8 &
  \cAlignHack 31 &
  \cAlignHack \\
\cAlignHack 20-29 &
  \cAlignHack 12 &
  \cAlignHack 12 &
  \cAlignHack 7 &
  \cAlignHack 31 &
  \cAlignHack \\
\cAlignHack 30-39 &
  \cAlignHack 10 &
  \cAlignHack 3 &
  \cAlignHack 5 &
  \cAlignHack 18 &
  \cAlignHack  0.6483\\
\cAlignHack 40-49 &
  \cAlignHack 6 &
  \cAlignHack 4 &
  \cAlignHack 4 &
  \cAlignHack 14 &
  \cAlignHack \\
\cAlignHack 50-59 &
  \cAlignHack 2 &
  \cAlignHack 1 &
  \cAlignHack 2 &
  \cAlignHack 5 &
  \cAlignHack \\
\cAlignHack 60-69 &
  \cAlignHack 1 &
  \cAlignHack 0 &
  \cAlignHack 0 &
  \cAlignHack 1 &
  \cAlignHack \\
\cAlignHack Total &
  \cAlignHack 45 &
  \cAlignHack 29 &
  \cAlignHack 26 &
  \cAlignHack 100 &
  \cAlignHack \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

    
\section{RESULTS}
\textbf{Gender}

In this study, out of 100 patients, gender distribution almost equal, where females were 51 and the remaining 49 were males. P value is not significant. There is no significant relationship between gender and occurrence of seizures. Figure~\ref{f-498366e6258c} explains the distribution of gender in two groups from the total study sample.

\textbf{Age}

The Mean \ensuremath{\pm} SD of age of the total study population was found to be 28.35\ensuremath{\pm}11.7 years. Then, the patients were categorized based on their age. Out of 100 patients, 31 (31\%) of them were from each of the 15-19 years \& 20-29 years age group, followed by 18 (18\%) from 30-39 years, 14 (14\%) from 40-49 years, and 5 (5\%) from 50-59 years. Only 1 (1\%) participant was from the 60-69 years age group. In the present study, except in the 40-49 years and 50-59 years age group, males were found to be more in all the age groups. P value is significant. There is a significant relationship between age and occurrence of seizures. Table~\ref{tw-f4eea0d7294b}  explains about the detailed distribution of subjects with their respective age groups.

\textbf{Distribution based on the type of seizures}

Study participants were categorized based on the type of seizures they were diagnosed with. Out of the 100 patients, 57 (57\%) were classified as GTCS, followed by 17 (17\%) focal seizures, 14 (14\%) CPS and the remaining 12 (12\%) were classified as other types of seizures. Figure~\ref{f-6a96c54ebd16} explains about the detailed distribution of subjects seizures based on types among the total study population.

\textbf{Distribution based on the type of classification of drugs used}

In the present study, drugs belonging to Iminostilbenes were the most prescribed among the AEDs, 44 subjects (24.2\%) were prescribed these drugs. This was followed by Benzodiazepines- which were prescribed to 38 subjects (20.9\%),34 subjects (18.7\%) were treated with Aliphatic Carboxylic acids, Hydantoins- prescribed to 25 subjects (13.7\%), and newer drugs- prescribed to 24 subjects (13.2\%). Barbiturates were the least prescribed among AEDs with 17 subjects (9.3\%) being prescribed for this. Figure~\ref{f-c104e479e4c7} explains the distribution based on type of classification of drugs used among study participants.

\textbf{Type of Anti-Epileptic drugs (AEDs)}

In the present study, out of the 100 sample, few participants were under poly drug therapy, i.e., more than one drug prescribed for their condition. In this manner, a total of 182 AEDs were being taken by the participants. It was found that, of these 182 AEDs, the most commonly prescribed drugs were: those treated with Clobazam were 36(20\%), followed by Divalproex Sodium- 34(19\%), Carbamazepine- 32(18\%), Phenytoin- 25(14\%), Leviteracetam- 22(12\%), Phenobarbitone- 17(9\%), Oxcarbazepine- 12(7\%), and lastly, those treated with Topiramate and Clonazepam were only 2(1\%) each. Figure~\ref{f-6b5f840de24c} explains the type of Anti-Epileptic drugs used among the study participants.

\textbf{Types of Prescribed Therapy}

In the present study subjects we categorized and treated with different types of therapies such as 44 were Single drug therapy and followed by 35 were Double drug therapy, 17 were Triple drug therapy, 3 of them Quadrant therapy and finally 1 subject treated with five drug therapy. Table~\ref{tw-41bd2b8ee0be} explains the type of Anti-Epileptic drugs used among the study participants.

\textbf{Single drug therapy pattern of AED's prescription}

In the present study subjects treated with Single therapy was Prescribed to 44 subjects out of them 12(27\%) are treated with Divalproex Sodium, 11(25\%) are treated with Carbamazepine, 9(20\%) are treated with Leviteracetam, 7(16\%) are treated with Phenytoin, 4(9\%) are treated with Oxcarbamazepine, and finally 1(2\%) are treated with Phenobarbitone. Table~\ref{tw-ef99c51d5f15}  explains the single drug therapy pattern of AED's prescription among the study participants.

\textbf{Dual Drug Therapy pattern of AED's prescription}

In the present study, the dual therapy was prescribed to 35 subjects out of them the most commonly prescribed combinations are CLO+P given to 7 subjects (2 0\%), followed by CLO+D given to 6 subjects (17\%), followed by CLO+O given to 4 subjects (11\%), followed by CLO+L,CLO+C,C+D,O+L,D+L are given to 2 subjects (6\%) respectively, and finally CLO+O,PB+C,C+L,C+P,D+P,D+CN,O+T are given to 1 subject (3\%) respectively. Table~\ref{tw-faf703084293}  explains the dual drug therapy pattern of AED's prescription among the study participants.

\textbf{Triple Drug Therapy pattern of AED's prescription}

In the present study the Triple therapy was prescribed to 17 subjects out of them the most commonly prescribed combinations are CLO+C+P are given to 4 subjects (24\%), followed by CLO+PB+C,CLO+PB+D,CLO+PB+O are given to 2 subjects (12\%) respectively, and finally CLO+O+L, CLO+C+T, CLO+C+D, P+O+L, CLO+C+L, PB+C+L, PB+C+P are given to 1 subject (6\%) respectively. Table~\ref{tw-6bfa46c5d441}  explains the triple drug therapy pattern of AED's prescription among the study participants.


\begingroup
\makeatletter\if@twocolumn\@ifundefined{theposttbl}{\gdef\TwoColDocument{true}\onecolumn\onecolumn}{}\fi\makeatother \setlength\LTcapwidth{\textwidth}
\begin{longtable}{p{\dimexpr.14130000000000003\linewidth-2\tabcolsep}p{\dimexpr.19799999999999997\linewidth-2\tabcolsep}p{\dimexpr.28410000000000004\linewidth-2\tabcolsep}p{\dimexpr.14919999999999998\linewidth-2\tabcolsep}p{\dimexpr.22740000000000002\linewidth-2\tabcolsep}}
\caption{\boldmath {Drug therapy in relation to the diagnosis among the study participants} }
\label{tw-04f14554ff95}
\def\arraystretch{1.1}\\\endfirsthead \hline \noalign{\vskip3pt} \noalign{\textit{Table \thetable\ continued}} \noalign{\vskip3pt} 
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Sl. No & \cAlignHack Type of seizure & \cAlignHack Drugs prescribed & No. of subjects & \cAlignHack Type of therapy\\
\tblmidrule \endhead \hline \noalign{\vskip3pt} \noalign{\textit{\hfill Continued on next page}} \noalign{\vskip3pt} \endfoot \endlastfoot 
\tbltoprule \rowcolor{kwdboxcolor}\cAlignHack Sl. No & \cAlignHack Type of seizure & \cAlignHack Drugs prescribed & No. of subjects & \cAlignHack Type of therapy\\
\tblmidrule 
\cAlignHack 1 &
  \cAlignHack  &
  \cAlignHack C &
  \cAlignHack 4 &
  \cAlignHack Monotherapy\\
 &
   &
  \cAlignHack P &
  \cAlignHack 5 &
  \cAlignHack Monotherapy\\
 &
  \cAlignHack GTCS &
  \cAlignHack D &
  \cAlignHack 8 &
  \cAlignHack Monotherapy\\
 &
   &
  \cAlignHack O~&
  \cAlignHack 3 &
  \cAlignHack Monotherapy\\
 &
   &
  \cAlignHack PB &
  \cAlignHack 1 &
  \cAlignHack Monotherapy\\
 &
   &
  \cAlignHack L &
  \cAlignHack 6 &
  \cAlignHack Monotherapy\\
 &
   &
  \cAlignHack CLO+D &
  \cAlignHack 4 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack CLO+P &
  \cAlignHack 7 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack PB+D &
  \cAlignHack 2 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack C+L &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack D+L &
  \cAlignHack 2 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack CLO+L &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack CLO+C &
  \cAlignHack 2 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack PB+P &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack D+P &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack C+D &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack C+P &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack CLO+C+P &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack CLO+O+L &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack CLO+C+T &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack CLO+PB+C &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack CLO+PB+D &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack CLO+C+D &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
  \cAlignHack CLO+C+D+P &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
   &
   &
  \\
\cAlignHack 2 &
   &
  \cAlignHack C &
  \cAlignHack 3 &
  \cAlignHack Monotherapy\\
 &
   &
   &
   &
  \\
 &
  \cAlignHack FOCAL &
  \cAlignHack P &
  \cAlignHack 1 &
  \cAlignHack Monotherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack O~&
  \cAlignHack 1 &
  \cAlignHack Monotherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack PB+D &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack D+CN &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack PB+C &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack O+T &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack P+O+L &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack CLO+PB+C &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack CLO+C+P &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack CLO+C+L &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack CLO+PB+D+L+CN &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
   &
   &
  \\
\cAlignHack 3 &
   &
  \cAlignHack D &
  \cAlignHack 2 &
  \cAlignHack Monotherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack C &
  \cAlignHack 3 &
  \cAlignHack Monotherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack L &
  \cAlignHack 1 &
  \cAlignHack Monotherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack PB+D &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack O+L &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack CLO+O &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack CLO+L &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack CLO+D &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack PB+C+L &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack CLO+PB+O &
  \cAlignHack 2 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack PB+C+P &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack CLO+C+P &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack CLO+PB+D &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
   &
   &
  \\
 &
   &
   &
   &
  \\
 &
   &
   &
   &
  \\
\cAlignHack 4 &
   &
  \cAlignHack D &
  \cAlignHack 2 &
  \cAlignHack Monotherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack C &
  \cAlignHack 1 &
  \cAlignHack Monotherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack L &
  \cAlignHack 2 &
  \cAlignHack Monotherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack P &
  \cAlignHack 1 &
  \cAlignHack Monotherapy\\
 &
   &
   &
   &
  \\
 &
  \cAlignHack OTHERS &
  \cAlignHack CLO+D &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack O+L &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack C+D &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack CLO+C+P &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack CLO+PB+C+D &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
 &
   &
   &
   &
  \\
 &
   &
  \cAlignHack CLO+C+P+L &
  \cAlignHack 1 &
  \cAlignHack Polytherapy\\
\tblbottomrule 
\end{longtable}
\endgroup
\makeatletter\@ifundefined{TwoColDocument}{}{\twocolumn}\makeatother 
\textbf{Quadruple drug therapy pattern of AED's prescription}

In the present study, the Quadruple  therapy was prescribed to 3 subjects out of them the most commonly prescribed combination is CLO+C+D+P,CLO+PB+C+D,CLO+C+P+L are given to 1 subject (33.33\%) respectively. Table~\ref{tw-c50e95b1d7b7}  explains the Quadruple drug therapy pattern of AED's prescription among the study participants.

\textbf{Quintuple drug therapy pattern of AED's prescription}

In the present study, CLO+PB+D+L+CN was the five drug combination and given to a single subject.

\textbf{Drug Compliance}

In the present study, overall drug compliance was found to be better as the participants with high level of drug compliance were 45 (45\%), and those with low level of drug compliance were 26 (26\%). p  value is not significant. There is no significant relationship between age and drug compliance. But when compared with number of seizure attacks past 3 months, p  value is significant. There is a significant relationship between number of seizure attacks past 3 months and drug compliance. Table~\ref{tw-537e7d428062} explains the Drug compliance among the study participants.

\textbf{Drug therapy in relation to the diagnosis}

In the present study, type of drug therapy varied with the diagnosis among the study participants. The results are presented in Table~\ref{tw-04f14554ff95}.

\textbf{Prescribing of newer vs older antiepileptics}

In the present study, older antiepileptic drugs were most prescribed than newer antiepileptic drugs. Results are depicted in Figure~\ref{f-1a62792b5233}.


\bgroup
\fixFloatSize{images/5c558de5-bf55-40fc-a69a-80da021d0973-upicture1.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/5c558de5-bf55-40fc-a69a-80da021d0973-upicture1.png}{\includegraphics{images/5c558de5-bf55-40fc-a69a-80da021d0973-upicture1.png}}{}
\makeatother 
\caption{\boldmath {Gender wise distribution of the study participants}}
\label{f-498366e6258c}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/8279c1a7-7611-4747-b9aa-341a425db8bf-upicture2.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/8279c1a7-7611-4747-b9aa-341a425db8bf-upicture2.png}{\includegraphics{images/8279c1a7-7611-4747-b9aa-341a425db8bf-upicture2.png}}{}
\makeatother 
\caption{\boldmath {Type of seizure distribution among the study participants}}
\label{f-6a96c54ebd16}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/61f79f33-9b83-4465-b3a8-75477ca798b0-upicture3.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/61f79f33-9b83-4465-b3a8-75477ca798b0-upicture3.png}{\includegraphics{images/61f79f33-9b83-4465-b3a8-75477ca798b0-upicture3.png}}{}
\makeatother 
\caption{\boldmath {Distribution based on type of classification of drugs used}}
\label{f-c104e479e4c7}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/5e2e64d0-3ae0-4df8-b93f-b0a40972766d-upicture4.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/5e2e64d0-3ae0-4df8-b93f-b0a40972766d-upicture4.png}{\includegraphics{images/5e2e64d0-3ae0-4df8-b93f-b0a40972766d-upicture4.png}}{}
\makeatother 
\caption{\boldmath {Type of Anti-Epileptic drugs used among the study participants}}
\label{f-6b5f840de24c}
\end{figure}
\egroup

\bgroup
\fixFloatSize{images/f426cfee-cee7-488b-b4e5-2127525510bd-upicture5.png}
\begin{figure}[!htbp]
\centering \makeatletter\IfFileExists{images/f426cfee-cee7-488b-b4e5-2127525510bd-upicture5.png}{\includegraphics{images/f426cfee-cee7-488b-b4e5-2127525510bd-upicture5.png}}{}
\makeatother 
\caption{\boldmath {Prescribing of Newer Vs Older Antiepileptics among the Study Population}}
\label{f-1a62792b5233}
\end{figure}
\egroup

    
\section{DISCUSSION}
\textbf{Gender}

Among 100 patients studied; we seen female (N=51, 51\%) were predominant than males (N=49, 49\%). In contrast to our results; Murthy NV et al. \unskip~\cite{1116687:22341511}, showed males were more frequently attacked with epilepsy than females. It is however that T.Badwaik et al. \unskip~\cite{1116687:22341509}, seen females were more than males in their study exposed to antiepileptic drugs, which complements our result.

\textbf{Age}

The average age of the patients in the present study was 28.35\ensuremath{\pm}11.7 years.  In the present study, both age groups of 15-19 and 20-29 has highest percentage of patients, with each group having 31(31\%) patients. The age groups in descending order contains followed by 18 (18\%) from 30-39 years, 14 (14\%) from 40-49 years, 5 (5\%) from 50-59 years, and finally the least number of patients i.e., 1 (1\%) from 60-69 years. The results are similar to the studies from Faizan Mazhar et al. \unskip~\cite{1116687:22341509}, Nurulumi Ahmad et al. \unskip~\cite{1116687:22341522} and Kavitha Palanisamy et al. \unskip~\cite{1116687:22341534}.\ensuremath{^{}}

All the above studies concluded that most of the epileptic patients were from the age groups of 10-30. In Faizan Mazhar et al. \unskip~\cite{1116687:22341509}.  24.75 \% of patients being younger than 19 years of age. In Nurulumi Ahmad et al. \unskip~\cite{1116687:22341522}, there were 24 (46.2\%) patients under the age of 30 years, 22 (42.3\%) patients between 30-60 years and 6 (11.5\%) patients above 60 years. In Kavitha Palanisamy et al. \unskip~\cite{1116687:22341534}, patients between age group 0-14 years were dominant with 59 (32.78\%) subjects followed by patients from the age group 15-29 years (25.55\%). From this it is clearly evident that adults are more likely to have epilepsy than any other age group.

\textbf{Types of Epilepsy}

In our hospital, most patients were suffering from generalized tonic clonic seizures, followed by Complex partial seizures, Focal seizures, and other types of seizures. A study from Mysore, South India also seen similar pattern of epilepsy \unskip~\cite{1116687:22341502}. These results are similar to the studies conducted by Kavitha Palanisamy et al. \unskip~\cite{1116687:22341534}, Ramesh Rajesh Pol et al. \unskip~\cite{1116687:22341519}, where they concluded that generalized tonic clonic seizures are the most frequent type to occur among all types of seizures. In Kavitha Palanisamy et al. \unskip~\cite{1116687:22341534}, majority of the study subjects were affected with generalized seizures and 84 (46.66\%) subjects had generalized tonic clonic seizure followed by 35 (19.44\%) cases of complex partial seizures and 28 (15.55\%) cases of myoclonic seizures. Whereas, in Ramesh Rajesh Pol et al. \unskip~\cite{1116687:22341519}  occurrence of seizures depicts a highest percentage of generalized seizures (51\%) than the partial and other types.

\textbf{Type of prescribed therapy}

Problems in polytherapy is undue increase in cost, drug interaction with other drugs, increased chance of side effects and less compliance to patient which can be complicating the therapy leading to decrease in therapeutic outcome. Careful administration of other antiepileptic is needed if necessary.

In the present study, it is observed 44 patients were on single drug therapy(45\%), 35 were on double drug therapy (35\%), 17 were on triple drug therapy (17\%), 3 patients were treated with four drugs (3\%) and finally 1 patient was treated with five drug therapy. These results are in concordance with studies done by Murthy VN et al. \unskip~\cite{1116687:22341511}, Arulkumaran KSG et al. \unskip~\cite{1116687:22341507}, Malerba A. et al. \unskip~\cite{1116687:22341516}, where they found that most of the patients were prescribed single drug. These results are also similar to the study Shilpa B. N. et al. \unskip~\cite{1116687:22341508}, where majority of patients received monotherapy with various drugs (67\%). About 33\% of the patients received combination therapy with two or more drugs. Guidelines mention that medical management of newly diagnosed epileptic patients should start with monotherapy. Polytherapy should be considered when failure of two attempts of monotherapy.

\textbf{Type of AEDs among study population}

There are above 20 antiepileptic drugs which are available for clinical use today. In the present study, 9 different antiepileptic drugs were used. However. In 100 prescriptions a total of 182 antiepileptic drugs were used. , Clobazam 36(i.e., 20\%) is the most prescribed drug followed by divalproex sodium 34(19\%) and carbamazepine 32(18\%). This study highlighted that clobazam was the most commonly prescribed antiepileptic drug. Recently published studies (2002- 2013), Pathak S et al. \unskip~\cite{1116687:22341539}, Malerba A et al.\unskip~\cite{1116687:22341516}, Landmark CJ et al. \unskip~\cite{1116687:22341513}, mention that divalproex sodium was the most commonly drug prescribed followed by phenytoin or other drugs. An Indian study by Thomas SV et al. \unskip~\cite{1116687:22341506}, in 2001 mentioned that carbamazepine was prescribed most commonly. In the present study newer drugs such as Topiramate and clonazepam were not used frequently. This illustrates the existence of wide variation in prescribing the antiepileptic drugs. The reason for discrepancies may be attributed to factors like availability, affordability, place of practice, type of epilepsy and preference of treating neurologist. Clobazam is an antiepileptic belonging to benzodiazepines most commonly used for complex partial onset seizure as well as generalised tonic clonic seizures in combinations. Being cheap, it is also widely available, which enhances its use in our set up of tertiary care hospital.

\textbf{Indication wise use of Antiepileptic drugs}

Drug therapy is the mainstay of epilepsy treatment. The choice of antiepileptic drugs will depend on type of epilepsy, drug specific adverse drug reactions and patient preferences. To treat epilepsy, basic treatment approach is to begin with monotherapy, where about 50\% to 70\% of patients can be maintained on one antiepileptic drug. Among 57 Generalised tonic clonic seizures patients single drug was prescribed to 27 patients, 23 patients were prescribed two drugs and remaining 7 patients were prescribed with more than 2 drugs. From the present study it is observed that it is observed divalproex sodium is the most commonly used drug in single drug prescribed patients followed by leviteracetam to patients suffering with generalized tonic-clonic seizures. In poly therapy receiving patients Clobazam along with the phenytoin is the most commonly prescribed combination followed by Clobazam along with divalproex sodium.

Among 14 focal Seizure patients, single drug was prescribed to 5 patients, 4 patients were prescribed two drugs and remaining 5 patients were prescribed with more than 2 drugs. It is observed carbamazepine is the most commonly prescribed drug to the focal seizures patients as monotherpy. Whereas, Clobazam is the most commonly prescribed drug along with add-ons such as Phenobarbitone, carbamazepine, and in 1 case phenytoin along with Clobazam and leviteracetam along with Clobazam is also used.

Among 17 Complex Partial Seizure patients single drug was prescribed to 5 patients, 4 patients were prescribed two drug regimen and remaining 5 patients were prescribed with more than 2 drugs. In this study we observed that it is observed carbamazepine is the most commonly prescribed drug to patients suffering with complex partial seizures receiving single drug. Similar results were found in Shobhana Mathur et al. \unskip~\cite{1116687:22341541}. Whereas, in patients receiving two drugs clobazam is commonly used drug. It is used in combination with drugs such as carbamazepine, leviteracetam, and divalproex sodium. In patients receiving more than two drugs, clobazam is frequently used combined with phenobarbitone and oxcarbazepine. Among 12 other types of Seizure patients single drug was prescribed to 6 patients and 3 patients were prescribed two drugs and remaining 3 patients were prescribed with more than 2 drugs. From this study, it is observed that in other types of seizures divalproex sodium and leviteracetam are the drugs commonly used in patients receiving single drug. Whereas in patients receiving two drugs divalproex is mainly used drug with combination of either clobazam or carbamazepine. In patients receiving more than 2 drugs clobazam is commonly used along with carbamazepine and phenytoin. Based on these findings we highlighted that divalproex sodium is the drug mainly used in generalised tonic clonic seizures, complex partial seizures, and other types of seizures as monotherapy. Leviteracetam is the drug mainly used in generalised tonic clonic seizures, and other types of seizures as monotherapy. Whereas carbamazepine is used in focal seizures and complex partial seizures as monotherapy. Clobazam is the main drug used in any type of seizures in combination with other antiepileptics.

\textbf{Single therapy}

In the present study single drug therapy was prescribed to 44 subjects. From the results of the study, it is observed that divalproex sodium is the most commonly used drug given to 12 (27\%) patients followed by carbamazepine, leviteracetam, phenytoin oxcarbazepine and lastly phenobarbitone which were given to 11 (25\%), 9 (20\%), 7 (16\%), 4 (9\%) and 1 (2\%) of the patients as a monotherapy respectively.

In a study done by Meenakshi B et al. \unskip~\cite{1116687:22341512}, Divalproex sodium was the most commonly used monotherapeutic agent followed by carbamazepine, leviteracetam, phenytoin and lastly phenobarbitone.  So, the present study is in concordance with study done by Meenakshi B et al.

\textbf{Dual therapy}

In the present study dual drug therapy was prescribed to 35 patients. Upon considering the results of the study it is observed that the most commonly prescribed combination is clobazam along with phenytoin which constitutes 20\% (7) of the patients receiving dual drug therapy. Followed by clobazam along with Divalproex sodium constitutes 17\%(6), clobazam along with oxcarbazepine 11\%(4).

Combination of Clobazam with either leviteracetam or carbamazepine constitutes 6\% of the patients receiving the dual drug therapy.

The similar study was conducted by Meenakshi B et al. \unskip~\cite{1116687:22341512}, where they found that  the most commonly prescribed combination was divalproex sodium with carbamazepine followed by divalproex sodium with phenobarbitone. When the present study compared to this there is no similarity between them. From the present study, Clobazam is the most commonly prescribed drug in combination therapy.

Ngangom Gunindro et al.\unskip~\cite{1116687:22341525}, concluded that Oxcarbazepine with Clobazam was the most prescribed 2 drugs combination (36\%) while Oxcarbazepine.

\textbf{Triple therapy}

In the present study triple drug therapy was prescribed to 17 subjects. From the results of the study, it is observed that the most prescribed combination is clobazam +carbamazepine+ phenytoin which constitutes 24\% (4) of the patients receiving triple drug therapy. Followed by combination of clobazam and phenobarbitone with Carbamazepine, divalproex sodium, oxcarbazepine constitutes the second most portion of the patients receiving triple drug therapy with 12\% each. Finally combinations of clobazam with other antiepileptics occupy the next place among patients with triple drug therapy.

The similar study was conducted by Meenakshi B et al. \unskip~\cite{1116687:22341512}, where they found that  the most commonly prescribed combination was divalproex Sodium with phenytoin and carbamazepine. When the present study compared to this there is no similarity between them. From the present study, Clobazam is the most commonly prescribed drug in combination therapy.

Ngangom Gunindro et al. \unskip~\cite{1116687:22341525}, concluded that Clobazam with Levetiracetam topped the list of 3 drugs combinations.

\textbf{Quadruple therapy}

In the present study, Quadruple drug therapy was prescribed to 3 subjects. From the results of the study it is observed that the most prescribed combination is clobazam + carbamazepine +divalproex sodium +phenytoin and clobazam+phenobarbitone+carbamazepine +divalproex sodium and clobazam + carbamazepine  +phenytoin +leviteracetam are the three types of combinations prescribed to each patient constituting 33.3\%.

The similar study was conducted by Ngangom Gunindro et al. \unskip~\cite{1116687:22341525}, where they found that  33.33\% of the 4 drugs combinations comprised of Oxcarbazepine, Phenobarbitone, Levetiracetam and Divalproex combination.

\textbf{Quintuple therapy}

In the present study, quintuple therapy was prescribed to one patient. The combination of Clobazam + Phenobarbitone + Divalproex sodium + Leviteracetam + Clonazepam was prescribed. No other studies mentioned about quintuple therapy.

\textbf{Type of Classification of AEDs Prescribed}

In the present study, six groups of antiepileptic agents were prescribed to the epileptic patients. Among them Iminostilbenes were the most commonly prescribed, which constitutes (24\%) given in 44 prescriptions. Benzodiazepines were prescribed in 20.879\% followed by aliphatic carboxylic acids which were prescribed to  18.681\%. Hydantoins were prescribed to 13.736\%, Newer drugs were prescribed 13.187\% and lastly Barbiturates were the least prescribed group among AEDs accounting for 17 prescriptions 9.3407\%.

\textbf{Prescribing of newer VS older Antiepileptics}

Drugs introduced before and 1990's are called older and newer antiepileptic drugs respectively. In the present study, it is observed that It is observed newer antiepileptic drugs were prescribed very rarely when compared to older ones. This is similar to Arulkumaran KSG et al.\unskip~\cite{1116687:22341507}, study performed in India, which highlighted the limited use of newer antiepileptics drugs. Guidelines for the management of epilepsy in India, 2013 shows that newer antiepileptic drugs and their discovery has not altered treatment regimen. However, it has increased treatment choice in refractory cases. So far, no study has shown that newer drugs have superior anticonvulsant efficacy than older ones. Less usage in our settings may also be due to higher cost of these agents compared to older ones. In present study the present study it is observed that it is observed Leviteracetam, Clonazepam, Topiramate, oxcarbazepine are the frequently used newer antiepileptic drugs and Carbamazepine, Phenytoin, divalproex sodium, Clobazam and Phenobarbitone are the older ones that are prescribed. Two drug combination is far more common than the triple and quadruple anti-epileptic regimens.

\textbf{Medication Adherence}

Adherence to medication is defined as the extent to which a patient's behavior taking the medication prescribed by the physician changes after therapeutic plan agreement is established, between patient and physician \unskip~\cite{1116687:22341514}. Adherence level of the patient is relied upon on the drug side effects, which can be easily resolved. In epilepsy, patients have to take medications for years. Hence, observing medication adherence behavior of this patient vital. Medication adherence can be assessed by indirect or direct methods. Direct observed therapy, measurement of the level of medication or metabolite and biological markers in the blood are direct methods to observe medication adherence. Indirect methods include patient self-reporting, records of drug refills, pill counts, patient's treatment response assessment and the use of electronic medication-monitoring devices. In the present study patient self-reporting method is used to assess medication adherence by validated MMAS-8 questionnaires. This questionnaire consists of  8questions where 0 is given to answer `Yes' and 1 is given to answer `No' from question 1 to 7where as in question number 8, answer are reported in 0 to 4 scale. After filling the questionnaire one can add all the score to provide medication adherence score for patient which can come from 0 to 8. Further these score are classified as adherence level as high adherence (0), medium adherence (1-2) and low adherence (3-8).

In the present study it is observed that 45\% of the patients were having it is observed high medication adherence 45 \%, 29\% of patients having medium adherence and finally low medication adherence in 26\% patients.
    
\section{CONCLUSION}
Based on the results we would like to conclude that: Females were predominant than males. Adults were more prone to epilepsy. Generalised tonic clonic seizures were the most common type of seizures occurring followed by Complex partial seizures. Iminostilbenes were the most prescribed classification of antiepileptic drugs followed by Benzodiazepines and Aliphatic carboxylic acids. The average number of antiepileptic drugs prescribed per patient was approximately 2 drugs.  Clobazam was the most prescribed drug among study population. Single drug therapy was the most common type of therapy prescribed followed by Double drug therapy, and Triple drug therapy. In single drug therapy, Divalproex sodium, in dual therapy clobazam along with phenytoin and in triple therapy combination of clobazam, carbamazepine, phenytoin were mostly prescribed. There was high medication adherence among study patients followed by medium and low medication adherence. Drug therapy was specific to respective indications. Very less new antiepileptic drugs were used than older ones in prescriptions.
    
\section{ACKNOWLEDGEMENT }
We thank to Dr. Venugopal sir, MBBS, MD General Medicine, DM Neurology, who supported us in our study.

\textbf{Ethical Considerations}

We obtained patient informed consent and done our study in the guidance of health experts without harm to the subjects.

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest.

\textbf{Funding Support }

The authors declare that they have no funding support for this study.
    
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