Epilepsy control with phenobarbital or phenytoin in rural south India: the Yelandur study

Background: Epilepsy is a controllable disorder if detected and treated early. For most families in rural areas of less developed countries, however, treatment can be delayed because of the inaccessibility of specialist neurological assessment facilities. We aimed to find a practical solution to rural epilepsy control by doing a non-randomised trial in south India. Methods: 135 patients with partial or generalised tonic-clonic seizures agreed to long-term treatment with phenobarbital (n=68), phenytoin (n=60), or both (n=7). Drugs were given once daily, and at the lowest effective dose, by trained primary-care physicians and health workers. All management was entirely clinical. The main outcome measure was absence of seizures of any type for at least 2 years (terminal remission). Analysis was by intention to treat. Findings: The proportion with terminal remission at each of 4 successive years of follow-up ranged from 58% to 66% for patients who were drug compliant and who had a lifetime total of 30 or fewer generalised tonic-clonic seizures. The corresponding range for patients who were not compliant and who had ever had more than 30 such seizures was 6-16%. Multivariate logistic regression analysis confirmed that strict drug compliance and early treatment were important predictors of a 2-year terminal remission. Clinical adverse effects were noted in three (4%) patients on phenobarbital and 67 (43%) of those on phenytoin (mainly in the form of gingival hyperplasia). Interpretation: In rural areas of less developed countries, epilepsy control in its early stages can be practical and effective with existing resources. The key to success is a combination of trained primary-care physicians, health workers, inexpensive phenobarbital, drug compliance, health education, and follow-up