DRUG UTILIZATION REVIEW OF ANTIEPILEPTIC DRUGS: A ... · induced shock, NMDA receptors are released...

www.wjpps.com Vol 5, Issue 3, 2016.

684

Banu et al. World Journal of Pharmacy and Pharmaceutical Sciences

DRUG UTILIZATION REVIEW OF ANTIEPILEPTIC DRUGS: A

RETROPROSPECTIVE STUDY

Zeenath Banu* and Syeda Juveria Fatima

Assistant Professors, Shadan Women’s College of Pharmacy, Khiartabad, Hyderabad.

ABSTRACT

Drug utilization review can be defined as review of drugs used in a

population to determine effectiveness, potential dangers, problems

with drug interaction and other issues. It aims at providing guidelines

to doctors with respect to the rational use of drugs, minimizing side

effects, poly pharmacy and exposure to potent drugs. Our aim of

choosing this topic is to give a brief idea about the disease and

highlight the rational and cost effective use of the anti-epileptic drugs

which is not rational may ultimately lead to poor patient outcome and

significant wastage of money and resources Method: A retrospective

observational study was conducted at Princess Durre Shehvar

Children’s and General Hospital, Hyderabad. It was conducted over a

period of one month. A total 100 patient’s data were collected, Percentage of men 47(61%)

suffering from epilepsy was higher than female 30 (40%).Our data shows that most of the

patients 77 were from age group (0-10) years; followed by 8 of patient in the age group of

(11-20)years. Conclusion, the use of anti-epileptic drugs was almost found to be rational.

Pharmacist is the key person for better management of therapy based on stage and condition

of patient.

KEYWORDS: Drug Utilization, Prescription Pattern, Seizures, Antiepileptic drugs.

INTRODUCTION

The word “Epilepsy” is derived from a Greek word meaning “a condition of being

overcome, seized, or attacked”. The word “Epilepsy” means nothing more than the tendency

to have seizures. It is defined as a chronic disorder which causes disturbances in the electrical

signalling and its transmission in the brain and is characterized by recurrent and sudden

occurrence of seizures which stop spontaneously. [1]

WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

SJIF Impact Factor 6.041

Volume 5, Issue 3, 684-702. Research Article ISSN 2278 – 4357

Article Received on

14 Jan 2016,

Revised on 05 Feb 2016,

Accepted on 26 Feb 2016

*Correspondence for

Author

Zeenath Banu

Assistant Professors,

Shadan Women’s College

of Pharmacy, Khiartabad,

Hyderabad.

http://www.wjpps.com/


685


ETIOLOGY

The causes of epilepsy are as follows

Figure 1: Causes of Epilepsy

PATHOPHYSIOLOGY

Neurons are interconnected in a complex network in which each individual neuron is linked

through synapses with hundreds of others. A small electrical current is discharged by neurons

to release neurotransmitters at synapses levels to permit communication with each other.

Epilepsy occurs when there is an imbalance between excitatory and inhibitory influences in

brain.

(a) Na+

or Ca2+

ion conductance of the neuronal membrane.

(b) Inhibitatory GABA neuronal circuits, i.e. defects in GABA transmission.

(c) Excitatory mechanisms involving NMDA receptor channels to produce depolarization

and

(d) Other functions related to pre- or postsynaptic activity.[2]

Excitatory Imbalance: When there is excessive discharge of impulses i.e. seizure Mg+2

induced shock, NMDA receptors are released which causes Ca+2

influx which leads to the

activation of calmodulin and other kinases as a result of increased AMP receptor sensitivity

and release of Glutamate which further leads to the opening of Na+

channels which results in

the generation of impulses.

Inhibitory Imbalances: GABA (Gamma amino butyric acid) is an inhibitatory

neurotransmitter in brain. The levels of GABA are maintained in the brain by GABA

transaminase enzyme which is responsible for its degradation. In epileptic conditions, GABA



686


transaminase activity is imbalanced as a result its inhibitory effect is suppressed which leads

to increased excitatory activity which results in seizures. [3]

A neuron discharging can either

excite or inhibit neurons connected to it. An excited neuron will activate the next neuron

whereas an inhibited neuron will not. In this manner information is conveyed, transmitted and

processed throughout the central nervous system. If neurons are damaged, injured or suffer a

chemical or metabolic insult, a change in the discharge pattern may develop.

In case of epilepsy, regular low frequency discharge is replaced by bursts of high frequency

discharges usually followed by period of inactivity. This occur due to influx of extracellular

Ca+2

ions in very high amounts followed by opening of voltage gated sodium channels

(depolarization phase).

Figure 2: Pathophysiology

A single neuron discharging in abnormal manners usually has no clinical significance. It is

only when a whole population of neurons discharges synchronously in an abnormal way that

an epileptic seizure may be trigged. This abnormal discharge may remain localized or it may

spread to adjacent areas, recruiting more neurons as it expands [2]

. The area from which the

abnormal discharge originates is known as the epileptic focus. An EEG recording carried out

during one of these abnormal discharges may show a variety of atypical signs, depending on

which area of the brain involved its progression and how the discharging area projects to the

superficial cortex. [2]

CLASSIFICATIONS OF EPILEPSY

Epileptic seizures can be classified into two types



687


Figure 3: Classification of Epilepsy

1. Partial seizures / Focal seizures: These are the most common type of seizures which are

always due to a focal brain lesion.

(a) Simple partial seizures: Simple partial seizures are localized seizures that occur in only

one part of the brain. A wide range of clinical phenomena may occur depending on the

site of the brain lesion.

Motor: This begins as recurrent contractions of a part of the body and may spread to

involve contiguous areas.

Sensory with numbness or parasthesia limited to one part of the body.

Olfactory, Gustatory, Auditory and vertiginous symptoms.

Autonomic symptoms

Psychic Symptoms such as déjà-vu and dreamy states or unwarranted sense of fear or

anger. [4]

Figure 4(a): Simple partial seizure



688


A simple partial seizure with motor symptoms.

(a) First the fingers then the hand and arm are jerking.

(b) It has spread to the upper shoulder.

(c) The woman’s head is drawn towards her shoulder.

(d) The leg is drawn up.

Figure 4(b): Simple partial seizure

(b) Complex partial seizures or Psychomotor Epilepsy

This seizures originate in temporal lobes (frontal lobe & accompanied with partial loss of

consciousness) of brain. The patient may present with altered or automatic behaviour:

plucking his or her clothes fiddling with various object and acting in confused manner. Lips

smacking/Chewing movements, undressing performing aimless activities and wandering

around in a drunken fashion may occur on their own or in different combinations during

complex partial seizures. [2]

Figure 5: Complex partial seizure



689


(c) Secondary Generalized seizures

When partial seizures progresses to generalized seizures in which the discharge spread to the

entire brain. The patient may have warnings but not every time.

Figure 6: Secondary Generalized Seizure

EEG shows localized onset but involvement of entire brain leads to same convulsive attacks

as that in generalized tonic – clonic seizures.

2.Generalized seizures: This type of seizures involves initial activation of both hemisphere

of brain simultaneously. It results in impairment of consciousness from the onset.

a) Absence Seizure (petit-mal): The rarely occurring seizures are seen only in children&

young adults. It consists of sudden cessation of ongoing conscious activity without

convulsive movement & without loss of postural control. The point appears to go blank for

one second to one minute, & there may be accompanying fluttering of eyelids or small

chewing movements of the mouth.

Figure 7: Absence Seizure

The EEG shows Symmetric spikes at 3 Hz & wave pattern of discharge /sec hat begins &

ends suddenly.



690


b) Myoclonic Seizures

These are abrupt, very brief involuntary shock like jerks, which may involve the whole body

or the arms or the head .EEG shows 2 Hz spikes & wave pattern/sec.[13]

Figure 8: Myoclonic seizure

c) Tonic –Clonic Seizures or Grandmal epilepsy: These are the commonest of all epileptic

seizures without warning, the patient suddenly goes stiff, fall and convulses with laboured

breathing and salvation.

Figure 9: Tonic – Clonic Seizure

The attack may be accompanied by tongue biting, frothing at the mouth and incontinence.

The convulsion ceases after a few minutes and may often be followed by a period of

drowsiness, Confusion Headache and Sleep.

EEG shows a bilateral diffuse pattern of high voltage poly spikes of 10 - 30Hz/ sec.

d) Tonic Seizures

Tonic seizures are characterized by the muscles stiffening and the person falling to the

ground. These seizures frequently occur in clusters during sleep. People who suffer from

tonic seizures are at risk of head injury from falls.



691


Figure 10: Tonic Seizure

(e) Atonic (Akinetic) Seizure: These comprise a sudden loss of muscle tone, causing the

person to collapse to the ground suddenly. These kinds of seizures generally occur in

children, are turns drop attacks whose recovering is almost instantaneous.

EEG shows brief spikes and wave discharge is slow. [2]

Figure 11: Atonic Seizure

DIAGNOSIS

Diagnosis is based on detailed history of seizures, clinical examination, electro

encephalogram (EEG) and appropriate neuron-imaging.

A diagnosis of epilepsy is made after the patient has had more than one event recognizable as

a seizure not related to fever. Diagnosis of epilepsy in people aged over 60 years is more

difficult than in younger adults and children. Diagnosis of epilepsy can be compounded by an

inadequate medical history or documentation, particularly if there is a substantial period of

time between witnessed seizures.[2]

1.ELECTROENCEPHALOGRAM

Electroencephalography (EEG) is the recording of electrical activity along the scalp. EEG

measures voltage fluctuations resulting from ionic current flows within the neurons of


http://en.wikipedia.org/wiki/Electrical

http://en.wikipedia.org/wiki/Scalp

http://en.wikipedia.org/wiki/Neurons


692


the brain. It is aim to record abnormal neuronal discharges. However, EEGs have limitation

that should be clearly understood up to 5% of people without Epilepsy may have not specific

abnormalities in their EEG recording, while up to 40%of people with Epilepsy may have a

normal EEG recording between seizures. [2]

Figure 12: EEG

Therefore the diagnoses of Epilepsy should be strongly supported by a history of epileptic

attacks otherwise EEG will be invaluable. The change of recording the discharges of an

actual seizure during a routine EEG, which usually takes 20-30 minutes.

(a) Ambulatory EEG

It allows recording in day to day circumstances using a small cassette recorder.

(b) EEG video –Telemetry

In this, patient is hospitalized and kept under continuous monitoring. It is useful in the

assessment of difficult cases, particularly if surgeries are considered. This is only helpful in a

few cases, and it is best suited for patients who have frequent seizures. [3]

CLASSIFICATION OF ANTI-EPILEPTIC DRUGS

1.Hydantoin derivatives: Phenytoin, Fosphenytoin

2.Barbiturates: Phenobarbitone and Primidone

3.Iminostilbenes: Carbamazepine , Oxcarbazepine

4.Succinimide: Ethosuximide, Methsuximide

5.GABA-transaminase inhibitors: Sodium valproate, vigabatrin

6.GABA reuptake inhibitors: Tiagabin

7.GABA agonists: Gabapentin

8.Benzodiazepines: Clonazepam, Diazepam, Clobazepam, Lorazepam

9.Miscellaneous: Lamotrigine, Sulthiame, Phenacemide and amphetamine.[4]


http://en.wikipedia.org/wiki/Brain


693


METHODOLOGY: PHASES AND STEPS INVOLVED IN CONDUCTING A DRUG

UTILIZATION REVIEW

STEP 1: IDENTIFY DRUGS OR AREAS OF PRACTICE FOR POSSIBLE STUDY

Identify drugs or therapeutic areas of practice for possible inclusion in the program .It is not

possible and also unnecessary to examine every drug that is used in the hospital .Hence ,the

DUR committee must identify priority drugs or areas of practice where improvement in use

will result in the greatest clinical impart .These areas can be identified through various source

of information , such as medication error , adverse drug reaction reports , feedback from

prescribes or clinical pharmacists , local microbiology that and the medical and

pharmaceutical literature.[5]

STEP 2: DESIGN OF STUDY

Observational research methods are most commonly used than experimental methods such as

randomized controlled trials .Cross sectional studies, where drug use is examined at a single

point in time, are useful for proper identification .The pre post design where drug use is

examined before and after interventions to improve prescribing is another commonly used

observational method. During a retrospective DUR, drug therapy is reviewed after a patient

has completed a course therapy.

STEP 3: DEFINE CRITERIA AND STANDARDS

After the DUR target has been selected, it is important to conduct a comprehensive literature

review. Standard are professionally developed expressions of the range of acceptable

variation from a criterion .Criteria should be scientifically based and be supported by clinical

or research literature .They must be valid, unambiguous, realistic, easily measured and

outcome oriented. [6]

STEP 4: DESIGN THE DATA COLLECTION FORM

Just as it is impossible to monitor and evaluate all drugs used in the hospital, it is also

impossible to address all aspect of use for each individual drug.

STEP 5: DATA COLLECTION

Data collectors should be choosing carefully and should be familiar with new information is

arranged in the patients care notes .Knowledge of drug names, strength and the way orders

are written is also important .Depending upon their availability, physicians, pharmacist and

nurses make ideal data collectors. [7]



694


STEP 6: EVALUATE RESULTS

Data evaluation is one of the most critical steps in DUR. The data obtained should be

collected using available resources such as spread sheets, data bases, and word processing.

The next step is to summarize the major categories of results and to identify where exactly

the data shows deviation from guidelines and usage criteria that are previously identified.

STEP 7: PROVIDE FEEDBACK OF RESULTS

The success of any DUR strategy depends on feedback of the results to prescribers, other

hospital staff involve in the study and in the administrative heads. The result can also be

circulated to hospital staff via newsletters, DUR meetings or hospital academy meetings. [8]

This study was conducted in the Princess Durru Shevar Children’s & General Hospital,

Hyderabad, Andhra Pradesh, which is a reputed hospital. It has also a pharmacy in it. Many

patients from in and around AP visit here. It was conducted over a period of 1 month Princess

Durru Shevar Children’s & General Hospital. About 100 patients was surveyed, their case

sheets were studied in detail. The study includes retrospective treatment chart reviews. We

focused on different parameters like various class of drugs given to the patients, gender, age,

route of administration.

SOURCE OF INFORMATION

Documented information was collected from the case sheet of respective wards, only in the

presence of deputed neurologist and his assistants though the identity of the patient was

confidential, an ID number was given for each patient. [9]

DATA COLLECTION

A total of 100 cases were reviewed and the analysis of forms was done according to the

neurologist guidelines .The data collection for included the information:

Patient ID no.

Date of admission and date of discharge

Age

Sex

History of illness

Provisional diagnosis

Names of drugs prescribed

Dose

Route of administration



695


Data collection chosen must be familiar with how information is arranged in the patient’s

case sheet .Knowledge of drugs names, strengths, and the way the order is written is also

important. Retrospective review was performed during the course of treatment and it involves

the review of drug therapy after the patient has completed a course. [10]

RESULTS AND DISCUSSION

PATEINT DEMOGRAPHIC DATA

A total of 80 patients were treated with anti-epileptic drugs for various types of epilepsy

disorders. The number of patients were maximum from children (first) aged group (0-10

years) which account for 75% of the total patients. Of the 80 patients, 50 (62.5%) and 30

(37.5%) were male and female, respectively. The disorder like simple febrile seizure and

generalized seizure were prominent. The most common route of administration in the

treatment of epilepsy was found to be parenteral (83.7%) than oral (81.2%).

1. DEMOGRAPHIC DATA OF PATIENT

S.No. Age Group No. of patients Percentage

1 0 - 10 62 77.5%

2 11 – 20 6 7.5%

3 21 – 30 5 6.2%

4 31 – 40 - -

5 41 – 50 - -

6 51 – 60 4 5.1%

7 61 – 70 3 3.7%

Based on Demographic Data of Patients

77.5

6 50 0

4 3

0

10

20

30

40

50

60

70

80

90

Age Group

% o

f P

ati

en

ts

0-10

11-20

21-30

31-40

41-50

51-60

61-70

2. BASED ON GENDER

S.No. Gender No. of Patients Percentage

1 Male 50 62.5%

2 Female 30 37.5%



696


Based On Gender

62.5

37.5

0

10

20

30

40

50

60

70

Gender

% o

f P

atie

nts

Male

Female

3. BASED ON ROUTE OF ADMINISTRATION

S.No. Route of Admin. No. of Drugs Percentage

1 Oral 65 49.2%

2 Parenteral 67 50.7%

Based on Route of Administration

49.2 50.7

0

10

20

30

40

50

Route

% o

f Pat

ient

s

Oral

Parenteral

4. PRESCRIBING FREQUENCIES OF SELECTED DRUG CATEGORIES

S.No. Class of Drugs Total no. of

Patients

Males Drugs

%

Females Drugs %

1 Benzodiazepines 77 50 64.9% 27 35%

2 Hydantoin 39 27 69.2% 12 30.7%

3 GABA Transominase

Inhibitor

15 11 73.3% 4 26.6%

4 Barbiturate 2 2 100% 0 0



697


Based on Prescribing Frequencies of

Selected Drugs in Males

64.969.2

73.3

100

0

20

40

60

80

100

Classes of Drug

% o

f P

ati

en

ts Benzodiazepine

Hydantoin

GABA

Barbiturate

Based on Prescribing Frequencies of

Selected Drugs in Females

35

30.7

26.6

00

5

10

15

20

25

30

35

40

Classes of Drug

% o

f P

ati

en

ts Benzodiazepine

Hydantoin

GABA

Barbiturate

5. PRESCRIBING FREQUENCIES OF OTHER DRUGS

S.No. Classes of Drugs Total No. of

Patients Males Drugs % Females Drugs %

1 Antibiotics 94 61 64.8% 33 35.1%

2 Anti-pyretic 51 37 72.5% 14 27.4%

3 Analgesics 51 35 68.6% 16 31.3%

4 Anti-emetics 29 14 48.2% 15 51.7%

5 Anti-ulcer 26 10 38.4% 16 61.5%

6 Anti-amoebic 6 2 33.3% 4 66.6%

7 Anti-diarrheal 6 3 50% 3 50%

8 Anti-depressant 1 0 1 100%

9 Diuretics 6 2 33.8% 4 66.6%

10 Anti-anxiety 1 1 100% 0

11 Anti-diabetic 1 1 100% 0

12 Anti-allergic 2 2 100% 0

13 Anti-septic 1 1 100% 0

14 Laxatives 2 1 50% 1 50%

15 Autacoids 5 2 40% 3 60%

16 Multivitamins & Mineral

Combination 12 1 8.3% 11 91.6%

17 Anti-malarial 4 1 25% 3 75%

18 Haematinics 2 0 2 100%



698


Based on Prescribing Frequencies of Other Drugs in Males

61

37 35

1410

2 3 2 1 1 2 2 1 2 1 1

0

10

20

30

40

50

60

70

Classes of Drug

No

. o

f D

rug

s

Antibiotics

Anti-pyretics

Analgesics

Anti-emetics

Anti-ulcer

Anti-amoebic

Anti-diarroheal

Diuretic

Anti-anxiety

Anti-diabetic

Anti-allergic

Anti-septic

Laxative

Autocoid

Multivitamin

Anti-malarial

Based on Prescribing Frequencies of Other Drugs in Females

33

1416 15 16

4 31

4

13

11

3 2

0

5

10

15

20

25

30

35

Classes of Drugs

No

. o

f D

rug

s

Antibiotics

Anti-pyretic

Analgesic

Anti-emetic

Anti-ulcer

Anti-amoebic

Anti-diarrhoeal

Anti-depressant

Diuretic

Laxative

Autacoid

Multiviatmin

Anti-malarial

Haematinic

6. BASED ON ETIOLOGY

S.No. Causes Total No. of

Patients

Male

No. %

Female

No. %

1 Genetic / Hereditary 31 15 48.3% 16 51.6%

2 Infection 38 26 68.4% 12 31.5%

3 Metabolic Disorder 5 3 60% 2 40%

4 High Fever 15 12 80% 3 20%

5 Tumor 1 1 100% 0

6 Sudden Withdrawal of Drug 7 1 14.2% 6 85.7%

7 Developmental Delay 6 6 100% 0

Based on Etiology in Males

15

26

3

12

1 1

6

0

5

10

15

20

25

30

Causes

No

. o

f M

ale

s

Genetic

Infection

Metabolic Disorder

High Fever

Tumor

Drug Withdrawal

Developmental Delay



699


Based on Etiology in Females

16

12

23

6

0

2

4

6

8

10

12

14

16

18

Causes

No

. o

f F

emal

es Genetic

Infection

Metabolic Disorder

High Fever

Drug Withdrawal

7. BASED ON SIGNS AND SYMPTOMS

S.No. Signs and Symptoms Total no. of

Patients

Male No.

%

Female No.

%

1 Up rolling of eye balls 49 26 53.06% 23 46.9%

2 Tonic pasturing of UL & LL 50 37 74% 13 26%

3 Cough & cold 19 14 73.6% 5 26.3%

4 Involuntary movements 14 7 50% 7 50%

5 Frothing from mouth 12 10 83.3% 2 16.6%

6 Fever 53 33 62.26% 20 37.7%

Based on Signs & Symptoms in Males

26

37

14

710

33

0

5

10

15

20

25

30

35

40

Signs & Symptoms

No

. o

f M

ale

s

Up rolling of eyes

Tonic pasturing of LL & UL

Cough & cold

Involuntary movements

Frothing from mouth

Fever

Based on Signs & Symptoms in Females

23

13

57

2

20

0

5

10

15

20

25

Signs & Symptoms

No

. o

f F

em

ale

s

Up rolling of eyes

Tonic pasturing of LL & UL

Cough & cold

Involuntary movemnets

Frothing from mouth

Fever



700


8.BASED ON CLASSIFICATION OF EPILEPTIC DISORDER

S.No. Disorder Total No. of Patients Percentage

1 Simple Febrile 26 32.5%

2 Complex Febrile 4 5%

3 Generalized 16 20%

4 Atypical Febrile 4 5%

5 Status 2 2.5%

6 Acute Febrile 6 7.5%

7 Seizure Under Evaluation 18 22.5%

8 Seizure Disorder 16 20%

Based on Classification of Epileptic Disorders

32.5

5

20

52.5

7.5

22.520

0

5

10

15

20

25

30

35

Disorder

% o

f P

ati

en

ts

Simple Febrile

Complex Febrile

Generalized

Aypical

Status

Acute Febrile

Seizure Under

EvaluationSeizure Disorder

7.Based on Generic Incidence of Epileptic Disorder

S.No. Disorder Total no. of

Patients

Male

No. %

Females

No. %

1 Simple Febrile 26 20 76.9% 6 23.07%

2 Complex Febrile 4 2 50% 2 50%

3 Generalized 16 11 68% 4 25%

4 Atypical Febrile 4 1 25% 3 75%

5 Status 2 2 100% 0

6 Acute Febrile 6 1 16% 5 83%

7 Seizure under Evaluation 18 13 72% 5 27.7%

8 Seizure Disorder 16 6 37.5% 10 62.5%

Based on Generic Incidence of Epileptic Disorder in Males

20

2

11

12

1

13

6

0

5

10

15

20

25

Disorder

No

. o

f M

ale

s

Simple Febrile

Complex Febrile

Generalized

Aypical

Status

Acute Febrile

Seizure Under

EvaluationSeizure Disorder



701


Based on Generic Incidence of Epileptic Disorder in Females

6

2

43

5 5

10

0

2

4

6

8

10

12

Disorder

No

. o

f F

em

ale

s

Simple Febrile

Complex Febrile

Generalized

Aypical

Acute Febrile

Seizure Under

Evaluation

Seizure Disorder

CONCLUSION

The use of antiepileptic drugs was almost found to be rational. In this hospital 3 different

drugs were prescribed which are from National list of essential drugs. Rational use of drugs

minimizes poly pharmacy drug interaction. In turn it minimizes the hospital stay. Though it

may take a long way, but gradually it is possible to achieve the objectives. The prescribing

habits are appropriate and are in accordance with WHO guidelines. Pharmacists are the key

persons for better management of therapy based on stage and condition of patient.Thus, the

pharmacist is a “DRUG EXPERT who carries out valuable, knowledge based duties and

serves the community in a very dutiful manner”.

REFERENCES

1. Goodman & Gilman’s-The pharmacological basis of therapeutics, 19th

edition, pg.no :

521.

2. Roger Walker, Cate Whittlesea, Clinical Pharmacy and Therapeutics. Professor of

pharmacy Practice, Welsh School of Pharmacy. London:4th

edition,pg.no:447-449.

3. Sharma &Sharma:Essential Of Pharmacology Basic Principles And General Concepts,3th

edition pg.no:

4. R.S Satoskar:Pharmacology & Pharmacotherapeutics 16th

edition,pg.no:117

5. Parthasarathi ,K.N Hansen. Clinical pharmacy ,Chapter 22:Drug Utilization Review

,pg.no 362

6. Fisher Rs,van Emde Boas W, Blume W,Epileptic seizures and epilepsy: Defination

proposed by the International League Against Epilepsy

7. K.S.G.ArulKumaran, S.Palanisamy, A.Rajasekaran: A study on drug use evaluation of

anti-epileptics at a multispecialty tertiary care teaching hospital, International Journal of

Pharm Tech Research , Oct-Dec 2009; 1(4): 1541-1547.



702


8. Yagnik Ravikant Maheshchandra, Elizabeth Sally Thomas, Roozbeh Azari; prescribing

pattern of antiepileptic drugs in a tertiary care hospital; visveswarapura institute of

pharmaceutical sciences;banglore

9. Drug utilization review.com[online].Indianpolis:Indiana University Department;[updated

18 May2007;cited 30 May 2007].Available from:http://A:/ dur 54.htm.

10. M Gauthier-Lewis, E Scopelitis, H Calmes, & C Jastram; A Drug Utilization

Evaluation:establishing Guidelines For NonEmergency IV Phenytoin / Fosphenytoin Use

Xavier University of Louisiana, College of Pharmacy.


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