Risk of Unnatural Mortality in People With Epilepsy

Abstract

Importance: People with epilepsy are at increased risk of mortality, but, to date, the cause-specific risks of all unnatural causes have not been reported.

Objective: To estimate cause-specific unnatural mortality risks in people with epilepsy and to identify the medication types involved in poisoning deaths.

Design, setting, and participants: This population-based cohort study used 2 electronic primary care data sets linked to hospitalization and mortality records, the Clinical Practice Research Datalink (CPRD) in England (from January 1, 1998, to March 31, 2014) and the Secure Anonymised Information Linkage (SAIL) Databank in Wales (from January 1, 2001, to December 31, 2014). Each person with epilepsy was matched on age (within 2 years), sex, and general practice with up to 20 individuals without epilepsy. Unnatural mortality was determined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes V01 through Y98 in the Office for National Statistics mortality records. Hazard ratios (HRs) were estimated in each data set using a stratified Cox proportional hazards model, and meta-analyses were conducted using DerSimonian and Laird random-effects models. The analysis was performed from January 5, 2016, to November 16, 2017.

Exposures: People with epilepsy were identified using primary care epilepsy diagnoses and associated antiepileptic drug prescriptions.

Main outcomes and measures: Hazard ratios (HRs) for unnatural mortality and the frequency of each involved medication type estimated as a percentage of all medication poisoning deaths.

Results: In total, 44 678 individuals in the CPRD and 14 051 individuals in the SAIL Databank were identified in the prevalent epilepsy cohorts, and 891 429 (CPRD) and 279 365 (SAIL) individuals were identified in the comparison cohorts. In both data sets, 51% of the epilepsy and comparison cohorts were male, and the median age at entry was 40 years (interquartile range, 25-60 years) in the CPRD cohorts and 43 years (interquartile range, 24-64 years) in the SAIL cohorts. People with epilepsy were significantly more likely to die of any unnatural cause (HR, 2.77; 95% CI, 2.43-3.16), unintentional injury or poisoning (HR, 2.97; 95% CI, 2.54-3.48) or suicide (HR, 2.15; 95% CI, 1.51-3.07) than people in the comparison cohort. Particularly large risk increases were observed in the epilepsy cohorts for unintentional medication poisoning (HR, 4.99; 95% CI, 3.22-7.74) and intentional self-poisoning with medication (HR, 3.55; 95% CI, 1.01-12.53). Opioids (56.5% [95% CI, 43.3%-69.0%]) and psychotropic medication (32.3% [95% CI, 20.9%-45.3%)] were more commonly involved than antiepileptic drugs (9.7% [95% CI, 3.6%-19.9%]) in poisoning deaths in people with epilepsy.

Conclusions and relevance: Compared with people without epilepsy, people with epilepsy are at increased risk of unnatural death and thus should be adequately advised about unintentional injury prevention and monitored for suicidal ideation, thoughts, and behaviors. The suitability and toxicity of concomitant medication should be considered when prescribing for comorbid conditions.

Figure 1.. Flow Diagram Showing Delineation of Epilepsy and Comparison Cohorts

Identification of epilepsy and comparison cohorts from the Secure Anonymised Information Linkage (SAIL) Databank and the Clinical Practice Research Datalink (CPRD) database. Individuals who did not meet the cohort definition criteria were excluded at the identified stages of cohort construction. AED indicates antiepileptic drug; HES, Hospital Episode Statistics; and ONS, Office for National Statistics.

Figure 2.. Forest Plot Showing Deprivation-Adjusted Hazard Ratios (HRs) for Cause-Specific Unnatural Mortality

Deprivation-adjusted HRs for cause-specific mortality in the prevalent epilepsy cohort vs comparison cohort. The HRs were estimated separately using data from the Secure Anonymised Information Linkage (SAIL) Databank and the Clinical Practice Research Datalink (CPRD), and the meta-analyses were conducted using DerSimonian and Laird random-effects models. Weights are from random-effects analysis. Cause of death was determined from the Office for National Statistics–recorded underlying cause of death as classified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes.

Figure 3.. Forest Plot Showing Deprivation-Adjusted Hazard Ratios (HRs) Estimated From Prevalent and Incident Epilepsy Cohorts

Deprivation-adjusted HRs for all deaths, unnatural deaths, unintentional deaths, and suicides are shown for prevalent and incident epilepsy cohorts vs comparison cohorts. The HRs were estimated separately using the Secure Anonymised Information Linkage (SAIL) Databank and the Clinical Practice Research Datalink (CPRD) database, and meta-analyses were conducted using DerSimonian and Laird random-effects models. Weights are from random-effects analysis. Cause of death was determined from the Office for National Statistics–recorded underlying cause of death as classified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes.