Phenobarbital: missing in action.

Editorials 871 Epilepsy affects more than 60 million people worldwide, and over 80% of them live in resource-poor countries. 1 Approximately 85% of these people do not receive appropriate treatment 2 because of economic, cultural, social and legislative barriers, compounded by little interest on the part of pharmaceutical companies because drug distribution is not lucrative. Left untreated, people with epilepsy face devastating social consequences, including stigma and discrimination, and can even die from seizures. The morbidity and premature mortality associated with epilepsy and the large economic burden the disease imposes on health-care systems can only be mitigated by making effective antiepileptic treatment widely available. Phenobarbital, an effective anti-epileptic drug, has been used since the early twentieth century. 3 Its relatively low cost and favourable cost–efficacy ratio, which is lower than that of any other anti-epileptic drug in current use, 4 makes the drug affordable and suitable for use in low-and middle-income countries, where cost-effectiveness often supersedes other priorities. In addition, the drug's half-life allows for the use of a single daily dose, which is convenient. The World Health Organization (WHO) recommends phenobarbital as a first-line treatment for convulsive seizures in resource-poor countries 5 and includes it in its Model Lists of Essential Medicines. Accordingly, a continuous supply of phenobarbital of assured quality in appropriate dosage forms should be available in all of WHO's Member States, duly accompanied by information on its use. Phenobarbital controls seizures effectively. 3 In an observational study in rural Mali, the drug prevented seizures in about 80% of individuals and reduced the frequency of seizures in 16%. 6 A more recent study from Mali found that almost 60% of the people who took phenobarbital were seizure-free at the last follow-up. 7 In an interventional study in rural China, 68% of the 1897 patients who completed 12 months' treatment with phenobarbital experienced a substantial reduction in seizure frequency and 34% stopped having seizures altogether. 8 Subsequent research into the costs of treatment in two of the communities in rural China showed that phenobarbital treatment significantly reduced each patient's total expenditure over the course of one year. 9 D e s p i t e t h e a d v a nt a g e s o f phenobarbital, the epilepsy treatment gap is large. A survey of pharmacies in Zambia revealed that almost half of them did not stock any anti-epileptic drugs at all and that …