Effects of antiepileptic drug therapy on vitamin D status and biochemical markers of bone turnover in children with epilepsy

Vitamin D Supplementation for Children with Epilepsy on Antiseizure Medications: A Randomized Controlled Trial

BACKGROUND

Antiseizure medications (ASMs) are crucial for managing epilepsy in children. However, a well-documented side effect of ASMs is their impact on bone health, often due to interference with vitamin D metabolism. This can lead to vitamin D deficiency in children with epilepsy. This study aimed to determine if a daily dose of 400 IU or 1000 IU would maintain adequate vitamin D levels in children with epilepsy.

METHODS

A phase IV randomized controlled trial enrolled children aged 2-16 years with epilepsy and receiving antiseizure medications. Children were divided into two groups: the monotherapy group, which was defined as children on one antiseizure medication (ASM), and the polytherapy group, which was defined as children receiving two or more ASMs. Eligible children with levels above 75 nmol/L were randomized to receive a maintenance dose of either 400 IU/day or 1000 IU/day of cholecalciferol. Baseline and 6-month assessments included demographic data, anthropometric measurements, seizure type, medications, seizure control, and 25(OH)D level.

RESULTS

Out of 163 children, 90 were on monotherapy and 25 on polytherapy. After 6 months of vitamin D maintenance, the proportion of children with 25(OH)D concentration below 75 nmol/L was 75.0% in the 400 IU group and 54.8% in the 1000 IU group. In the monotherapy group, baseline seizure-free children increased from 69% to 83.6% after treating vitamin D deficiency.

CONCLUSION

Daily vitamin D supplementation with 1000 IU may be beneficial for children with epilepsy, particularly those receiving monotherapy, to maintain sufficiency and potentially improve seizure control.

Vitamin D content and prevalence of vitamin D deficiency in patients with epilepsy: a systematic review and meta-analysis

Introduction

The prevalence of vitamin D deficiency and vitamin D levels in patients with epilepsy (PWE) were systematically evaluated, and the differences between subgroups were analyzed.

Method

We identified all articles investigating the prevalence of vitamin D deficiency in patients with epilepsy from the database established in March 2024 from PubMed, Web of Science, and Embase. We divided them into anti-seizure medication (ASM) interventions and non-ASM interventions according to whether or not someone used ASM.

Results

A total of 68 articles were included. The prevalence of newly diagnosed epilepsy was 50.2% (95% CI: 38.7-61.7%), and the prevalence after ASM intervention was 47.9% (95% CI: 40-55.9%), including 7,070 patients with epilepsy. Subgroup and meta-regression analyses were performed according to the diagnostic criteria, economic development level, region, age, ASM treatment, and other factors. The results showed that the differences were not significant. In addition, the vitamin D content of epilepsy patients (18.719 ng/mL) was lower than that of healthy people (20.295 ng/mL).

Conclusion

The prevalence of vitamin D deficiency in patients with epilepsy is very high. Still, the related factors have little effect on the high prevalence of vitamin D in epilepsy, and ASM intervention can reduce the vitamin D content in patients with epilepsy. Therefore, it is emphasized that monitoring vitamin D levels is part of the routine management of patients with epilepsy.

Systematic review registration

The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO). (registration number CRD42023493896). https://www.crd.york.ac.uk/PROSPERO/ # myprospero.

[Vitamin D deficiency in patients with epilepsy: consideration to take into account]

Introduction

Bone development in offspring of pregnant rats treated with carbamazepine: Evaluation by three different methods

OBJECTIVE

This study was carried out to determine the effect of intrauterine carbamazepine (CBZ) exposure on fetal bone development during pregnancy.

METHODS

In the study, 24 female Wistar pregnant rats were used. Rats were 20 weeks old. They had an average body weight of 150-200 g. Pregnant rats were randomly selected and divided (n = 6) into a control group, low-dose CBZ (10 mg/kg/day) group, medium-dose CBZ (25 mg/kg/day) group, and high-dose CBZ (50 mg/kg/day) group. The ossification length (mm) and ossification area (mm² ) of the long bones of the fetuses in the experimental and control groups were calculated. The densities of alkaline phosphatase (AP) and tartrate-resistant acid phosphatase (TRAP) were analyzed. The ossification regions of the femurs of the fetuses were examined under a light microscope. Microstructural images of the femurs were evaluated with scanning electron microscope photographs. The densities of minerals involved in the ossification process were analyzed.

RESULTS

According to the results of the study, all three doses of CBZ caused loss of ossification areas, and it was observed that this bone loss also increased statistically significantly depending on the dose increase (p < .05). Calcium concentration decreased in the CBZ groups. When the electron microscope images were examined, it was determined that the cartilage matrix of the CBZ groups was thinned. In the histological evaluation of the groups, narrowing of the primary bone collar and smaller bone spicules in the ossification region compared to the control group were noted due to the increase in dose in the CBZ groups. In immunohistochemical staining, it was observed that the TRAP and AP expression values of the femurs were the lowest in the CBZ groups. These decreases were also statistically significant when compared with the control group.

SIGNIFICANCE

It was revealed with both microscopic and macroscopic findings that exposure to intrauterine CBZ negatively affected ossification and bone growth.

Standard and high dose ergocalciferol regimens for treatment of hypovitaminosis D in epileptic children and adolescents

OBJECTIVES

Children with epilepsy are at increased risk of vitamin D deficiency. We aimed to compare the effect of two ergocalciferol regimens given for 90 days.

METHODS

Epileptic patients aged 5-18 years who received at least one antiepileptic drug (AED) for more than 6 months and had serum 25-OHD <30 ng/mL were randomized to receive 20,000 IU/10 d (standard dose, n=41) or 60,000 IU/10 d (high dose, n=41) of oral ergocalciferol. Serum Ca, P, Mg, ALP, iPTH and urine Ca/Cr ratio were measured at baseline and after 90 days of treatment. Change in serum 25-OHD and vitamin D status after treatment was evaluated.

RESULTS

The initial serum 25-OHD in the standard dose and high dose group was 19.5 ± 4.9 and 18.4 ± 4.6 ng/mL, respectively. Serum 25-OHD after treatment was significantly higher in the high dose group (39.0 ± 11.5 vs. 27.5 ± 8.6 ng/mL, p<0.05). The average increase in serum 25-OHD in the high dose and standard dose group was 20.6 ± 11.4 and 7.2 ± 7.5 ng/mL, respectively (p<0.05). Normalized serum 25-OHD was achieved in 80.5% of the high dose group compared to 36.6% of the standard dose group (p<0.05). No adverse events were found. Patients with a BMI Z-score>0 had a 2.5 times greater risk of continued hypovitaminosis D after treatment compared to those with a BMI Z-score<0 (95% CI: 1.0-5.9, p<0.05).

CONCLUSIONS

Oral ergocalciferol 60,000 IU/10 d for 90 days was more effective at normalizing serum 25-OHD than 20,000 IU/10 d in epileptic children and adolescents who were receiving AEDs.

Vitamin D Status in Children on Anticonvulsant Therapy

OBJECTIVE

To assess vitamin D status of children on long-term anticonvulsants, including the less studied widely used levetiracetam, and the potential risk factors for deficiency.

METHOD

Children on antiepileptic drugs (cases, n = 269) were compared with controls (n = 295) for serum biochemistry, 25OHD, parathormone (PTH), sun exposure, dietary calcium, and vitamin D intake.

RESULTS

Cases had lower serum 25OHD [median (IQR) 18.4 (11.5-24.1) ng/mL] compared to controls [20.8 (15.4-26.2] ng/mL, p < 0.001), as well as more frequent vitamin D deficiency (25OHD < 12 ng/mL, 27.1%) and insufficiency (25OHD < 20 ng/mL, 57.6%) than did controls (11.2% and 46.1%, respectively). Significantly lower median (IQR) serum calcium [8.8 (8.1-9.4) vs. 9.2 (8.5-10.0) mg/dL], phosphorous [3.8 (3.3-4.2) vs. 4.7 (4.0-5.3) mg/dL), and higher PTH [58.4 (42.9-85.8) vs. 38.9 (24.6-55.5) pg/mL, p < 0.001 for all] and proportion of elevated alkaline phosphatase (11.2% vs. 5.1%, p < 0.01) was seen in cases versus controls. Vitamin D deficiency was present in 53.4% of children with cerebral palsy (CP) versus 19.9% in those without CP (p < 0.001). Serum 25OHD did not differ between patients on cytochrome P450 inducers versus noninducers, neither among the 3 major groups, users of carbamazepine, valproate, and levetiracetam. Logistic regression analysis showed serum 25OHD < 12 ng/mL to be independently influenced by case or control status, presence of CP, and season of sampling.

CONCLUSION

Vitamin D deficiency is common with anticonvulsant therapy, especially in those having CP. In Kerala, the hot, dry season from March to May is protective.

The burden of vitamin D deficiency in household members of children presenting with symptomatic vitamin D deficiency

BACKGROUND

Micronutrient deficiencies are common among household/family members due to shared lifestyle and dietary habits. The extent of biochemical abnormalities in household members of children presenting with symptomatic vitamin D deficiency remains unknown.

AIM

Investigate the prevalence of vitamin D deficiency and biochemical osteomalacia in the mothers and siblings of children presenting with symptomatic vitamin D deficiency.

METHODS

All mothers and sibling of children referred to a single tertiary endocrine centre between January 2018 and December 2021, with symptomatic vitamin D deficiency were investigated prospectively for vitamin D deficiency [defined as 25 hydroxyvitamin D (25OHD) < 30nmol/L] and biochemical osteomalacia [vitamin D deficiency and elevated alkaline phosphatase (ALP) and/or parathormone (PTH)] as per clinical guidelines.

REULTS

Ninety-seven family members (68 siblings and 29 mothers) of 29 index cases (median age 1.7 years, 55.5% male) were investigated. The majority (65.5%, n=19) were of Asian ethnic background. The mean (SD) 25OHD levels of the index, maternal and sibling cohorts were 15 (10), 15 (7) and 20 (10) nmol/L respectively. Vitamin D deficiency was noted in 93% of the maternal and 79% of the sibling cohorts. Biochemical osteomalacia was present in 72% of the maternal and 79% of the sibling cohorts. Mothers of infants had significantly lower mean 25OHD levels compared to mothers of older children [11 (n=12) vs 18 nmol/L (n=17) respectively, p=0.006)], most of whom were symptomatic (66.6%, n=8/12). None of the mothers had hypocalcaemia. Among the 10% (n=7) of the siblings with hypocalcaemia, 86% (n=6/7) had concurrent dietary calcium deficiency and 71.4% (n= 5/7) reported symptoms in retrospect. Hypocalcaemic siblings had significantly lower 25OHD (7 vs 15 nmol/L, p<0.001), higher PTH (175 vs 58 ng/L, p<0.001) and ALP (846 vs 318 IU/L, p<0.001), respectively compared to normocalcaemic siblings.

CONCLUSIONS

In view of the substantial morbidity uncovered in household/family members of children diagnosed with symptomatic vitamin D deficiency, we recommend universal supplementation of all risk groups. Biochemical testing and treatment is indicated to replenish stores only in those at highest risk such as mothers of infants, individuals with concurrent dietary calcium deficiency and those with clinical symptoms.

DK, Chaudhary DG. A Comparative Study of Serum 25-Hydroxy Vitamin D Levels in Children with Seizures Receiving Monotherapy and Polytherapy

The association between serum 25-hydroxy vitamin D (25(OH)D) antiepileptic drugs (AEDs) and bone health in individuals with epilepsy has been recognized for more than 30 years. Several studies indicate an increased risk for bone loss in patients on antiepileptic medication as well as low levels of serum 25(OH)D. Patients on polytherapy AED are at a higher risk of adverse drug effects compared with those on monotherapy. The present study assessed serum 25(OH)D levels in children receiving AED and compares those children receiving monotherapy versus polytherapy. This is a prospective cross-sectional study conducted in a tertiary care hospital setting on children with seizures receiving AEDs for period of more than 6 months. Participants were enrolled in three groups: 25 children on monotherapy, 25 children on polytherapy, and 25 healthy controls. Serum 25(OH)D level was performed for all children and analyzed. Serum 25(OH)D levels were normal in 52%, insufficient levels in 43.3%, and deficient in 6.7% of children. Vitamin D level was insufficient in 40% of children receiving monotherapy and 52% receiving polytherapy AED. Vitamin D deficiency was present in 4% in monotherapy group and 16% in polytherapy group which was statistically significant (p-value 0.047). Vitamin D deficiency was higher in children receiving AED compared with normal controls. Vitamin D deficiency and insufficiency were higher in children on polytherapy. Our study emphasized the importance of monitoring vitamin D levels in children receiving AED to detect abnormalities in vitamin D levels.

Effects of long-term antiepileptic polytherapy on bone biochemical markers in ambulatory children and adolescents and possible benefits of vitamin D supplementation: a prospective interventional study

PURPOSE

Our aim was to investigate any adverse effects of long-term polytherapy (VPA and add-on-therapy) on bone biochemical markers in ambulatory children and adolescents with epilepsy and the possible benefits of vitamin D supplementation on the same markers.

METHODS

In this prospective interventional study, the levels of 25(OH)D and the bone turnover markers of CrossLaps (CTX), total alkaline phosphatase (tALP), osteoprotegerin (OPG), and the receptor activator for nuclear factor kB (RANK) ligand (sRANKL) were determined in forty-two ambulatory children with epilepsy on polytherapy (valproic acid + one or more other from levetiracetam, topiramate, lamotrigine, or rufinamide). The same markers were assessed after a year's supplementation of vitamin D (400 IU/d) and were compared with those of clinically healthy controls. The respective mean (±SD) ages were 11.9 ± 4.6 and 11.4 ± 4.4 yrs.

RESULTS

The basal mean 25(OH)D levels in the patients did not differ from controls (23.9 ± 11.5 vs 27.4 ± 13.3 ng/ml), but increased significantly after the vitamin D intake (31.1 ± 13.3 ng/ml, p < 0.01). In parallel, basal serum CTX levels were found to be significantly lower in the patients than controls (0.89 ± 0.63 vs 1.22 ± 0.58 ng/ml, p < 0.02), but not tALP. Osteoprotegerin was higher in the patients (5.7 ± 7.7 pmol/L vs 2.6 ± 1.0 pmol/L, p < 0.03), while sRANKL did not differ. After vitamin D, the CTX levels increased to comparable levels in controls (0.99 ± 0.57 ng/ml), and those of OPG decreased to levels that did not differ from controls (4.9 ± 5.1 pmol/L). The ratio of OPG/sRANKL was higher in patients than controls before treatment (0.030 ± 0.045 vs 0.009 ± 0.005, p < 0.03), but decreased (0.026 ± 0.038) to comparable values in controls later.

CONCLUSIONS

These findings imply a lower bone turnover in the young patients on long-term polytherapy (VPA and add-on-therapy), but after one year's vitamin D intake, bone biochemical markers improved.

Targeted Gene Sequencing, Bone Health, and Body Composition in Cornelia de Lange Syndrome

The aim of this study was to evaluate bone health and body composition by dual-energy X-ray absorptiometry (DXA) in individuals with Cornelia de Lange Syndrome (CdLS). Overall, nine individuals with CdLS (five females, all Caucasian, aged 5–38 years) were assessed. Total body less head (TBLH) and lumbar spine (LS) scans were performed, and bone serum biomarkers were determined. Molecular analyses were carried out and clinical scores and skeletal features were assessed. Based on deep sequencing of a custom target gene panel, it was discovered that eight of the nine CdLS patients had potentially causative genetic variants in NIPBL. Fat and lean mass indices (FMI and LMI) were 3.4–11.1 and 8.4–17.0 kg/m2, respectively. For TBLH areal bone mineral density (aBMD), after adjusting for height for age Z-score of children and adolescents, two individuals (an adolescent and an adult) had low BMD (aBMD Z-scores less than –2.0 SD). Calcium, phosphorus, 25-OH-vitamin D, parathyroid hormone, and alkaline phosphatase levels were 2.08–2.49 nmol/L, 2.10–3.75 nmol/L, 39.94–78.37 nmol/L, 23.4–80.3 pg/mL, and 43–203 IU/L, respectively. Individuals with CdLS might have normal adiposity and low levels of lean mass measured with DXA. Bone health in this population seems to be less of a concern during childhood and adolescence. However, they might be at risk for impaired bone health due to low aBMD in adulthood.

Valproic acid therapy decreases serum 25-hydroxyvitamin D level in female infants and toddlers with epilepsy- a pilot longitudinal study

To evaluate if valproic acid (VPA) therapy is associated with vitamin D deficiency among infants and toddlers with epilepsy, a cross-sectional clinical study was conducted in 25 children with epilepsy taking VPA. Blood levels of calcium, phosphorus, alkaline phosphatase, and 25-hydroxy vitamin D [25(OH)D] and plasma VPA level were measured at 1- to 3-month intervals. At the initial and final measurements, vitamin D deficiency or insufficiency was recognized in 8 (32%) and 12 (42%), respectively. In girls, a decreasing trend in serum 25(OH)D levels (P<0.05) was observed. Polytherapy had a significant negative effect on the longitudinal change of 25(OH)D (P<0.05) in girls. In conclusion, our study indicates that a high proportion of girls after VPA therapy had hypovitaminosis D.

Vitamin D deficiency in pediatric patients using antiepileptic drugs: systematic review with meta-analysis

OBJECTIVES

To measure the prevalence of vitamin D deficiency (through the 25-hydroxyvitamin D metabolite) in pediatric patients using antiepileptic drugs.

SOURCE OF DATA

Meta-analysis of studies identified through search in the PubMed, Embase, LILACS, and Cochrane Library databases, on February 19, 2019.

SUMMARY OF DATA

A total of 748 articles were identified, 29 of which were relevant to the objectives of this study. The prevalence of vitamin D deficiency found was 0.32 (95% CI=0.25-0.41; I²=92%, p<0.01). In the subgroup analyses, the most significant results were observed in the group of patients using cytochrome P450-inducing antiepileptic drugs, with a prevalence of 0.33 (95% CI=0.21-0.47; I²=86%, p<0.01) and, considering the study design, in the subgroup of cohort studies, with a prevalence of 0.52 (95% CI=0.40-0.64; I²=76%, p<0.01).

CONCLUSIONS

Taking into account the deleterious effects of vitamin D deficiency on the bone health of individuals using antiepileptic drugs, it is suggested to include in their care 25-hydroxyvitamin D monitoring, cholecalciferol supplementation, and treatment of the deficiency, when present.

Association of common genetic variants with vitamin D status in Malaysian children with epilepsy

PURPOSE

Children with epilepsy (CWE) are at risk of vitamin D deficiency. Single nucleotide polymorphisms (SNPs) affecting the vitamin D pathway are potentially important risk factors for serum 25-hydroxyvitamin D [25(OH)D] concentration. The aims of our study were to evaluate the association of vitamin d-related SNPs to serum 25(OH)D concentrations in Malaysian CWE.

METHODS

Cross-sectional study of Malaysian ambulant CWE on antiseizure medication for >1 year. Sixteen SNPs in 8 genes (GC, VDR, CYP2R1, CYP24A1, CYP27B1, CYP27A1, CYP3A4, NADSYN1/DHCR7) were genotyped. Linear and logistic regression models and co-variates adjusted analyses were used. SNPs with significant associations were further analysed in a group of ethnically-matched healthy Malaysian children.

RESULTS

239 CWE were recruited (52.7% Malay, 24.3% Chinese and 23.0% Indian) with mean serum 25(OH)D of 58.8 nmol/L (SD 25.7). Prevalence of vitamin D deficiency (≤37.5 nmol/L) was 23.0%. Minor allele of GC-rs4588-A was associated with lower serum 25(OH)D in the meta-analysis of both CWE (β -8.11, P = 0.002) and Malaysian healthy children (β -5.08, P < 0.001), while VDR-rs7975232-A was significantly associated with reduced odds of vitamin D deficiency in Malay subgroup of CWE (OR: 0.16; 95% CI: 0.06-0.49; P = 0.001) and this association was not found in the healthy children group.

CONCLUSIONS

Our results suggest that GC-rs4588 is associated with lower serum 25(OH)D concentration in both Malaysian CWE and healthy children, while VDR-rs7975232A is associated with lower risk of vitamin D deficiency in Malaysian CWE of Malay ethnicity. Our findings may assist in the genetic risk stratification of low vitamin D status among CWE.

Vitamin D status among patients with drug-resistant and non-drug-resistant epilepsy

Background & Aims: Epilepsy affects nearly 70 million people worldwide. Vitamin D deficiency may influence the balance of certain epilepsies. The purpose of this study was to determine the vitamin D status and anthropometric measurements of people with epilepsy (PWE), according to their pharmacosensitivity. Methods: Forty-six PWE, with or without drug resistance, underwent nutritional assessment after giving consent. Weight, body mass index (BMI), triceps skinfold thickness (TSF), fat mass (FM) and free fat mass (FFM) by bioelectrical impedance analysis were measured. Serum vitamin D was determined without supplementation. Deficiency was defined as a level < 30 ng/mL. Statistical analysis involved Student t test, ANOVA and Chi². Results: Patients were aged 44.5 ± 14.3 years, with 60.9% of drug-resistance. BMI was 28.7 ± 7.0, 2.2% were malnourished and 30.4% obese according to the BMI. The average vitamin D level was 15.3 ± 9.9 ng/mL, with 87.0% of deficiency, and 40.0% of severe deficiency (<10 ng/mL). The TSF was higher in drug-resistant cases (p = 0.03). There was no link between drug resistance and anthropometric measurements, FM, FFM or vitamin D concentration. Conclusions: Although limited in size, this study showed that PWE are more often obese. Vitamin D deficiency is more common than in the general population, with a much higher prevalence of severe deficiency.

Effects of enzyme-inducing antiseizure medication on vitamin D dosing in adult veterans with epilepsy

BACKGROUND

The association of antiseizure medication (ASM) and bone density abnormalities has long been recognized; however, there remains a lack of consensus on efficacy and optimal vitamin D dosing in patients receiving enzyme inducing and non-inducing ASMs. The objective was to explore the relationship between ASMs and vitamin D supplementation requirements in a population of adult patients with epilepsy.

METHODS

Patients with a diagnosis of epilepsy receiving supplemental vitamin D were included in this retrospective chart review. All instances of 25-hydroxyvitamin D₃ (25-OHD) measured among those patients were compared between patients taking an enzyme inducing antiseizure medication (EIASM) to patients receiving ASM regimens only containing non-enzyme inducing antiseizure medications (NIASM). ASM use, prescription and over the counter (OTC) vitamin D use, 25-OHD plasma concentration, presence of chronic kidney disease (CKD), age, gender, and ethnicity were collected. Multiple linear regression was used to adjust for potentially confounding variables; the model included a cluster by participant term to account for repeated patients in the dataset.

RESULTS

There were 542 vitamin D levels evaluated from 172 unique patients. There was an 11.5 % higher absolute percent increase in patients who achieved a 25-OHD level over 30 ng/mL in the NIASM (p = 0.012). Patients on EIASMs were supplemented with an additional 508 units of vitamin D daily (95 %CI 136-878, p = 0.007). When adjusted for CKD, OTC vitamin D use, OTC multivitamin use, age, gender, and ethnicity, patients on EIASMs were supplemented with an additional 445 units of vitamin D (95 %CI -69 to 960, p = 0.089) compared to NIASM use.

CONCLUSIONS

Patients taking EIASMs had an increase in vitamin D deficiency and vitamin D supplementation suggesting that EIASMs impact vitamin D metabolism. Closer monitoring of vitamin D status in patients with epilepsy, especially those on EIASMs, is warranted. This evaluation suggests that for patients taking ASM, use of a lower dose OTC requires closer monitoring of vitamin D status in patients with epilepsy, especially those on EIASMs, is warranted. vitamin D agent may not be adequate.

Bone Health Screening Practices Among Neurologists in Patients on Antiepileptic Drugs: A Quality Improvement Project

BACKGROUND

Pediatric patients with epilepsy are at risk for low vitamin D levels, increasing the risk for bone fractures, yet standardized bone health screening is not part of routine care.

METHODS

We surveyed pediatric neurologists (n = 68) at our center regarding screening practices, using an 11-item survey; constructed a bone health treatment algorithm; and developed a training intervention to improve screening rates.

RESULTS

The overall survey response rate was 47%. Among respondents, 64% estimated that they screened for bone health less than 25% of the time. Chart review before the intervention demonstrated an overall screening rate of 25.1% (n = 50/199). One year after implementation of a standardized algorithm, the overall screening rates increased to 53.8% (n = 100/186). The frequency of prescribing vitamin D for patients treated with antiepileptic medications increased among general neurologists (preintervention rate 16%, postintervention rate 51%, P < 0.01) as well as among epileptologists (preintervention rate 45%, postintervention rate 57%, P = 0.04).

CONCLUSION

In a relatively short follow-up period, there were significant changes in care patterns regarding screening for bone health in pediatric patients with epilepsy. Further implementation measures are underway to increase bone health screening and care in this population.

Vitamin D supplementation and bone markers in ambulatory children on long-term valproic acid therapy. A prospective interventional study

PURPOSE

Our aim was to investigate any adverse effects of long-term valproic acid (VPA) therapy on bone biochemical markers in ambulatory children and adolescents with epilepsy, and the possible benefits of vitamin D supplementation on the same markers.

METHODS

In this single center, the prospective interventional study levels of 25-hydroxyvitamin D (25OHD) and the bone turnover indices of Crosslaps (CTX), total alkaline phosphatase (tALP), osteoprotegerin (OPG), and the receptor activator for nuclear factor kB (RANK) ligand (sRANKL) were assessed before and after one year of vitamin D intake (400 IU/d) and were compared with those of clinically healthy controls. Fifty-four ambulatory children with mean (±standard deviation [SD]) age 9.0 ± 4.5 yrs on VPA (200-1200 mg/d) long-term monotherapy (mean: 3.2 ± 2.6 yrs) were studied, before and after a year's vitamin D intake (400 IU/d).

RESULTS

Nearly half of the cases were vitamin D insufficient/deficient with mean levels 23.1 ± 12.8 vs 31.8 ± 16.2 ng/mL of controls (p = 0.004) and after the year of vitamin D intake increased to 43.2 ± 21.7 ng/mL (p < 0.0001). In parallel, serum CTX and tALP had a decreasing trend approaching control levels but OPG and sRANKL did not change and were not different from controls. However, after vitamin D intake, a positive correlation was seen between 25OHD and OPG but not before.

CONCLUSIONS

The findings imply a higher bone turnover in the young patients on long-term VPA therapy that decreased after vitamin D intake.

Valproate decreases vitamin D levels in pediatric patients with epilepsy

PURPOSE

To compare Vitamin D (Vit D) levels in children with epilepsy on valproate monotherapy with healthy controls.

METHODS

A meta-analysis performed on articles identified from PubMed and Web of Science online databases evaluated using National Institute of Health National Heart, Lung, and Blood Institute Study Quality Assessment Tools. Subgroup analyses and publication bias assessments were also performed.

RESULTS

Eleven publications were eligible based on inclusion/exclusion criteria for the meta-analysis. Results noted a decrease in the mean Vit D level in children with epilepsy on valproate monotherapy compared with healthy children with a Standard Mean Difference = -0.313 [-0.457, -0.169]. Cumulative meta-analysis showed progressive negative effect of valproate therapy on Vit D levels across time. Other antiepileptic medications caused a similar effect on Vit D status. There was no evidence of publication bias in the analyses. Type of study design and country of origin introduced heterogeneities into the meta-analyses.

CONCLUSION

This meta-analysis provides evidence that long-term therapy with valproate causes a decrease in Vit D levels in children. Therefore, in children with a seizure disorder on long-term valproate therapy, 25-OH-Vit D levels should be monitored and appropriate supplementation implemented if levels are deficient.

An update on the problem of osteoporosis in people with epilepsy taking antiepileptic drugs

INTRODUCTION

Antiepileptic drugs (AEDs) have been associated with a negative impact on bone health. Comorbid disorders in patients with epilepsy may require drugs exerting a pro-osteoporotic effect, so a possibility of untoward interactions with AEDs is probable.

AREAS COVERED

This review discusses evidence related to the deteriorating influence of AEDs on bone, demonstrating generally stronger negative effects of conventional AEDs. Lamotrigine seems to be a safer AED in this regard. Further, literature data indicate that generally AEDs can lower the serum concentration of vitamin D. Importantly, pediatric patients are of greater risk of bone problems during therapy with AEDs, which is probably due to their effects on bone-forming processes.

EXPERT OPINION

Supplementation with vitamin D and calcium is frequently recommended in patients taking AEDs chronically. Whether to add a bisphosphonate remains an open question due to the limited data on this issue. A possibility of negative interactions exists between AEDs and other pro-osteoporotic drugs: glucocorticoids, proton pump inhibitors and aromatase inhibitors. Depression is a frequent comorbidity in patients with epilepsy. Clinical data indicate that antidepressant drugs may also increase the risk of fractures. Again, patients with epilepsy and depression may be exposed to a greater risk of osteoporosis.

Effect of Long-term Carbamazepine Therapy on Bone Health

Introduction:

Recent research reported that prolonged use of AET is associated with changes in bone metabolism, with consequent reduction in bone mineral density (BMD) and increased risk of fractures.

Objectives:

Therefore, the aim of our study was to investigate the effects of carbamazepine on serum levels of 25 -hydroxyvitamin D and on biomarker of bone formation and resorption (serum levels of osteocalcin).

Material and methods:

We measured serum levels of 25-OHD and osteocalcin (OCLN) in normal controls (n=30) and in epilepsy patients taking carbamazepine (CBZ) (n=50) in monotherapy for a period of at least twelve months. For each participant, mineral density (BMD) was evaluated by dual-energy X-ray absorptiometry method.

Results:

The average value of vitamin D in serum was significantly lower in CBZ group than in control group (Vit D 17.03+12.86 vs. 32.03+6.99, p=0.0001). The average value of osteocalcin in serum was significantly higher in CBZ group than in control group (26.06+10.78 vs. 19.64+6, 54, p=0.004).BMD value in CBZ group was significantly lower than in control group (T. score CBZ: 0.08+1.38 vs. T. score control: 0.73+ 1.13, p=0.031; Z score CBZ:-0.05+1.17 vs. Z. score control: 0.55+0.79, p=0.015).

Conclusion:

AEDs are associated with bone disease, as evidenced by biochemical abnormalities and decreased BMD. Patients on long-term antiepileptic therapy, especially with enzyme-inducing agents, could benefit of routine measurement of biochemical markers of bone turnover, and BMD measurement as part of osteoporosis investigation.

Familial congenital choanal atresia with GATA3 associated hypoparathyroidism-deafness-renal dysplasia syndrome unidentified on auditory brainstem response

Hypoparathyroidism-deafness-renal dysplasia (HDR) syndrome is a rare autosomal dominant disorder primarily caused by GATA3 haploinsufficiency and is challenging to diagnose in early childhood. We report a Japanese family with HDR syndrome and congenital choanal atresia. The 6-year-old female proband was diagnosed with epilepsy at the age of three. Under carbamazepine monotherapy, the patient presented hypoparathyroidism accompanied by severe hypocalcemia. Subsequently, renal ultrasound analysis revealed bilateral multicystic dysplastic kidneys. Because she had difficulty hearing, we sequenced GATA3 and determined that she had a c.708_709insC (p.Ser237Glnfs*66) allelic variant in exon 3. As a result, we found a family of this disease. Each family member, including her grandfather, mother, and two siblings, had HDR syndrome of varying clinical penetrance. We found a craniofacial anomaly, congenital choanal atresia, which was inherited as an autosomal dominant trait. Hypocalcemia coupled with vitamin D deficiency, triggered by carbamazepine treatment, ultimately revealed the proband's childhood- onset HDR syndrome. Pure-tone audiometry revealed different severities of deafness as well as the progression of sensory hearing loss. However, auditory brainstem response for hearing screening is probably insufficient for ascertaining HDR syndrome in the early stages of life. We presented new clinical clues to diagnose the HDR syndrome.

Vitamin D supplementation to prevent vitamin D deficiency for children with epilepsy: Randomized pragmatic trial protocol

BACKGROUND

Vitamin D deficiency is highly prevalent among children with epilepsy. Lack of high-quality evidence led to variability among scientific societies recommendations. Therefore, we aim to determine the efficacy of different common doses used in the pediatric practice to maintain optimal 25-hydroxy vitamin D (25 [OH] vitamin D) level in children with epilepsy and normal baseline 25 (OH) vitamin D level over 6 months of supplementation.

METHODS

This is a protocol for phase IV pragmatic randomized superiority controlled open-label trial at King Saud University Medical City in Riyadh. Children with epilepsy and receiving chronic antiepliptic medication and normal baseline 25 (OH) vitamin D level will be randomly assigned to receive Cholecalciferol 400 IU/day versus 1000 IU/day for 6 months. Our primary outcome is the proportion of children with vitamin D insufficiency (25 (OH) vitamin D level < 75nmol/L) at 6 months. Secondary outcomes include seizure treatment failure, seizure frequency, parathyroid hormone (PTH) levels, bone mineral density, and safety.

DISCUSSION

Our trial is set out to evaluate the efficacy of common different vitamin D maintenance doses on 25 (OH) vitamin D level, seizure control, and bone health for children with epilepsy. The results of our study will possibly help in shaping current vitamin D guidelines for vitamin D supplementation in children with epilepsy and provide a link between 25 (OH) vitamin D level and seizure control.

Bilateral avascular necrosis of the femoral head following asynchronous postictal femoral neck fractures: a case report and review of the literature

Bilateral avascular necrosis (AVN) following postictal bilateral fracture neck of the femur is a rare occurrence. Here, we report a case of bilateral AVN of the femoral head following an asynchronous bilateral postictal fracture neck of the femur. A 16-year-old autistic boy presented with left hip pain following an episode of seizures and radiographs showed Delbet type II fracture neck of the left femur. This was treated by closed reduction and cancellous screw fixation and skeletal traction for 6 weeks. At 3 months, follow-up radiograph showed union of the fracture, but he had developed segmental AVN with collapse of the head. At 8 months, the patient presented with pain in the right hip following another episode of seizures and radiograph of the pelvis showed a fresh Delbet type II fracture neck of the right femur with established AVN of the left femoral head. He underwent closed reduction and cancellous screw fixation of the right hip and implant exit of the left hip. At the 6-month follow-up after this surgery, his radiograph of the pelvis showed AVN with collapse and extrusion of the femoral head on the right side as well. Literature review shows an increased risk of fracture neck of the femur among epileptics. The incidence of AVN is maximum in Delbet type I, followed by Delbet type II and type III in that order. Although there are no clear guidelines on the management of post-traumatic AVN of the femoral head, the majority have reported that most of them will eventually develop arthritis and will require total hip replacement at a later date. Upon extensive literature search, no case report of bilateral fracture neck of the femur with bilateral AVN was found and hence this case was reported.

Epilepsy and vitamin D: a comprehensive review of current knowledge

Vitamin D has been considered as neurosteroid, and its pivotal role in neuroprotection, brain development, and immunomodulation has been noticed in studies; however, our knowledge regarding its role in neurological disorders is still developing. The potential role of vitamin D in the pathophysiology and treatment of epilepsy, as one the most prevalent neurological disorders, has received less attention in recent years. In this article, we review the possible relationship between vitamin D and epilepsy from different aspects, including the action mechanism of vitamin D in the central nervous system and ecological and epidemiological findings. We also present the outcome of studies that evaluated the level of vitamin D and the impact of administrating vitamin D in epileptic patients or animal subjects. We also review the current evidence on interactions between vitamin D and antiepileptic drugs.

Vitamin D status of children with cerebral palsy: Should vitamin D levels be checked in children with cerebral palsy?

OBJECTIVE:

We aimed to investigate the vitamin D status of children with cerebral palsy (CP).

METHODS:

A total of 274 children (111 females and 163 males), aged between 1 and 19 years with CP, who came to the Physical Medicine and Rehabilitation, Pediatric Rehabilitation Outpatient Clinic between October 2013 and March 2017, were included in our study. Demographics, data concerning the details of each child’s comorbidity, the Gross Motor Function Classification System (GMFCS), and Manual Ability Classification System (MACS) scores were recorded. The serum 25 hydroxy vitamin D [25(OH)D], calcium (Ca), phosphate (P), and parathormone (PTH) levels were also recorded.

RESULTS:

The mean age of children with CP was 7.59±6.09 years. The distribution by the CP type was 24.8% spastic unilateral, 59.8% spastic bilateral, 1.4% dyskinetic, 0.7% ataxic, 7.6% mixed, and 5.1% unclassified. The serum 25(OH)D levels of the 235 children with CP were measured. There were 79 children at the 25(OH)D level ≤12 ng/ml, regarded as vitamin D deficiency; 62 children at the 25(OH)D level 12-≤20 ng/ml, considered as vitamin D insufficiency, 43 children at the 25(OH)D level 20-≤30 ng/ml, considered as vitamin D sufficiency, and 15 children at the 25(OH)D level >30 ng/ml. A total of 36 children were already taking vitamin D supplements. There was a significant correlation between the 25(OH)D levels and GMFCS and MACS levels and associated impairments such as the epilepsy history, intellectual delay, teeth problems, and growth retardation (p<0.05).

CONCLUSION:

Our results revealed that the children with CP who are not ambulatory (GMFCS levels IV–V) and have associated impairments were prone to vitamin D deficiency, and thus should be checked for vitamin D.

Effect of impaired ambulation and anti-epileptic drug intake on vitamin D status of children with cerebral palsy

BACKGROUND

Children with cerebral palsy (CP) are vulnerable to developing vitamin D deficiency. There is little information on the prevalence and severity of vitamin D deficiency in these patients.

OBJECTIVE

To study vitamin D status in children with CP with special reference to their intake of anti-epileptic drugs (AED) and ambulatory status.

METHODS

The relative effects of AED use and ambulatory status on the vitamin D status of 120 children with CP aged 2-10 years were examined in this observational study. The patients were classified into four groups (30 in each) on the basis of AED use and ambulatory status: ambulatory (CPA), ambulatory receiving AED (CPAD), non-ambulatory (CPNA) and non-ambulatory receiving AED (CPNAD). A control group of 30 age-matched healthy children was also included. Parameters assessed included dietary calcium intake, sun exposure, serum total and ionised calcium (tCa, iCa), inorganic phosphate (iP), alkaline phosphatase (ALP), parathormone (PTH), 25 hydroxy vitamin D [25(OH)D] levels and a wrist radiograph to detect rickets. Vitamin D status was defined on the basis of serum 25(OH)D levels as normal (>50 nmol/L), mild deficiency (25-50 nmol/L), moderate deficiency (12.5-25 nmol/L), severe deficiency (<12.5 nmol/L).

RESULTS

Median (IQR) serum 25 (OH)D levels in patients with CP were 35.6 (26.75-64) nmol/L compared with 60 (37-69.25) nmol/L in controls (p = 0.04). Sixty per cent of children with CP and 36.7% of controls were vitamin D-deficient [25(OH)D < 50 nmol/L]. Children with CP had a significantly lower dietary calcium intake and sun exposure than controls (p < 0.0001 each). Serum tCa and iCa levels were significantly lower (p = 0.01 and p < 0.001, respectively) and PTH and ALP levels significantly higher (p = 0.04 and p = 0.001, respectively) in children with CP than in controls. Patients in the CPNAD group were the worst affected, 83.3% of them being vitamin D-deficient with median (IQR) 25(OH)D levels of 33.5 (12.5-45.25) nmol/L. Also, 53.3% of them had raised ALP and 17.2% raised PTH levels.

CONCLUSION

Children with CP are highly vulnerable to vitamin D deficiency. In these patients, AED use and lack of sun exposure contribute towards poor vitamin D status, the effect being more pronounced when they co-exist.

Potential risk factors for vitamin D levels in medium- and long-term use of antiepileptic drugs in childhood

Antiepileptic drugs (AED) have potential side effects through vitamin-D. Prevalence of vitamin D insufficiency and potential risk factors for the longitudinal changes of vitamin D levels compared to its baseline levels under AED treatment were investigated in this study. This retrospective study includes patients whose AED therapy were started in only autumn months, between 2000 and 2014. Detailed assessment of neurologic diagnosis and brain MRI findings, ambulatory status, types and durations of AED treatment, and baseline bone health blood tests (vitamin-D, alkaline phosphatase, calcium, and phosphate levels) were obtained on all patients. Vitamin-D deficiency was defined as 25(OH)D <20 ng/mL, while vitamin-D insufficiency was defined as 25(OH)D between 21 and 29 ng/mL. A total of 172 children (mean age 9.6 ± 4.3 years) were followed up 5.3 years in average (range 1-14.7). The mean baseline 25(OH)D level was decreased from 24.4 ± 11.6 to 19.6 ± 10.7 ng/mL at the last follow up. The mean change in the vitamin-D levels (ΔD-vitamin) was -4.8 ng/mL (p = 0.003). The rate of vitamin-D deficiency was 54% and insufficiency was 25%. Multivariate logistic regression analysis identified only long-term use of AEDs as a risk factor for the longitudinal decrease. Monotherapy with valproic acid (n = 45), carbamazepine (n = 20), levetiracetam (n = 10) and phenobarbital (n = 12) was compared with each other. There was no difference in terms of longitudinal changes in 25(OH)D levels. In the treatment of childhood epilepsy, 25(OH)D levels should be monitored, especially when long-term AED used, in order to prevent D-hypovitaminosis.

Bone mineral density and vitamin D status in children with epilepsy, cerebral palsy, and cerebral palsy with epilepsy

PURPOSE

We aimed to evaluate the relationship between bone mineral density (BMD) disorders and possible risk factors in patients with epilepsy only (EO), cerebral palsy only (CPO), and cerebral palsy-epilepsy (CP + E).

METHODS

A total of 122 patients [EO (n = 54), CPO (n = 30), CP + E (n = 38)] and 30 healthy children were evaluated. BMD was only measured in patient groups, not in control subjects. BMD of lumbar vertebrae was determined by dual energy X-ray absorptiometry (DXA). An abnormal BMD was defined as low or low normal BMD.

RESULTS

Low BMD rate in EO, CPO, and CP + E group was 3.7, 50, and 39.5 %, respectively. Abnormal BMD values were significantly related to inadequate dietary Ca intake (p = 0.017), severe intellectual disability (p < 0.001), and immobility (p = 0.018). In multivariate regression analysis, the risk of abnormal BMD was higher (3.9-fold) in patients not able to walk independently than the others (p = 0.029). However, serum Ca-Vitamin D levels, insufficient exposure to sunlight, low BMI, and use of AED were not correlated with abnormal BMD.

CONCLUSION

Abnormal BMD is a common problem in patients with CP and CP + E. Abnormal BMD was related to the severity of CP, but not to vitamin D levels or AED treatment.

Markers of bone turnover in patients with epilepsy and their relationship to management of bone diseases induced by antiepileptic drugs

Data from cross-sectional and prospective studies revealed that patients with epilepsy and on long-term treatment with antiepileptic drugs (AEDs) are at increased risk for metabolic bone diseases. Bone diseases were reported in about 50% of patients on AEDs. Low bone mineral density, osteopenia/osteoporosis, osteomalacia, rickets, altered concentration of bone turnover markers and fractures were reported with phenobarbital, phenytoin, carbamazepine, valproate, oxcarbazepine and lamotrigine. The mechanisms for AEDs-induced bone diseases are heterogeneous and include hypovitaminosis D, hypocalcemia and direct acceleration of bone loss and/or reduction of bone formation. This article reviews the evidence, predictors and mechanisms of AEDs-induced bone abnormalities and its clinical implications. For patients on AEDs, regular monitoring of bone health is recommended. Prophylactic administration of calcium and vitamin D is recommended for all patients. Treatment doses of calcium and vitamin D and even anti-resorptive drug therapy are reserved for patients at high risk of pathological fracture.

Markers of bone turnover in patients with epilepsy and their relationship to management of bone diseases induced by antiepileptic drugs

Data from cross-sectional and prospective studies revealed that patients with epilepsy and on long-term treatment with antiepileptic drugs (AEDs) are at increased risk for metabolic bone diseases. Bone diseases were reported in about 50% of patients on AEDs. Low bone mineral density, osteopenia/osteoporosis, osteomalacia, rickets, altered concentration of bone turnover markers and fractures were reported with phenobarbital, phenytoin, carbamazepine, valproate, oxcarbazepine and lamotrigine. The mechanisms for AEDs-induced bone diseases are heterogeneous and include hypovitaminosis D, hypocalcemia and direct acceleration of bone loss and/or reduction of bone formation. This article reviews the evidence, predictors and mechanisms of AEDs-induced bone abnormalities and its clinical implications. For patients on AEDs, regular monitoring of bone health is recommended. Prophylactic administration of calcium and vitamin D is recommended for all patients. Treatment doses of calcium and vitamin D and even anti-resorptive drug therapy are reserved for patients at high risk of pathological fracture.

Risk factors of vitamin D deficiency in children with epilepsy taking anticonvulsants at initial and during follow-up

PURPOSE

Vitamin D status was evaluated in children with epilepsy taking anticonvulsants to determine the prevalence and risk factors of vitamin D deficiency.

METHODS

This study was designed as both a cross-sectional and a retrospective cohort study. A sum of 198 children who were diagnosed with epilepsy at the Department of Pediatrics in Dankook University Hospital was included. Their serum vitamin D levels were reviewed based on clinical information, and analyzed using IBM SPSS ver. 20.0.

RESULTS

One hundred twenty-four children (62.6%) had vitamin D deficiency. Two risk factors were associated: winter to spring season (odds ratio [OR], 3.71; 95% confidence interval [CI], 1.835-7.492) and age more than 12 years (OR, 3.22; 95% CI, 1.377-7.542). Out of the 57 patients who were not vitamin D deficient at the time of initial assay, 47 patients (82.5%) became vitamin D deficient during followup. The change of serum 25-hydroxy vitamin D3 (25(OH)D) levels during follow up showed a weak negative correlation with the duration of medication (r=-0.283, P=0.033). Medication duration was longer and brain magnetic resonance imaging (MRI) abnormality, abnormal underlying conditions, and nonambulatory status were more frequently present in twenty-five patients (44%) who showed a decline of more than 15 ng/mL during follow-up (P<0.05).

CONCLUSION

Vitamin D deficiency is common in children with epilepsy taking anticonvulsants, especially in adolescents more than 12 years of age. This study emphasizes the regular monitoring of vitamin D level, especially in the presence of longer duration of medication, brain MRI abnormality, abnormal underlying conditions, and nonambulatory status.

[Effect of supplementation with a single dose of vitamin D in children with cerebral palsy. Preliminary randomised controlled study]

INTRODUCTION

Children with cerebral palsy (CP) have an increased risk of vitamin D (VD) deficiency. Although there are many studies on VD and CP, there is limited information about VD supplementation in these patients.

OBJECTIVE

To evaluate the effect of supplementation with a single dose of VD on the plasma concentrations of 25-hydroxy-vitamin-D (25OHD) in children with CP.

PATIENTS AND METHOD

Prospective-randomised-controlled-trial, including 30 Chilean children (19 males) with CP, median age 9.9 years (6.2-13.5). Clinical and biochemical variables including 25OHD, were recorded (time 0 and 8 weeks). Patients were allocated to the supplemented (S) group receiving 100,000 IU oral D3 at baseline, and compared with the placebo (P) group.

RESULTS

Among clinical features are highlighted: gastrostomy (60%), underweight (30%), bed-ridden (93.3%), antiepileptic drugs (70%), and 43.3% used VD metabolism inducing antiepileptics. Baseline biochemical measurements were normal. The 25OHD was insufficient in 4/30 and deficient in 6/30. 25OHD levels were not associated with the variables studied. Eight patients completed the study in the S group, and 10 in P group. The placebo and supplementation groups had no significant difference in baseline variables. Serum calcium, phosphate, and alkaline phosphatase levels at 8 weeks were normal in both groups, with no statistically significant differences. 25OHD in the P group was normal in 6/10, and insufficient+deficient in 4/10, and the S group was normal in all (8/8) (exact Fisher test P=.07).

CONCLUSIONS

A single dose of 100,000 IU VD could normalise the concentrations of 25OHD after 8 weeks of supplementation in Children with CP, but more studies are required to confirm these results.

Vitamin D in epilepsy: vitamin D levels in epilepsy patients, patients on antiepileptic drug polytherapy and drug-resistant epilepsy sufferers

The objective of this study was to assess vitamin D levels in epileptic patients and to compare its serum levels in patients on antiepileptic monotherapy and polytherapy. We analyzed the serum 25-hydroxy (25-OH) vitamin D levels in 98 consecutive subjects (43 epileptic patients and 55 non-epileptics). Factors influencing its serum levels such as degree of sun exposure, physical activity and dietary intake were taken into consideration. Overall, 41% had deficient, 49% had insufficient and 9% had sufficient levels of serum vitamin D. Elderly individuals (>60 years) and people employed in offices and schools had lower blood vitamin D levels. Across both the sexes, epileptic patients and non-epileptics, epileptic patients on monotherapy and polytherapy and patients with drug-responsive and -resistant seizures, there were no significant differences in serum 25-OH vitamin D levels. Our study shows that people with epilepsy suffer with vitamin D deficiency along with their normal peers.

Effects of antiepileptic drugs on bone mineral density and bone metabolism in children: a meta-analysis

OBJECTIVE

The aim of our meta-analysis was to assess the effects of antiepileptic drugs on bone mineral density and bone metabolism in epileptic children.

METHODS

Searches of PubMed and Web of Science were undertaken to identify studies evaluating the association between antiepileptic drugs and bone mineral density and bone metabolism.

RESULTS

A total of 22 studies with 1492 subjects were included in our research. We identified: (1) a reduction in bone mineral density at lumbar spine (standardized mean difference (SMD)=-0.30, 95% confidence interval (CI) [-0.61, -0.05]), trochanter (mean difference (MD)=-0.07, 95% CI [-0.10, -0.05]), femoral neck (MD=-0.05, 95% CI [-0.09, -0.02]), and total body bone mineral density (MD=-0.33, 95% CI [-0.51, -0.15]); (2) a reduction in 25-hydroxyvitamin D (MD=-3.37, 95% CI [-5.94, -0.80]) and an increase in serum alkaline phosphatase (SMD=0.71, 95% CI [0.38, 1.05]); (3) no significant changes in serum parathyroid hormone, calcium, or phosphorus.

CONCLUSIONS

Our meta-analysis suggests that treatment with antiepileptic drugs may be associated with decreased bone mineral density in epileptic children.

The use of natural health products by paediatric patients in respite care

OBJECTIVES

To determine the use and potential interactions of natural health products (NHPs) with conventional medications in children with life-limiting illnesses.

METHODS

The present study was a retrospective medical record review of palliative care patients <18 years of age who were admitted for respite care to a Canadian paediatric hospice between January 1, 2008 and December 31, 2013. The NHPs were identified according to Health Canada's inclusion criteria.

RESULTS

A total of 106 children were included in the present study. Eighty-two (77.4%) had used one or more NHPs: 60 (56%) used vitamins and minerals; 45 (42.5%) used other products including probiotics, omega-3, organic acids and essential fatty acids; 34 (32.1%) used everyday consumer products; 12 (11.3%) used herb or plant-based remedies; and one (0.9%) used homeopathic remedies. Thirty-nine potential NHP-medication and 10 potential NHP-NHP interactions were identified. A considerable number of patients (n=54) used at least one medication and NHP, or two NHPs with potential interactions. The most common type of interaction was pharmacokinetic: decreasing blood concentrations of the medication, NHP or both (43.9% of NHP users); and enhancing the blood concentration of an NHP for NHP-NHP interactions (22% of NHP users).

CONCLUSION

A high proportion of patients in respite care use NHPs. Most used NHPs and medications that have potential interactions, although there were no adverse clinical manifestations in the present study. It is important to educate health care professionals about NHPs, the evidence available and lack thereof. This could reduce the most serious interactions and improve the alliance between parents and health care providers to balance the potential risks and benefits of NHPs.

Vitamin D supplementation in children with epilepsy and intellectual disability

BACKGROUND

Children with epilepsy and intellectual disability have an increased risk of vitamin D deficiency. In this patient group, it is neither clear which factors are associated with the level of 25-hydroxyvitamin D nor what the therapeutic results are when Dutch guidelines are followed.

METHODS

This retrospective study included 30 patients who, in October 2012, were residents of the children's wards of a tertiary epilepsy center in The Netherlands (Kempenhaeghe). From November 2012 onward they received cholecalciferol supplementation in doses that met or exceeded Dutch guidelines. At baseline, after 6, and 15 months, serum 25-hydroxyvitamin D concentration was measured.

RESULTS

At baseline, the vitamin D status in 11 (36.7%) residents was found to be deficient, in 10 (33.3%) to be insufficient and in 9 (30.0%) sufficient. Supplementation dose, diet, body mass index, intellectual disability, and mobility were significantly associated with baseline 25-hydroxyvitamin D concentrations. The mean 25-hydroxyvitamin D concentration increased significantly from 57.40 ± 22.00 nmol/L at baseline to 89.47 ± 26.77 nmol/L after 15 months (P < 0.001). In spite of supplementation ranging from 400 to 1200 IU/day, 64% of the residents in the deficient category and 30% of those with an insufficient level at baseline failed to attain a sufficient vitamin D status after 15 months.

CONCLUSIONS

Not all residents reached a sufficient vitamin D status after supplementation at least equal to the amount recommended by the Dutch guidelines. In a high-risk population, such as our residents, we advise monitoring 25-hydroxyvitamin D concentrations, adjusting supplementation accordingly and following patients to ensure they reach sufficiency.

Longitudinal change of vitamin D status in children with epilepsy on antiepileptic drugs: prevalence and risk factors

BACKGROUND

Our aim was to evaluate the prevalence and risk factors of vitamin D deficiency and the changes of vitamin D level among children with epilepsy on antiepileptic drugs.

METHODS

The levels of serum 25-hydroxy vitamin D were measured at the start of antiepileptic drugs and at 6- to 12-month intervals in children with epilepsy taking antiepileptic drugs in Pusan National University Children's Hospital. Vitamin D deficiency was defined as 25-hydroxy vitamin D levels <20 ng/mL and insufficiency between 21 and 29 ng/mL.

RESULTS

A total of 143 children (103 boys and 40 girls) with the mean age of 7.4 ± 5.4 years were included. The mean follow-up duration was 1.8 ± 0.8 years. At the start of antiepileptic drugs and the last follow-up, vitamin D deficiency or insufficiency was recognized in 56.6% (81 of 143) and 79.0% (113 of 143), respectively (P < 0.01). The mean value of initial 25-hydroxy vitamin D was 31.1 ± 14.7 ng/mL, which was significantly decreased to 20.2 ± 14.9 ng/mL (P < 0.01) in the last follow-up. Polytherapy (-16.0 ± 13.6 ng/mL), longer duration of ≥2 years (-23.5 ± 9.1 ng/mL), tube feeding (-18.2 ± 14.5 ng/mL), and overweight with body mass index of eighty-fifth percentile or greater (-17.0 ± 12.1 ng/mL) had a significant negative effect for the longitudinal change of 25-hydroxy vitamin D. Age, etiologies, seizure outcomes, and type of antiepileptic drugs (enzyme-inducing versus nonenzyme-inducing antiepileptic drugs) did not affect the longitudinal decrease of 25-hydroxy vitamin D.

CONCLUSIONS

A high proportion of these children on antiepileptic drugs had hypovitaminosis D and a significant decrease between the initial and the last follow-up. Polytherapy and longer duration of antiepileptic drugs, tube feeding, and overweight were independently associated with longitudinally significant decrease of 25-hydroxy vitamin D.

Epilepsy treatment by sacrificing vitamin D

Epilepsy is one of the most common neurologic disorders in childhood that often requires long term treatment with antiepileptic drugs. Both antiepileptic treatment and the comorbidities associated with epilepsy have a negative impact on bone health in growing children. Given the fact that vitamin D deficiency is a major public health problem worldwide, clinicians caring for children with chronic diseases should be aware of effects of the medication on the bone metabolism. Yet, vitamin D deficiency due to antiepileptic treatment is an overlooked issue among neurologists. In this review, we briefly describe vitamin D metabolism and the effect of vitamin D in the brain. We also discuss the literature in terms of vitamin D deficiency and antiepileptic treatment in the pediatric population.

Vitamin D deficiency among children with epilepsy in South Queensland

This study evaluated prevalence and risk factors for vitamin D deficiency among children with epilepsy on long-term antiepileptic drugs treated in South Queensland, Australia. Children with epilepsy seen in a tertiary neurology clinic were contacted requesting bone health blood tests during winter of 2011. Vitamin D deficiency was defined as 25-hydroxy vitamin D levels <20 ng/mL, and insufficiency between 21 and 29 ng/mL. One hundred thirty letters were sent, with 111 (85%) subsequently having blood tests performed. Vitamin D deficiency was identified in 24 (22%) of 111 and an additional 45 (41%) of 111 had vitamin D insufficiency. Multiple logistic regression analysis identified children on >2 antiepileptic drugs or with underlying genetic etiologies were more likely to have vitamin D deficiency. High proportion of children on long-term antiepileptic drugs in Queensland risk vitamin D deficiency and insufficiency despite living in the subtropics. Vitamin D monitoring and supplementation is important in the management of children on long-term antiepileptic drugs requiring tertiary care in Queensland.

Vitamin D levels in children and adolescents with antiepileptic drug treatment

PURPOSE

This study was to evaluate the relationship of 25(OH)D3 levels with anticonvulsant use and other possible factors in epileptic children and adolescents.

MATERIALS AND METHODS

We studied 143 patients with epilepsy (90 boys, 53 girls; 11.21±4.49 years), who had been treated with anticonvulsants for more than 1 year. Patients who had taken multiple vitamins before the blood test and those who have the limitation of physical activity (wheelchair-bound) were excluded from the study. We evaluated the difference in vitamin D status according to the type and number of anticonvulsants taken and other factors such as gender, age, intelligence and seizure variables.

RESULTS

For patients with mental retardation or developmental delay, 25(OH)D3 levels were lower than the levels in patients with normal intelligence quotient levels (p=0.03). 25(OH)D3 levels were lower in patients who had taken anticonvulsants for more than 2 years as compared to those who had taken them for less than 2 years (p=0.03). Those taking oxcarbazepine had significantly lower vitamin D levels than patients taking valproic acid (p=0.01). However, no effects of number of anticonvulsants taken were detectable. More than two-thirds of the patients were diagnosed with osteopenia or osteoporosis in patients showing either vitamin D insufficiency or deficiency.

CONCLUSION

The possibility of vitamin D deficiency can be considered in pediatric patients taking anticonvulsants if they have mental retardation or developmental delay or if they have been taking anticonvulsants for more than 2 years or taking hepatic enzyme inducing drugs.

Epilepsy and vitamin D

Several disorders, both systemic and those of the nervous system, have been linked with vitamin D deficiency. Neurological disorders with a vitamin D link include but are not limited to multiple sclerosis, Alzheimer and Parkinson disease, as well as cerebrovascular disorders. Epilepsy which is the second leading neurological disorder received much less attention. We review evidence supporting a link between vitamin D and epilepsy including those coming from ecological as well as interventional and animal studies. We also assess the literature on the interaction between antiepileptic drugs and vitamin D. Converging evidence indicates a role for vitamin D deficiency in the pathophysiology of epilepsy.

Effects of carbamazepine on serum parathormone, 25- hydroxyvitamin D, bone specific alkaline phosphatase, C-telopeptide, and osteocalcin levels in healthy rats

It is still not completely clear whether carbamazepine causes alterations in vitamin D status and in bone metabolism. The objective of this study was to investigate the effects of carbamazepine on serum levels of 25-hydroxyvitamin D and on biomarkers of bone formation and resorption in healthy rats. Levels of calcium, 25- hydroxyvitamin D, parathormone, C-telopeptide, bone specific alkaline phosphatase and osteocalcin were measured in 3 groups of rats consisting of controls (n=10), isotonic saline solution group (n=10) and carbamazepine group (n=10). Mean calcium levels were found to be significantly lower in healthy controls in comparison to isotonic saline solution and carbamazepine groups (10.0±0.24, 10.81±0.16, 10.93±0.22 mg/dL, respectively, p<0.05). Mean levels of 25- hydroxyvitamin D, were found to be significantly higher in control group compared to isotonic saline solution group (25- hydroxyvitamin D; 25.91±1.12, 19.99±0.99 ng/mL, respectively, p<0.01). Mean levels of parathormone and osteocalcin were found to be significantly higher in control group compared to isotonic saline solution group and carbamazepine group. Parathormone levels were measured as 3.46±0.83, 1.08±0.08, 0.94±0.02 pg/mL, respectively (p<0.01). Osteocalcine levels were measured as 1.66±0.001, 1.32±0.002, 1.32±0.001 ng/mL, respectively (p<0.001). A significant difference in terms of mean serum bone specific alkaline phosphatase and C-telopeptide levels among groups was not observed. The main outcome of this prospective study in healthy rats showed no change in biochemical parameters of bone turnover during treatment with carbamazepine.

Drug-vitamin D interactions: a systematic review of the literature

Extensive media coverage of the potential health benefits of vitamin D supplementation has translated into substantial increases in supplement sales over recent years. Yet, the potential for drug-vitamin D interactions is rarely considered. This systematic review of the literature was conducted to evaluate the extent to which drugs affect vitamin D status or supplementation alters drug effectiveness or toxicity in humans. Electronic databases were used to identify eligible peer-reviewed studies published through September 1, 2010. Study characteristics and findings were abstracted, and quality was assessed for each study. A total of 109 unique reports met the inclusion criteria. The majority of eligible studies were classified as class C (nonrandomized trials, case-control studies, or time series) or D (cross-sectional, trend, case report/series, or before-and-after studies). Only 2 class C and 3 class D studies were of positive quality. Insufficient evidence was available to determine whether lipase inhibitors, antimicrobial agents, antiepileptic drugs, highly active antiretroviral agents, or H2 receptor antagonists alter serum 25(OH)D concentrations. Atorvastatin appears to increase 25(OH)D concentrations, whereas concurrent vitamin D supplementation decreases concentrations of atorvastatin. Use of thiazide diuretics in combination with calcium and vitamin D supplements may cause hypercalcemia in the elderly or those with compromised renal function or hyperparathyroidism. Larger studies with stronger study designs are needed to clarify potential drug-vitamin D interactions, especially for drugs metabolized by cytochrome P450 3A4 (CYP3A4). Healthcare providers should be aware of the potential for drug-vitamin D interactions.

Vitamin D deficiency in children with epilepsy: Do we need to detect and treat it?

Children and adolescents treated with antiepileptic drugs are known to have problems with bone metabolism, bone mineral density loss, and 2-3 times the fracture risk of healthy controls. We reviewed the literature regarding bone mineral density in children with epilepsy and vitamin D therapy in children treated with anti-epileptic drugs. Studies of bone mineral density markers in children with epilepsy have mostly found little significant difference in bone mineral density markers in children with epilepsy. They have been limited by small sample size and many of the studies have not corrected for confounding factors such as comorbidities, mobility, nutrition, and obesity. Studies of vitamin D therapy in children with epilepsy have shown little evidence of effect and have been similarly limited by lack of stratification with regard to confounding factors. There is a need for larger studies, using clinically significant outcomes such as fractures, including at risk populations such as symptomatic generalised epilepsy, impaired mobility, and polytherapy. At the present time in the absence of good evidence to the contrary, there remains concern that children with epilepsy are at risk of poor bone health and that vitamin D therapy may be beneficial. As low-dose vitamin D supplementation (400 IU per day) is now recommended for healthy children and it is biologically feasible that children with epilepsy may be at higher risk of clinically significant deficiency, it is important that neurologists ensure that low-dose vitamin D supplementation should be prescribed and compliance followed up in children with epilepsy.