Bone mineral density loss in ambulatory children with epilepsy in spite of using supplemental vitamin D in Southern Iran: a case-control study

Evaluation of vitamin D deficiency and low bone mass in children with asthma in fars province: A case-control study

Background and Aims

Asthma is a chronic inflammatory pulmonary disease which affects 10%-20% of children and adolescents. Inhaled corticosteroids (ICS) is one of its most effective therapies. The effect of systemic corticosteroids on decreasing bone mineral density (BMD) was investigated and proved in children; however, the influence of ICSs on bone density has still remained unclear. This study evaluates the bone mineral density of children and adolescents with asthma in southern Iran and the associated factors, for example, amount of used inhaled steroid.

Method

This case-control study enrolled 41 children and adolescents (aged 8-18 years) with asthma and their age and gender-matched controls in 2019-2020. Serum Calcium, phosphate, vitamin D, and bone mineral density were measured. Their physical activity, sun exposure, and fracture history were evaluated subjectively.

Results

Lumbar BMD and BMD Z-score in patients showed no significant difference with controls (p = 0.23, p = 0.73). Also, it showed that there was no significant difference in biochemical studies, growth, and bone densitometry parameters between patients who used ICSs for less than 3 months/year corticosteroid therapy compared to those with equal or more than 3 months/year usage. Prevalence of vitamin D deficiency was 28% and 8% in the controls and patients, respectively (p = 0.005).

Conclusion

The present study showed that 9.46% of children and adolescents with asthma had low bone mass for chronological age, and it is not significantly higher than normal population. Dosage of inhaled steroid did not associate with osteoporosis in these patients. Prevalence of vitamin D deficiency in patients was lower than normal population, probably due to receiving vitamin D in their routine follow-ups.

Evaluation of the effect of antiepileptic drugs on mandibular bone quality by fractal analysis

OBJECTIVES

Antiepileptic drugs (AEDs) are used to control seizures in epilepsy and their long-term use is common. AED use has been associated with decreased bone mineral density. The aim of this study is to determine the effect of AEDs on mandibular bone quality using fractal analysis and panoramic morphometric indices.

METHODS

In this study, dental and medical records of 132 patients (66 AED users and 66 control group) were used. Fractal analysis (FA), the panoramic mandibular index (PMI), mandibular cortical width (MCW), and Klemetti index (KI) measurements were performed on panoramic radiographs.

RESULTS

In all metrics, the mean values of the study group were significantly lower than the control group (p < 0.000). There is a statistically significant difference between the study and control groups in terms of KI distribution (p < 0.000). The mean fractal dimension (FD) values in each measured region of the female patients in the study group were found to be significantly lower than the female patients in the control group (p < 0.05). The mean FD values measured in ROI-2 and ROI-3 of male patients in the study group were found to be significantly lower than male patients in the control group (p < 0.05).

CONCLUSION

The side effects of AEDs on bone metabolism were shown in this study. Dentists examining patients with epilepsy should be careful about osteoporotic changes in the jaws.

Association between serum vitamin D status and the anti-seizure treatment in Chinese children with epilepsy

Objective

To compare the serum 25-OH-VitD levels, the major marker of vitamin D (VitD) status, between healthy children and children with epilepsy before initiation of and during anti-seizure medications (ASMs) treatment and to evaluate the potential influence factors on 25-OH-VitD levels. Another major aim was to assess the potential role of VitD supplementation.

Methods

For comparison, we finally enrolled and collected data from 6,338 healthy children presenting to Health Care Department and 648 children visiting primary care pediatricians with symptoms of epilepsy in Children’s Hospital of Nanjing Medical University from January 2019 to June 2021. The demographic and biochemical characteristics of each child were extracted from the hospital information system.

Results

Serum 25-OH-VitD levels in 648 children with epilepsy were significantly lower than those of 6,338 healthy children (P &lt; 0.0001), and the percentage of VitD insufficiency and deficiency status in pediatric patients was 49.19%. Of note, the serum 25-OH-VitD levels in children with newly diagnosed epilepsy before receiving any ASMs treatment were also significantly lower than those in healthy controls. Interestingly, ASMs therapy, alone or in combination, did not consistently reduce baseline serum VitD levels in children with epilepsy. The lower serum VitD levels in pediatric patients than those in healthy children might be related to the disease itself, rather than the ASMs treatment. As expected, VitD supplementation substantially increased the serum 25-OH-VitD levels (P &lt; 0.0001). More critically, children with epilepsy receiving VitD supplementation achieved good seizure control in our study.

Significance

In this retrospective study, the childhood epilepsy before initiation of and during ASMs treatment decreased the serum 25-OH-VitD concentrations, suggesting a clear association between epileptic disease and the risk of VitD deficiency. ASMs coadministration and long-term valproic acid treatment did not worse VitD-deficiency status, but in the small group receiving VitD supplementation, there was a significant improvement in reduction of seizure frequency. Therefore, pediatric clinicians are urged to raise public awareness of epilepsy-associated VitD deficiency.

Evaluation of Bone Metabolism in Children Using Antiseizure Drugs: A Single-Center Experience and Review of the Literature

The effect of anti-seizure drugs (ASDs) on bone mineral density (BMD) is a controversial topic. This study investigated the effect of monotherapy and polytherapy drugs separately. Patients with a history of epilepsy treated with the same ASDs for more than 6 months were included in the study. Data regarding patient demographics, biochemical markers related to bone metabolism (calcium, phosphorus, alkaline phosphatase, parathyroid hormone, vitamin D), and BMD with dual-energy X-ray absorptiometry (DXA) were collected and compared. In total, 104 children with epilepsy using valproic acid (VPA), levetiracetam (LEV), carbamazepine (CBZ) alone or in combination and 22 healthy controls were evaluated. The ages of the children (64 boys, 62 girls) ranged between 2 and 17, with a mean of 9.50 ± 4.03 years. BMD or Z-scores did not differ among the monotherapy groups or between them and the polytherapy group. The lowest mean Z-score was in the VPA group but without statistical significance. Alkaline phosphatase levels were significantly higher in the group using CBZ. Calcium levels significantly differed between the groups (p = 0.001). The CBZ and LEV groups had the lowest calcium levels. However, phosphorus and vitamin D measurements did not significantly differ by ASDs used. Unfortunately, low vitamin D levels were evident in all children with epilepsy and even among controls. Physical activity, sun exposure, and calcium intake might be recommended in children treated with ACDs and in combination with additional risk factors monitoring via DXA should be considered. Further studies in a large population are necessary to judge which ASDs are more at risk to reduce bone mineralization than others.

COL1A1 polymorphism and neurological complications in pediatric acute lymphoblastic leukemia patients and their associations with altered bone mineral density

Background

Osteoporosis and neurological complications are consequences of acute lymphoblastic leukemia (ALL). Collagen type I alpha 1 gene (COL1A1) polymorphism is associated with osteoporosis. This study aimed to detect the COL1A1 polymorphism and the neurological complications in ALL patients and their association with decreased lumbar spine bone mineral density (BMDLS). This study included 100 pediatric ALL patients and 100 controls. All participants were subjected to laboratory assessment and assessment of BMDLS at the start of the study and 3 years later. COLIA1 genotyping was done once for all participants.

Results

At the start of the study, there was a significant decrease in osteocalcin (OC), alkaline phosphatase (ALP), and BMDLS levels in the patients. G/T variants and “T” alleles were significantly more detected in the patients (34% and 35% respectively); also, significant differences were detected between patients with polymorphism (G/T and T/T) and those without polymorphism (G/G) regarding OC, ALP, and BMDLS. After 3 years, significant decrement in BMDLS, OC, and ALP was detected in the patients. Twenty-four patients had neurological complications and seven patients had bone fractures. Those patients had significant decrement in BMDLS, OC, and ALP levels. As regards COL1A1 gene polymorphism, the GT and TT variants were significantly detected in fractured patients, while there was no significant difference regarding GT and TT variants in the patients with neurological complications. T allele, neurological complications, high-risk stratification, and age were significantly associated with decreased BMDLS. T allele was the most significant risk factor.

Conclusion

COLIA1 gene polymorphism, decreased BMDLS, and neurological complications were significantly detected in pediatric ALL patients. COLIA1 gene polymorphism is a significant risk factor for decreased BMDLS in pediatric ALL patients. There is no significant relation between COLIA1 gene polymorphism and the development of neurologic complications.

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.

Effects of vitamin D and paricalcitol on epileptogenesis and behavioral properties of WAG/Rij rats with absence epilepsy

AIM

Vitamin D (Vit D) has been considered as a neurosteroid and has a pivotal role in neuroprotection including epilepsy. Vit D regulator acts via a Vit D receptor (VDR). WAG/Rij rats have a genetically epileptic model of absence epilepsy with comorbidity of depression. The aim of the present study was to investigate the effect of Vit D and paricalcitol (PRC) on WAG/Rij rats.

MATERIAL AND METHODS

Sixty-three male WAG/Rij rats and seven male Wistar rats were used. The effects of acute and chronic treatment with Vit D (5.000 and 60.000 IU/kg, i.p) and PRC (0.5, 5 and 10 μg/kg, i.p) on absence seizures, and related psychiatric comorbidity were investigated in WAG/Rij rats. Depression-like behavior was assayed by using the forced swimming test (FST) and; anxiety-like behavior by using the open field test (OFT).

RESULTS

Acute Vit D treatments (5.000 and 60.000 IU/kg) similarly reduced the number and duration of spike-wave discharges (SWDs) and showed anxiolytic-antidepressive effect whereas there were no significant changes in other measured parameters between the daily and the bolus dose of Vit D. Acute administration of PRC (0.5, 5 and 10 μg/kg) showed anti-convulsive and anxiolytic-antidepressive effect. The dose (0.5 μg/kg) of PRC was the most effective dose. Chronic treatment was more effective than acute therapy in all parameters.

CONCLUSION

The results of the present study demonstrate that Vit D and PRC have antiepileptic and anxiolytic-antidepressive effects on the absence epilepsy in WAG/Rij rats.

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.