Vitamin D Deficiency in Ambulant Children on Carbamazepine or Sodium Valproate Monotherapy

Community pharmacy is the key to improving vitamin D levels

Introduction

Vitamin D is an essential micronutrient that participates in the body's fundamental physiological processes. The pharmacist should involve the patient in his medication adherence, leading to a change in the patient's attitude towards his medication and towards his health problem, in order to achieve the pharmacological objective set.

Methods

Quasi-experimental multicenter study design with non-probabilistic convenience sampling. A pharmacist-led intervention in health education was carried out, divided in two groups, face-to-face interview and on-line survey, and the results were evaluated 3 months later to observe if there was any change in the patient's health status or in their vitamin D levels.

Results

The study was conducted in four pharmacies through face-to-face interviews (n = 49 patients) and online surveys (n = 23). Pharmaceutical intervention improved habits of exercise (0.81 ± 1.44 days/week face-to-face interviews vs -0.09 ± 2.35 days/week online surveys (p = 0.048)). In face-to-face interviews, consumption of vitamin D-rich foods was increased (0.55 unit of tuna/week; p = 0.035 and 0.56 unit of avocado/week; p = 0.001) and was improved correct intake of vitamin D supplements (32.5% baseline to 69.8% at 3 months). The increase in 25-hydroxyvitamin D levels (11.5 ng/mL after 3 months (p = 0.021)) was correlated to salmon consumption (0.951; p = 0.013) and the improvement of quality of life was correlated to avocado consumption (1; p < 0.001).

Conclusion

There are habits that improve vitamin D production such as increased physical activity, the correct use of vitamin D supplements and the consumption of foods with high vitamin D levels. The role of the pharmacist is crucial, involving the patient in the treatment making aware of the benefits for his/her health status of increasing vitamin D levels.

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.

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.

High burden of hypovitaminosis D among the children and adolescents in South Asia: a systematic review and meta-analysis

BACKGROUND

Vitamin D is vital for the growth and development of children. While deficiency and/or insufficiency of vitamin D among South Asian children are frequently reported in the literature, the lack of a meta-analysis has left its true extent poorly characterized. In this study, we aimed to conduct a systematic review and perform meta-analyses of the prevalence of hypovitaminosis D among the children of the South Asian countries.

METHODS

Two major electronic search engines (PubMed and Scopus) and one database (Google scholar) were used; original studies, conducted among South Asian children and adolescents and published between 1 January 2001 and 31 December 2019. A random-effect meta-analysis was also performed to calculate the pooled prevalence of hypovitaminosis D followed by subgroup analyses for countries and age groups.

RESULTS

After applying inclusion and exclusion criteria, a total of 41 studies with a total population size of 18,233 were finally selected. The overall prevalence of hypovitaminosis D was 61% [95% CI: 46% to 71%] with highly significant heterogeneity (I2 = 99.72%; p < 0.0001). The average level of serum vitamin D ranged from 5 ng/mL to 34 ng/mL, with a weighted mean of 19.15 ng/mL (weighted standard deviation 11.59 ng/mL). Country-wise analysis showed that hypovitaminosis D in Afghanistan was the highest [96.2%; 95% CI: 91% to 99%], followed by Pakistan [94%; 95% CI: 90% to 96%], India [64%; 95% CI: 46% to 79%], Bangladesh [35.48%; 95% CI: 32% to 39%], Nepal [35%; 95% CI: 1% to 83%], and Sri Lanka [25%; 95% CI: 16% to 36%]. Age group analyses revealed that hypovitaminosis D was most prevalent among neonates [85%; 95% CI: 76% to 91%], followed by school-going children [57%; 95% CI: 33% to 80%], and preschool children [55%; 95% CI: 35% to 75%].

CONCLUSION

This study generates quantitative evidence and specific extent of hypovitaminosis D in the South Asian countries as a public health concern. Being the first systematic review for this region, results from this study will create awareness and will facilitate adopting mitigation strategies by the policymakers and the governments to address this problem.

An integrated RNA-Seq and network study reveals that valproate inhibited progesterone production in human granulosa cells

BACKGROUND

Valproate (VPA) is an antiepileptic drug (AEDs) with an ideal effect against epilepsy as well as other neuropsychiatric diseases. There is considerable evidence that women taking VPA are prone to reproductive endocrine disorders. However, few studies have been published about VPA effects on human ovarian granulosa cells.

METHODS

By treating human ovarian granulosa cell line KGN with VPA, the cell viability and progesterone production function were evaluated. RNA-sequencing was applied to uncover the global gene expression upon VPA treatment.

RESULTS

We revealed that VPA dose-dependently repressed the viability of KGN. VPA treatment at 600 μM inhibited the progesterone production. The mRNA and protein expression of CYP11A1 and STAR, two key enzymes in the biosynthesis of progesterone, were both suppressed. Gene set enrichment analysis and Kyoto Encyclopedia of Genes and Genomes pathway analysis of the transcriptome revealed classical functions of VPA as a neuromodulator and regulator of histone acetylation modifications. In addition to this, VPA commonly affected many steroid metabolism related genes in follicle cells, such as promoting the expression of vitamin D receptor (VDR).

CONCLUSION

Our findings suggest that VPA caused steroids metabolism pathways disturbance related with ovarian function and inhibited progesterone biosynthesis by inhibiting the expression of steroidogenesis genes. Our research may provide theoretical basis for the better use of VPA and the possible ways to counteract its side effects.

Intermittent administration sodium valproate has a protective effect on bone health in ovariectomized rats

The present work was aimed to evaluate the effect of different administration modes of sodium valproate (VPA) on bone strength, bone mass and bone mineral density in ovariectomized (OVX) rats and further investigation of the possible mechanism. 60 female SD rats were randomly divided into 4 groups: Sham group (Sham, n = 15), OVX group (OVX, n = 15), OVX rats received intermittent VPA treatment group (IVPA, n = 15) and OVX rats received daily VPA treatment group (EVPA, n = 15). After 12 weeks of treatment, the rats were sacrificed, and serum and femur samples were harvested. DEXA, Micro-CT, history, biomechanical testing, biochemical index and western blot analysis were used to observe the therapeutic effect and explore the possible mechanism. Micro-CT and DEXA analysis of bones revealed better BMD and higher BV/TV, Tb. Th, Tb. N, Conn. D and lower Tb. Sp at femoral metaphysis evaluated in IVPA when compared with OVX and EVPA group (P < 0.05). Histological, fluorescent analysis and biological strength revealed more trabecular bone and higher relative mineral apposition rate, maximal load, elastic modulus and energy at break with evaluated in IVPA when compared with OVX and EVPA group (P < 0.05). The levels of P1NP, estrogen, CTX, TRAP-5b and RANKL of the IVPA group showed a significant increase when compared with the OVX and EVPA group (P < 0.05). We confirm adverse effects on protein expressions including Notch1, Jagged1, HEY1, Wnt 1, β-catenin and RUNX2 following daily VPA treatment in OVX female rats. Our current study demonstrated that intermittent administration of sodium valproate has a protective effect on bone health in OVX rats and these effects may be achieved by activating Notch/Wnt/β-catenin/RUNX2 signal axis.

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.

Effect of carbamazepine on the bone health of people with epilepsy: a systematic review and meta-analysis

Importance

Increasing evidence indicates that carbamazepine (CBZ) treatment in people with epilepsy (PWE) has adverse effects on bone health.

Objective

We conducted a meta-analysis to investigate the effect of CBZ on the bone health of PWE.

Methods

Two independent reviewers systematically searched PubMed and EMBASE for eligible studies. Standard mean deviations (SMDs) with 95% confidence intervals were used as a measure to investigate the effect of CBZ on bone-related outcomes in PWE.

Results

Levels of vitamin D (standardized mean difference [SMD]: −0.62, 95% CI: −0.89 to −0.35) and calcium (SMD: −0.38, 95% CI: −0.67 to −0.09) were significantly lower in the CBZ group than controls. Additionally, significantly higher alkaline phosphatase (SMD: 0.67, 95% CI: 0.52–0.82) was observed in patients using CBZ than controls. However, no significant difference in BMD was found between the two groups (SMD: −0.06, 95% CI: −0.55 to 0.43).

Conclusion and significance: This study provided evidence that CBZ treatment has a negative effect on bone health in PWE. Clinical implications are that long-term CBZ treatment may not be a good choice for PWE with skeletal diseases or osteoporosis.

Vitamin D Status of Epileptic Children in India: A Prospective Cross-Sectional Study from a Tertiary Care Centre

Vitamin D deficiency is prevalent all over the world, especially in tropical countries. In epileptics, antiepileptic drugs (AED) and associated comorbidities further impact vitamin D status. The aim of this study is to estimate the prevalence of 25(OH) vitamin D deficiency in epileptic children and evaluate probable risk factors. A cross-sectional study of 200 children between 1 and 18 years of age on AED was undertaken in the pediatric neurology clinic of a tertiary care center of Northern India. In all children, serum 25(OH) vitamin D levels, calcium, phosphorus, and alkaline phosphatase were estimated. The deficiency levels of vitamin D were categorized as: deficiency <20 ng/mL, insufficiency 20 to 30 ng/mL, and sufficiency >30 ng/mL. The potential risk factors for hypovitaminosis D, including type of epilepsy, AED regimen (specific medications, polytherapy vs. monotherapy), cerebral palsy, ambulatory status, intellectual disability, body mass index, gender, and vegetarianism were examined. Among the 200 enrolled children (60% boys), 106/200 (53%) were vitamin D deficient. There was no significant relation of vitamin D levels with gender, type of epilepsy, neurological deficit, and type of AED. An inverse relationship of higher phenytoin doses during monotherapy associated with lower vitamin D levels in monotherapy was found, thereby suggesting adverse effect of high doses of phenytoin on vitamin D levels. VDD is common among epileptic children on AED therapy. Vitamin D deficiency is common prevalent among epileptic children on AED therapy, and its detection and treatment correction should be an integral part of epilepsy management.

Bone Mineral Density Loss in People With Epilepsy Taking Valproate as a Monotherapy: A Systematic Review and Meta-Analysis

Objective: Data on changes in bone mineral density (BMD) from valproate (VPA) therapy are ambiguous and conflicting. Thus, the aim of this study was to systematically review the existing data and carry out a meta-analysis to investigate the effect of VPA as a monotherapy on BMD in people with epilepsy (PWE). Methods: We systematically searched PubMed, EMBASE, and MEDLINE for eligible studies. We calculated the standardized mean difference (SMD) with 95% confidence interval (CI) to investigate the statistical power of the association between VPA treatment and BMD. Results: Nineteen studies were included in this systematic review and meta-analysis. We found that BMD was lower in the VPA group than in the control group (SMD: -0.44; 95% CI: -0.65 to -0.22). A significant association was found in adult patients (SMD: -0.57; 95% CI: -0.88 to -0.26; I 2 = 69.8%) and pediatric patients (SMD: -0.32; 95% CI: -0.60 to -0.03; I 2 = 67.8%) by subgroup analysis. This study indicated that BMD was significantly lower in patients treated for more than 36 months than in controls (SMD: -0.52; 95% CI: -0.76 to -0.27; I 2 = 61.8%). However, a significant difference was not found between patients who were treated for less than 36 months and controls (SMD: -0.36; 95% CI: -0.72 to 0.01; I 2 = 74.8%). Conclusion and significance: The present study provided evidence that VPA treatment was significantly associated with BMD loss in PWE. Thus, for patients at a high risk of osteoporosis and fracture, especially for patients who need long-term treatment, VPA may not be a good choice.

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.

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.