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

Brain Trauma and the Secondary Cascade in Humans: Review of the Potential Role of Vitamins in Reparative Processes and Functional Outcome

An estimated sixty-nine million people sustain a traumatic brain injury each year. Trauma to the brain causes the primary insult and initiates a secondary biochemical cascade as part of the immune and reparative response to injury. The secondary cascade, although a normal physiological response, may also contribute to ongoing neuroinflammation, oxidative stress and axonal injury, continuing in some cases years after the initial insult. In this review, we explain some of the biochemical mechanisms of the secondary cascade and their potential deleterious effects on healthy neurons including secondary cell death. The second part of the review focuses on the role of micronutrients to neural mechanisms and their potential reparative effects with regards to the secondary cascade after brain injury. The biochemical response to injury, hypermetabolism and excessive renal clearance of nutrients after injury increases the demand for most vitamins. Currently, most research in the area has shown positive outcomes of vitamin supplementation after brain injury, although predominantly in animal (murine) models. There is a pressing need for more research in this area with human participants because vitamin supplementation post-trauma is a potential cost-effective adjunct to other clinical and therapeutic treatments. Importantly, traumatic brain injury should be considered a lifelong process and better evaluated across the lifespan of individuals who experience brain injury.

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 < 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 < 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.

Investigation of the Effect of Antiepileptics on Vitamin D and Calcium Levels

Purpose: The purpose of our study is to investigate Vitamin D and calcium levels in epilepsy patients using different antiepileptic agents and to investigate the relationship between vitamin D levels and various factors such as the type of antiepileptic agent, patient age and gender. Methodology: This retrospective case-control study enrolled a total of 290 participants, including 141 epilepsy patients followed up in AlanyaAlaaddinKeykubat University neurology outpatient clinic and 150 healthy individuals who applied to the neurology outpatient clinic for different reasons from January 2018 to January 2021. Demographics, detailed history, use of medications, duration of antiepileptic use, plasma 25-hydroxy Vitamin D and calcium levels of all participants were recorded. Results: The average Vitamin D level was 15.46 in the epilepsy group and 16.95 in the control group. Vitamin D level did not differ significantly by group (p>0.05). No significant relationship was found between age and vitamin D levels in both groups, and Vitamin D levels were statistically significantly lower in women in the epilepsy group. Vitamin D level was below 20 in 69.6% of healthy control group, 78.9% of carbamazepine users, 62.5% of lacosamide users, all lamotrigine users, 66.7% of levatiracetam users, and 72.4% of sodium valproate users. There was no significant relationship between Vitamin D level and the drug used (p>0.05).There was a significant relationship only between calcium level and carbamazepine (p

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.

How Antiepileptics May Change the Serum Level of Vitamin D, Calcium, and Phosphorus in Children with Epilepsy

Objective

Studies have shown vitamin (Vit) D deficiency and bone disease in long-term use of antiepileptics, especially in young individuals. This study aimed to determine the relationship between antiepileptic drugs and the level of Vit D, calcium (Ca), and phosphorus (P) in children with epilepsy at the Shohada Hospital from 2016 to 2017.

Materials & Methods

In this case-control study, 60 consecutive children with epilepsy at the Shohada Hospital from 2016 to 2017 under treatment with anticonvulsions for more than six months were enrolled as the case group. The level of Vit D, Ca, and P was determined in the case group and compared with 60 children without seizure as the control group.

Results

The mean Ca and P were alike across the groups (P > 0.05). The mean Vit D3 level was 31.3 and 40 in the case and control groups, respectively, with significant difference (P=0.0001). The mean Ca and P were alike across the types of drug in the case group (P > 0.05); however, the mean Vit D3 level was lower in the case versus control group with significant difference (P=0.040).

Conclusion

Totally, according to the obtained results, it may be concluded that treatment with antiepileptic drugs, especially stimulant type, is related to the lower Vit D3 level, but not to the Ca and P levels.

The Association between Vitamin D Status and Autism Spectrum Disorder (ASD): A Systematic Review and Meta-Analysis

The association between vitamin D status and autism spectrum disorder (ASD) is well-investigated but remains to be elucidated. We quantitatively combined relevant studies to estimate whether vitamin D status was related to ASD in this work. PubMed, EMBASE, Web of Science, and the Cochrane Library were searched to include eligible studies. A random-effects model was applied to pool overall estimates of vitamin D concentration or odds ratio (OR) for ASD. In total, 34 publications involving 20,580 participants were identified in this present study. Meta-analysis of 24 case-control studies demonstrated that children and adolescents with ASD had significantly lower vitamin D concentration than that of the control group (mean difference (MD): -7.46 ng/mL, 95% confidence interval (CI): -10.26; -4.66 ng/mL, p < 0.0001, I2 = 98%). Quantitative integration of 10 case-control studies reporting OR revealed that lower vitamin D was associated with higher risk of ASD (OR: 5.23, 95% CI: 3.13; 8.73, p < 0.0001, I2 = 78.2%). Analysis of 15 case-control studies barring data from previous meta-analysis reached a similar result with that of the meta-analysis of 24 case-control studies (MD: -6.2, 95% CI: -9.62; -2.78, p = 0.0004, I2 = 96.8%), which confirmed the association. Furthermore, meta-analysis of maternal and neonatal vitamin D showed a trend of decreased early-life vitamin D concentration in the ASD group (MD: -3.15, 95% CI: -6.57; 0.26, p = 0.07, I2 = 99%). Meta-analysis of prospective studies suggested that children with reduced maternal or neonatal vitamin D had 54% higher likelihood of developing ASD (OR: 1.54, 95% CI: 1.12; 2.10, p = 0.0071, I2 = 81.2%). These analyses indicated that vitamin D status was related to the risk of ASD. The detection and appropriate intervention of vitamin D deficiency in ASD patients and pregnant and lactating women have clinical and public significance.

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.

Antiepileptic Drugs and Bone Health: Current Concepts

Chronic use of antiepileptic drugs (AEDs) can induce the development of adverse effects on bone metabolism. In epileptic patients treated with AED, the monitoring of biochemical markers of bone turnover, such as the measurement of serum 25 (OH) vitamin D, bone mineral density, before the beginning of the treatment and during the follow-up is not routinely required. In the future, monitoring of biochemical markers in epileptic patients treated with AED may help us for adequate prevention therapy.

Risk factors of bone mineral metabolic disorders

Bone remodeling is a complex process which integrates different stimuli factors such as mechanical, nutritional and hormonal factors as well as cytokines and growth factors. Bone health depends on an adequate balance between all these factors. The typical bone pathology of the newborn is the metabolic bone disease of prematurity, favored by a lack of mineral accretion in the third trimester of gestation. The intrinsic defects of the bone tissue (primary osteoporosis) are usually of genetic or idiopathic origin and can affect both the term and the preterm newborn. Other risk factors for osteopenia (secondary osteoporosis) include maternal or gestational factors, nutritional deficits (calcium, phosphorus, vitamin D), endocrinological alterations, use of certain medications antagonistic to bone metabolism, mechanical factors and chronic diseases (renal or hepatic insufficiency, intestinal malabsorption, collagen or metabolic diseases). This review examines the risk factors of developing bone metabolic disorders in neonates.

Effects of vitamin D on drugs: Response and disposal

Vitamin D supplementation and vitamin D deficiency are common in clinical experience and in daily life. Vitamin D not only promotes calcium absorption and immune regulation, but also changes drug effects (pharmacodynamics and adverse reactions) and drug disposal in vivo when combined with various commonly used clinical drugs. The extensive physiological effects of vitamin D may cause synergism effects or alleviation of adverse reactions, and vitamin D's affect on drugs in vivo disposal through drug transporters or metabolic enzymes may also lead to changes in drug effects. Herein, the effects of vitamin D combined with commonly used drugs were reviewed from the perspective of drug efficacy and adverse reactions. The effects of vitamin D on drug transport and metabolism were summarized and analyzed. Hopefully, more attention will be paid to vitamin D supplementation and deficiency in clinical treatment and drug research and development.

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.

The Impact of Psychotropic Medications on Bone Health in Youth

PURPOSE OF REVIEW

Psychotropics are prescribed to youth at rapidly growing rates and may negatively impact bone health. Little awareness exists of this association among prescribing providers. Childhood and adolescence are critical times for bone development. Understanding these effects and their management is important to informed psychotropic use.

RECENT FINDINGS

Through a variety of mechanisms, antidepressants, benzodiazepines, mood stabilizers, neuroleptics, and stimulants may all negatively impact pediatric bone health. This confers added risk of osteoporosis in a population already at high risk for suboptimal bone health. Awareness of psychotropic-mediated effects on pediatric bone development is clinically relevant to the use and monitoring of these agents. Clinicians can manage these effects through informed consent, vitamin D supplementation, lifestyle modifications, and reducing polypharmacy. For mood stabilizers, vitamin D level monitoring and secondary prevention is indicated. Future longitudinal studies and development of monitoring guidelines regarding psychotropic impact on bone health are necessary.

Epilepsy and osteoporosis risk

PURPOSE OF REVIEW

It is well-recognized that individuals with epilepsy have an increased risk of vertebral and nonvertebral fractures; this increased risk has been described to be secondary to an increased bone fragility and to an increased risk of falls. Osteoporosis is the most common bone disease which has been characterized by microarchitectural deterioration of trabecula and cortical bone mass with a decrease in bone mineral density and bone strength. Specific side effects of antiepileptic drugs (AEDs) on bone metabolism have been identified; recent research publications further characterized some of the specific side effects of AEDs on bone metabolism. It is the purpose of this review to describe recent advances on the knowledge of the effects of AEDs on bone metabolism and the cause of osteoporosis in the field of epilepsy.

RECENT FINDINGS

Recent literature demonstrates that the increased risk of fractures in the epileptic patient population is likely multifactorial and includes seizure activity, injuries from falls, decreased bone strength, adverse effects from AEDs. Reviewed publications suggest that the mechanism of adverse effects on bone metabolism may differ among different AEDs. The impact of vitamin D deficiency or its metabolism in the epileptic population has also been a concern of several reviewed publications.

SUMMARY

This is a review is of the recent epilepsy and osteoporosis literature published over the past 18 months, highlighting reports and studies concerning the cause, pathogenesis, and possible preventive measures and effects of AEDs on changes of bone metabolism, bone loss, and development of osteoporosis. In addition, we also reviewed articles focusing on issues of prevention and treatment of osteoporosis in individuals with epilepsy. We utilized the search engines of PubMed and Cochrane Reviews from January 2016 to June 2017.

Bone Health and Endocrine Comorbidities in Pediatric Epilepsy

Antiseizure medications and dietary therapies have associated effects on the endocrine system. We provided an overview of the relationship between epilepsy treatment and bone health in children with epilepsy. Additionally, we discussed the effects of epilepsy treatment on other endocrine systems including thyroid function, growth, reproduction, and weight. The effect of epilepsy on bone health is multifactorial; there are direct and indirect effects of medication and dietary treatments as well as a decrease in physical activity, decreased sunlight exposure, decreased vitamin D levels, and additional comorbidities. Some medications have a greater effect on vitamin D and bone health than others, however all antiseizure medical treatments are associated with lower vitamin D levels in pediatric patients. We have provided practical suggestions for vitamin D surveillance in children with epilepsy as well as replacement strategies. Children with epilepsy have an increased likelihood of additional endocrine disorders including subclinical hypothyroidism, decreased growth, weight abnormalities, reproductive and sexual dysfunction. To a great extent, this is medication specific. Though more studies are needed to elucidate optimal treatment and monitoring of bone health and other endocrinopathies in children with epilepsy, it is critical that caregivers pay close attention to these issues to provide optimal comprehensive care to their patients.