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Goo Y, der Nederlanden AM, Bleasel A, Alffenaar JW, Kim HY. Dose Monitoring of Lamotrigine Monotherapy in Pregnancy: Are Pregnant Women with Epilepsy Currently Optimally Managed? A Systematic Review. Ther Drug Monit 2024; 46:181-194. [PMID: 38366344 DOI: 10.1097/ftd.0000000000001186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/20/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Lamotrigine monotherapy is the first-line treatment for epilepsy in pregnant women. However, altered pharmacokinetics during pregnancy can lead to suboptimal drug levels and increased seizure risk. This systematic review aimed to evaluate current therapeutic drug monitoring (TDM) strategies for lamotrigine monotherapy in pregnant women with epilepsy and provide guidance for monitoring and dose adjustments. METHODS A systematic search was performed using the Ovid-MEDLINE, Ovid-EMBASE, and Ovid-Cochrane Central Register of Controlled Trials databases. Studies were included if data on lamotrigine dosing, concentration, TDM strategies, efficacy, or safety were available. RESULTS Eleven studies were analyzed, revealing heterogeneity in outcomes with selective reporting of TDM strategies; however, clear similarities were observed. Blood samples were collected every 1-3 months during pregnancy to maintain prepregnancy baseline drug levels. Lamotrigine's apparent and relative clearance increased across trimesters, particularly in the second and third trimesters, coinciding with a period of increased seizure frequency and required dose adjustments. Details on dose adjustments were limited. Some studies have proposed using the threshold of the ratio to the target concentration to predict increased seizure risk. No distinct association was observed between adverse newborn outcomes and lamotrigine dose or serum concentration. Few maternal adverse effects have been reported after delivery, confirming the necessity of empirical postpartum tapering. CONCLUSIONS Further studies are required to establish evidence-based standardized protocols encompassing all aspects of TDM. Early interventions, such as empirical dose increases during pregnancy and postpartum tapering, and routine monitoring from preconception to the postpartum period may enhance seizure control, reducing the risk of breakthrough seizures for the mother and unborn child.
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Affiliation(s)
- Yeonkyung Goo
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | | | - Andrew Bleasel
- Neurology Department, Westmead Hospital, Westmead, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia ; and
| | - Jan-Willem Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Westmead, New South Wales, Australia
| | - Hannah Yejin Kim
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Westmead, New South Wales, Australia
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Toprani S, Meador KJ, Robalino CP, Brown CA, Matthews AG, Gerard EE, Penovich P, Gedzelman E, Cavitt J, Hwang ST, Kalayjian LA, Sam M, Pack A, Pennell PB. Effect of Epilepsy on Sleep Quality During Pregnancy and Postpartum. Neurology 2022; 99:e1584-e1597. [PMID: 35853745 PMCID: PMC9559942 DOI: 10.1212/wnl.0000000000200959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 05/25/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES This study seeks to understand how sleep is affected in pregnant women with epilepsy (WWE) relative to healthy pregnant women during pregnancy and postpartum and to nonpregnant WWE during comparative periods. Sleep affects maternal health and mood during pregnancy. Maternal sleep disturbances are related to poor fetal growth and increased fetal deaths. Epilepsy is the most common neurologic condition in pregnancy. Sleep disruption can worsen epileptic seizures. The interplay between epilepsy, pregnancy, and sleep is poorly understood. METHODS The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is an NIH-funded, prospective, observational, multicenter study, enrolling women from December 2012 through January 2016. Sleep quality was assessed using the average Pittsburgh Sleep Quality Index collected during pregnancy, postpartum, or analogous periods. Sleep scores range from 0 to 21 with higher scores indicating worse sleep quality; scores >5 are associated with poor sleep quality. RESULTS Of 351 pregnant WWE, 105 healthy pregnant women, and 109 nonpregnant WWE enrolled in the MONEAD study, data from 241 pregnant WWE, 74 healthy pregnant women, and 84 nonpregnant WWE were analyzed. Pregnant WWE had worse sleep (a higher mean sleep score) during pregnancy compared with healthy pregnant women in unadjusted analysis (p = 0.006), but no longer significant in adjusted analysis (p = 0.062); pregnant WWE (least square mean sleep score [95% CI] = 5.8 [5.5-6.1]) vs healthy pregnant women (5.1 [4.6-5.7]). During postpartum period, WWE (5.6 [5.4-5.9]) had similarly impaired sleep compared with healthy women (5.7 [5.2-6.2]; adjusted p = 0.838). Sleep was significantly worse in pregnant WWE vs nonpregnant WWE (for comparable period) in pregnancy and postpartum in unadjusted and adjusted analyses; adjusted scores for pregnant WWE in pregnancy (5.7 [5.4-6.0]) and those in postpartum (5.7 [5.4-6.0]) compared with those for nonpregnant WWE (4.7 [4.2-5.3]; p = 0.002) and (4.1 [3.6-4.7]; p < 0.001), respectively. Sleep quality between pregnancy and postpartum varied only in healthy pregnant women (change in mean score = 0.8 [0.2-1.3]; p = 0.01), whose sleep was worse in postpartum. DISCUSSION Pregnant WWE had worse sleep during pregnancy and postpartum period than nonpregnant WWE during comparable periods in the adjusted analysis. TRIAL REGISTRATION INFORMATION The study is registered at ClinicalTrials.gov as NCT01730170.
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Affiliation(s)
- Sheela Toprani
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA.
| | - Kimford J Meador
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Chelsea P Robalino
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Carrie Anne Brown
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Abigail G Matthews
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Elizabeth E Gerard
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Patricia Penovich
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Evan Gedzelman
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Jennifer Cavitt
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Sean T Hwang
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Laura A Kalayjian
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Maria Sam
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Alison Pack
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
| | - Page B Pennell
- From the Stanford University (S.T., K.J.M.), Palo Alto, CA; Emmes (C.P.R., C.A.B., A.G.M.), Rockville, MD; Northwestern University (E.E.G.), Chicago, IL; Minnesota Epilepsy Group (P.P.), Roseville; Emory University (E.G.), Atlanta, GA; University of Cincinnati (J.C.), OH; Northwell Health (S.T.H.), New Hyde Park, NY; University of Southern California (L.A.K.), Los Angeles; Wake Forest University Health Sciences (M.S.), Winston-Salem, NC; Columbia University (A.P.), New York; and University of Pittsburgh Medical Center (P.B.P.), PA
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