Neurologist knowledge about interactions between antiepileptic drugs and contraceptive methods

Lamotrigine and exogenous estrogen among females with epilepsy: A retrospective analysis of administrative claims data

OBJECTIVE

Exogenous estrogen reduces lamotrigine serum concentrations. Little is known about whether providers adjust lamotrigine doses for addition of exogenous estrogen among people with epilepsy, despite expert recommendations. We determined the incidence of dose increases in lamotrigine following incident prescription of estrogen among females with epilepsy (FWE) in claims data.

METHODS

We used Optum's de-identified Clinformatics® Data Mart Database to create a cohort of U.S. FWE prescribed lamotrigine at a stable dose, with a subsequent prescription for estrogen from 2011 to 2021. We calculated cumulative incidence functions of dose increases in lamotrigine following prescription of exogenous estrogen. We performed a Cox proportional hazards model for multiple candidate predictors of a lamotrigine dose increase.

RESULTS

The cohort included 643 FWE, with median age of 31 (interquartile ratio [IQR] 20-42). The cumulative incidence of any lamotrigine increase was 28% (95% confidence interval [CI] 25%-32%). The median number of days after the first estrogen fill until the first lamotrigine adjustment was 118 (IQR 48-188). In unadjusted Cox models, older age, use of estrogen in hormone replacement therapy as opposed to contraception, and annual household income of $50,000-$99,999 (compared with <$50,000) were significant negative predictors of a dose adjustment in lamotrigine with hazard ratios (HRs) of 0.82 (95% CI 0.72-0.92), 0.63 (95% CI 0.42-0.95), and 0.62 (95% CI 0.40-0.95). In the adjusted Cox model, age and income remained significant predictors with HRs of 0.79 (95% CI 0.66-0.94) and 0.59 (95% CI 0.36-0.95).

CONCLUSION

Dose increase of lamotrigine following addition of exogenous estrogen is rare among U.S. FWE, with potential disparities based on age and income level. More guidance may be needed for providers on this topic.

Dobbs Versus Jackson: Epilepsy, Reproductive Health, and Abortion

On June 24, 2022, Dobbs vs Jackson Women's Health Organization was decided by the Supreme Court effectively overturning the former precedent of Roe v. Wade. This ruling has direct consequences for the care of persons with epilepsy of childbearing potential. Now more than ever we need to provide informed and comprehensive care to our patients with epilepsy who are particularly vulnerable to the impact of this legislation on their reproductive decision-making. Important areas to understand include (1) the current state of affairs on abortion in the United States; (2) contraception options, their effectiveness, and interactions with anti-seizure medications (ASM); (3) teratogenic effects and adverse neurocognitive outcomes of ASMs; (4) folic acid supplementation; (5) the effect on perinatal and pediatric care; and (6) unique issues related to people of color.

Competency in the management of women of childbearing age with epilepsy among primary care and specialist doctors in Estonia

Objective

Although abundant new information has emerged in the last decade(s) on the management of women with epilepsy (WWE), whether said knowledge has reached clinical practice remains largely unknown. We assessed knowledge of this matter among primary care and specialist doctors in Estonia.

Methods

This study was conducted via an online questionnaire, which was used to explore healthcare specialists' awareness in five domains: pre-pregnancy counseling, contraception, side effects of antiseizure medications (ASMs), and the management of epilepsy during pregnancy and in the peri- and postpartum periods.

Results

The survey response rate was low - 8.14%. Knowledge of epilepsy management in WWE was inconsistent among different medical specialists. The median numbers of correctly answered questions among gynecologists, neurologists, and general practitioners were 7, 6.5, and 3 of 10, respectively. Gynecologists were more informed about appropriate contraceptive methods. Neurologists were more familiar with ASM side effects. General practitioners' knowledge level for this topic was low. Surprisingly, only 30.8% of general practitioners were aware of the high teratogenic potential of valproate.

Conclusions

We observed significant knowledge gaps regarding the optimal treatment of WWE of reproductive age. To improve epilepsy management, doctors' awareness of treatment considerations for this patient group needs to be increased.

Interactions between antiseizure medications and contraception: A study about the knowledge of patients and their specialist physicians

Planning pregnancy is very important for women with epilepsy (WWE), because of the potential teratogenic effects and neurodevelopmental disorders of different antiseizure medications (ASMs). Nevertheless, contraception in WWE can be challenging due to the existence of drug interactions between ASMs and hormonal contraception. The aim of this study was to assess women's knowledge of potential interactions between their ASMs and contraceptive options. The second objective was to assess neurologist's knowledge of the potential interactions between ASMs and contraceptive methods. An anonymous online survey was proposed to reproductive-age WWE during consultation with their neurologist. Another online survey was proposed to neurologists. These surveys were performed through a French regional medical network. A total of 79 patients agreed to respond to the survey. Forty-nine women used lamotrigine alone or in combination, 15 used an enzyme-inducing ASM alone or in combination, 13 used non-enzyme-inducing ASM and 2 used both lamotrigine and an enzyme-inducing ASM. Half of the WWE had mistaken beliefs about interactions between their ASM and contraception. Among them, 35% of the women treated with an enzyme-inducing ASM were unaware of a potential decreased efficacy of hormonal contraception. Moreover, 51% of the women who were taking lamotrigine did not know that combined hormonal contraception might decrease the efficacy of their ASM. On the other hand, 64.5% of WWE without an enzyme-inducing ASM wrongly thought that their ASM can decrease their hormonal contraceptive efficacy. A total of 20 neurologists answered the online survey. It revealed specific gaps concerning interactions between ASM and contraceptives; in fact, 35% of answers concerning the identification of specific enzyme-inducing ASMs were wrong. This study therefore highlights the need for educational efforts for both WWE and their physicians regarding drug interactions between ASMs and hormonal contraceptives.

Sexual and reproductive health concerns of women with epilepsy beginning in adolescence and young adulthood

BACKGROUND

Women with epilepsy (WWE) have potentially unique concerns regarding their sexual and reproductive health (SRH). Prior studies of WWE have focused narrowly on pregnancy and preconception experiences, and have not addressed concerns of nulliparous adolescent and young adult women not actively seeking pregnancy.

METHODS

We conducted individual semi-structured interviews with WWE 18-45 years of age. We sampled to maximize diversity of age and parity, and intentionally included many adolescent and young adult nulliparous women not actively planning pregnancy. Interviews broadly addressed participants' SRH concerns and experiences. Interviews were audio-recorded and transcribed. Two coders performed qualitative analysis using thematic analysis with deductive and inductive approaches.

RESULTS

Twenty WWE (median age 23 years, range 18-43 years) completed interviews. Twelve were nulliparous, six had children, one had a history of miscarriage only, and two were currently pregnant. WWE's narratives revealed significant concerns about family planning and reproductive health in the context of epilepsy, including: 1) seizures endangering pregnancies and children 2) teratogenic effects of antiseizure medication, 3) heritability of epilepsy, 4) antiseizure medication and epilepsy impacting fertility, and 5) interactions between antiseizure medication and contraception.

CONCLUSION

WWE, including nulliparous adolescent and young adult women who are not actively planning pregnancy, have significant concerns about how their epilepsy interacts with SRH. SRH counseling for WWE should begin during adolescence and be incorporated into the transition process from pediatric to adult healthcare. Insights from WWE may aid in the creation of relevant patient-facing educational resources as well as provider-facing training and tools to meaningfully support the reproductive decision-making of WWE throughout their childbearing years.

A survey of child neurologists about reproductive healthcare for adolescent women with epilepsy

OBJECTIVE

To evaluate child neurologists' knowledge, attitudes, and practices regarding sexual and reproductive health (SRH) care for adolescent and young adult women with epilepsy (WWE).

METHODS

Child neurologists (including attending physicians, residents, fellows, and advanced practitioners) completed an online survey distributed through subspecialty listservs. We analyzed results using descriptive statistics, chi-square, and logistic regression.

RESULTS

Two hundred eight child neurologists completed the survey. Most believed that child neurologists should counsel young WWE on: teratogenesis (99%, n = 206/207), contraception-antiseizure medication interactions (96%, n = 194/202), pregnancy (95%, n = 198/206), contraception (89%, n = 184/206) and folic acid supplementation (70%, n = 144/205). Fewer respondents felt confident with such counseling (teratogenesis: 90%, n = 188/208, drug interactions: 65%, n = 133/208, pregnancy 75%, n = 156/208, contraception: 47-64%, n = 96-134/208, p < 0.05). Ninety-five percent (n = 172/181) reported ever discussing SRH with typically developing young WWE, compared to 78% (n = 141/181) for young WWE with mild intellectual disability (p < 0.01). One third (n = 56/170) who ever discussed SRH did not do so routinely. Respondents correctly answered 87% ± 5% of knowledge questions about SRH for WWE, 80% ± 4% of questions about teratogenic antiseizure medications, and 61% ± 7% of questions about contraception-antiseizure drug interactions. The greatest barrier to SRH care was time constraints (80%, n = 149/186). The majority (64%, n = 119/186) identified solutions including longer appointment times and co-managing SRH care with other specialties.

CONCLUSIONS

Findings reveal gaps in SRH care by child neurologists for adolescent and young adult WWE, especially those with mild intellectual disability. Provider-identified barriers and solutions may serve as targets to improve SRH care for this population.

Gynecologic Management of Adolescents and Young Women With Seizure Disorders: ACOG Committee Opinion, Number 806

Seizure disorders frequently are diagnosed and managed during adolescence; therefore, obstetrician-gynecologists who care for adolescents should be familiar with epilepsy and other seizure disorders, as well as antiepileptic drugs. Patients diagnosed with seizure disorders during childhood may have increased seizure activity with puberty and menarche due to the neuroactive properties of endogenous steroid hormones. Compared with patients without epilepsy, patients with epilepsy are more likely to experience anovulatory cycles, irregular menstrual bleeding, and amenorrhea. Although hormonal suppression should not be initiated before puberty or menarche, prepubertal counseling may be appropriate, and obstetrician-gynecologists may work with young patients and their families to develop a plan to initiate with menarche. Additionally, obstetrician-gynecologists should be aware of any medication changes, including antiepileptics, for adolescent patients with seizure disorders. Research on hormonal therapy for the treatment of epilepsy is scant; however, the anticonvulsant properties of various progestins have been explored as potential treatment. There is no conclusive evidence that combination hormonal contraception increases epileptic seizures, and epilepsy itself poses no increased risk of an adverse outcome for those using combined oral contraceptive pills, the contraceptive patch, or a contraceptive ring. Because many antiepileptic drugs are teratogenic, discussing sexual health with and providing effective contraceptive choices to this population is critical. Obstetrician-gynecologists should work with patients with seizure disorders to develop a plan when pregnancy occurs.

Sexual and reproductive healthcare for adolescent and young adult women with epilepsy: A qualitative study of pediatric neurologists and epileptologists

OBJECTIVE

The objective of this study was to explore the attitudes and practices of pediatric neurologists and epileptologists regarding sexual and reproductive healthcare for adolescent and young adult women with epilepsy (WWE).

BACKGROUND

Adolescent and young adult WWE have unique sexual and reproductive healthcare needs, including counseling on teratogenesis, folic acid, and interactions between contraception and antiseizure medications. There are no prior studies regarding sexual and reproductive healthcare practices of pediatric neurologists or epileptologists.

DESIGN/METHODS

Individual semi-structured interviews were conducted with pediatric neurologists and epileptologists regarding their attitudes, practices, and experiences with sexual and reproductive healthcare for adolescent and young adult WWE. Interviews were audio-recorded and transcribed verbatim. Qualitative analysis was conducted using a thematic analysis approach.

RESULTS

Six child neurologists and 10 epileptologists (44% male) participated. Major themes included the following: (1) Sexual and reproductive healthcare is important for adolescent WWE, and neurologists have a key role in providing this care. (2) Sexual and reproductive healthcare should be comanaged with a primary care provider or women's health provider although neurologists have significant concerns regarding comanagement. (3) There is wide variability in sexual and reproductive healthcare practice among pediatric neurologists and epileptologists. Important subthemes included parent education and differences in sexual and reproductive healthcare practices for women with intellectual disabilities. (4) Many systemic and interpersonal barriers exist to delivering sexual and reproductive healthcare to adolescent and young adult WWE. Important barriers included limited time; provider, patient, or family discomfort; and lack of necessary knowledge or expertise. (5) Providers desire standardization of sexual and reproductive healthcare for adolescent WWE along with patient and provider education.

CONCLUSION

This is the first study to assess attitudes and practices of pediatric neurologists and epileptologists regarding sexual and reproductive healthcare for adolescent and young adult WWE. Our findings suggest that there is a need for development of improved systems for sexual and reproductive healthcare delivery and comanagement for adolescent and young adult WWE. Providers identified many barriers and facilitators that might serve as the basis for interventions to improve care.

Development of key performance indicators to capture in measuring the impact of pharmacists in caring for patients with epilepsy in primary healthcare: A Delphi consensual study

OBJECTIVE

This study was conducted to develop and achieve formal consensus on a core set of key performance indicators (KPIs) that can be captured in measuring the impact of pharmacists in caring for patients with epilepsy (PWE) visiting epilepsy clinics as outpatients in primary healthcare practice.

METHODS

In this study, a comprehensive literature search and review was conducted to extract candidate KPIs. Interviews with key contacts (6 pharmacists, 2 neurologists, 3 nurses, and 3 PWE) were also conducted to supplement the inventory set of KPI candidates. A three-round Delphi technique was followed among a panel of 40 members to achieve formal consensus on a core list of KPIs. Consensual KPIs were ranked by the ratings of the panelists.

RESULTS

The final consensual core set contained 8 KPIs in the thematic activity areas of pharmaceutical care, medication reconciliation and best possible medication history, patient education/counseling, interprofessional patient care, competence, and performance efficiency/patient satisfaction. The KPIs related to therapy problems identified and resolved by pharmacist and provision of proactive comprehensive direct patient care by a pharmacist received significantly higher (p-value: 0.0001) scores compared to the KPI related to complaints about pharmacists received.

CONCLUSION

Eight consensual KPIs to capture in measuring the impact of pharmacists in caring for PWE visiting epilepsy clinics as outpatients in primary healthcare practice were developed using the Delphi technique. If successfully adopted, implemented, captured, and analyzed, these consensual KPIs might help advance pharmaceutical care of PWE in primary healthcare practice.

Prevalence of highly effective contraception use by women with epilepsy

OBJECTIVE

To determine (1) the proportion of women with epilepsy (WWE) at risk of unintended pregnancy who use highly effective contraception, (2) demographic predictors, and (3) folic acid (FA) use.

METHODS

These cross-sectional data come from 311 US WWE, 18-47 years, who participated in the Epilepsy Birth Control Registry (EBCR) web-based survey in 2017. They provided demographic, epilepsy, antiepileptic drug (AED), contraceptive, and FA data. We report frequencies of highly effective contraception use and use logistic regression to determine demographic predictors. We report the proportion who take FA.

RESULTS

A total of 186 (59.8%) of the 311 WWE were at risk of unintended pregnancy. A total of 131 (70.4%) used a highly effective contraceptive category; 55 (29.6%) did not. An additional 13 (7.0%) used a combination of generally effective hormonal contraception with an enzyme-inducing AED, which poses increased risk of unintended pregnancy. Overall, 68 (36.6%) of the 186 WWE at risk did not use highly effective contraception. Increasing income (p = 0.004) and having insurance (p = 0.048) were predictors of highly effective contraception. A total of 50.0% took FA supplement. There was no significant difference in relation to the use or lack of use of highly effective contraception.

CONCLUSION

A total of 36.6% of WWE in the EBCR did not use highly effective contraception and 50.0% did not take FA in 2017 despite the important negative consequences of unintended pregnancy on pregnancy outcomes. There is a need for more readily available information and counseling on safe and effective contraception and FA use for this community.

Knowledge of women issues and epilepsy among doctors in Sudan

OBJECTIVE

The objective of this study was to assess the knowledge of doctors in Sudan about women issues related to epilepsy.

METHODS

In this cross-sectional study that was conducted in Sudan during the period from October 2017 to December 2017, we used Google forms to collect data from 154 doctors using Knowledge of Women Issues and Epilepsy (KOWIE) II standardized questionnaire.

RESULTS

Our studied group included house officers (n = 34), medical officers (n = 60), registrars (n = 52), and specialists (n = 8). The majority of participants were aware of the role of folic acid in reducing teratogenicity of antiepileptic drugs (AEDs) (89%) and that women with epilepsy (WWE) should not stop taking their AEDs during pregnancy (76.6%). Two-thirds of participants knew that most WWE have healthy children (68.2%) and that enzyme-inducing AEDs may reduce effectiveness of some contraceptives (72.1%). Half of participants were aware of the association between AEDs and osteomalacia (50%), and more than one-third (38.3%) knew that women taking AEDs can safely breastfeed (38.3%). Few of them (20.1%) knew that WWE have a higher incidence of sexual dysfunction compared with women without epilepsy, and only some (15.6%) knew that estrogen has a proconvulsant effect while progesterone has anticonvulsant qualities. The mean score of our participants was 5.53 out of 10 (standard deviation (SD) ± 1.64). Only registrars with the highest mean knowledge (6.15 ± 1.26) were statistically different from the rest of the medical degree groups.

CONCLUSIONS

In this small cross-sectional study, Sudanese doctors' knowledge was not satisfactory regarding the majority of questions on KOWIE II. Further education and training are indicated to decrease this knowledge gap and to improve care of WWE.

First-aid management of tonic-clonic seizures among healthcare personnel: A survey by the Apulian section of the Italian League Against Epilepsy

INTRODUCTION

To evaluate the knowledge of healthcare workers about first-aid measures to be performed during and after a tonic-clonic seizure.

METHODS

One hundred and fifty-four healthcare workers (86 physicians) working at 8 tertiary hospitals in the Apulia region, Italy, responded to a questionnaire comprising of 28 questions based on available Italian and international recommendations about what to do during a tonic-clonic seizure.

RESULTS

One hundred and fifty-four healthcare workers completed and returned surveys with a response rate of 96.25%. There were 55 nurses (35.7%), 86 physicians (55.8%), and 13 healthcare workers with different roles (Electroencephalograph technicians, psychologists, social workers). Among physicians, there were 7 cardiologists, 3 surgeons, 12 infectious-disease specialists, 11 internal medicine specialists, 2 psychiatrists, 2 gynecologists, 27 specialists working in the emergency department, and 22 physicians with different specializations. Nearly 90% of the respondents identified head protection as important first aid, while 100% responded to not keep the legs elevated. To avoid tongue bite, both physicians and other healthcare workers would put something in the mouth (54.0%), like a Guedel cannula (71.0%) fingers (29.5%). Grabbing arms and legs, trying to stop the seizure, would be potentially performed by 11.6% of our sample. Physicians would administer a benzodiazepine during the seizure (65.7%) and during the postictal phase (29.2%), even if the patient is known to have epilepsy (23.7%), and in this case, 11.3% of respondents would administer the usual antiepileptic medications. More than half of respondents would call the emergency telephone number, because of necessary hospitalization in case of tonic-clonic seizure, even if it is experienced by a patient known to have epilepsy.

CONCLUSION

Our survey suggests the need for epilepsy educational programs on first-aid management of seizures among healthcare workers.

Which information on women's issues in epilepsy does a community pharmacist need to know? A Delphi consensus study

OBJECTIVE

The aim of this study was to develop and achieve consensus on a core list of important knowledge items that community pharmacists should know on women's issues in epilepsy.

METHODS

This was a consensual study using a modified Delphi technique. Knowledge items were collected from the literature and from nine key contacts who were interviewed on their views on what information community pharmacists should have on women's issues in epilepsy. More knowledge items were suggested by five researchers with interest in women's issues who were contacted to rate and comment on the knowledge items collected. Two iterative Delphi rounds were conducted among a panel of pharmacists (n=30) to achieve consensus on the knowledge items to be included in the core list. Ten panelists ranked the knowledge items by their importance using the Analytical Hierarchy Process (AHP).

RESULTS

Consensus was achieved to include 68 knowledge under 13 categories in the final core list. Items ranked by their importance were related to the following: teratogenicity (10.3%), effect of pregnancy on epilepsy (7.4%), preconception counseling (10.3%), bone health (5.9%), catamenial epilepsy (7.4%), menopause and hormonal replacement therapy (2.9%), contraception (14.7%), menstrual disorders and infertility (8.8%), eclampsia (2.9%), breastfeeding (4.4%), folic acid and vitamin K (5.9%), counseling on general issues (14.7%), and sexuality (4.4%).

CONCLUSION

Using consensual knowledge lists might promote congruence in educating and/or training community pharmacists on women's issues in epilepsy. Future studies are needed to investigate if such lists can improve health services provided to women with epilepsy (WWE).

Pharmacists' knowledge of issues in pharmacotherapy of epilepsy using antiepileptic drugs: A cross-sectional study in Palestinian pharmacy practice

OBJECTIVE

Antiepileptic drugs (AEDs) are mainstay in controlling epileptic seizures. As experts in medications, pharmacists should be able to ensure accuracy of dosing regimens, explain adverse effects, and screen for and alert people with epilepsy (PWE) and their physicians to possible drug-drug interactions (DDIs). The aim of this study was to evaluate pharmacists' knowledge of issues in pharmacotherapy of epilepsy using AEDs.

METHODS

This was a cross-sectional observational study conducted in the Palestinian pharmacy practice. A 10-item case-based questionnaire was used to determine actions taken by pharmacists in theoretical situations in pharmacotherapy of epilepsy. Demographic and practice details of the study participants were also collected. Scores were calculated as percentage of correct answers for each participant.

RESULTS

The number of participants was 394. The majority (approximately 75%) identified themselves as community pharmacists. The median score was 33.4% with an IQR of 33.3. Pharmacists who received training on epilepsy and AEDs during their pharmacy degree program were 4.78-fold (95% C.I. of 1.82-12.60) more likely to score ≥50% in the test than those who did not receive training on epilepsy and AEDs. Despite gaps in knowledge, pharmacists tended to perform the necessary action in cases of adverse effects and aggravated seizures associated with AEDs.

CONCLUSION

Pharmacists can play a crucial role in providing essential information on AEDs to patients and prescribers. There are many knowledge gaps that need to be filled. Specifically designed pedagogic and/or training interventions might be helpful in filling these gaps.