Effects of antiepileptic drug on thyroid hormones in patients with epilepsy: A meta-analysis

Subacute thyroiditis in pregnancy: a narrative review

Thyroid dysfunction can adversely affect pregnancy outcomes. Apart from gestational thyrotoxicosis, thyroid dysfunction during pregnancy shares similar etiologies with the non-gravid state. Graves' disease is the most common cause of spontaneous hyperthyroidism in pregnancy, followed by thyroid autonomy. Although subacute thyroiditis is a less common cause of thyrotoxicosis in pregnancy, its associated pain, systemic symptoms, and thyroid dysfunction can present diagnostic and therapeutic challenges. In its painful form, subacute thyroiditis may lead to severe disability, with systemic glucocorticoids being the best effective treatment option. When painless, the condition often comes to medical attention due to thyroid dysfunction. During the thyrotoxic phase, subacute thyroiditis should be differentiated from gestational thyrotoxicosis, Graves' disease, and thyroid autonomy. Additionally, the transient hypothyroid phase may be misdiagnosed as permanent hypothyroidism, such as in Hashimoto's thyroiditis. Once properly diagnosed, management is symptomatic and focused on correcting the predominant abnormality. In this review, we summarize the current reported cases of subacute thyroiditis in pregnancy and discuss the challenges in diagnosis and management. Clinical trial number Not applicable.

Effect of antiepileptic drug monotherapy on endogenous sex hormonal profile in men and women with epilepsy

OBJECTIVE

To assess the alterations of endogenous sex hormone profiles in patients with epilepsy (PWE) on different antiepileptic drug (AED) monotherapies compared to healthy controls and drug naïve PWE (DNPWE).

METHODS

Four databases MEDLINE, EMBASE, SCOPUS, and CENTRAL were searched for analytical observational/intervention studies on the assessment of endogenous sex hormones in PWE compared to healthy controls and DNPWE. Two researchers reviewed the title/abstract, and full-text articles for the selection of the studies independently. Extracted data included information on study details, participant demographics, interventions, method of assessment and study results. The study outcomes were used to calculate the standard mean differences (SMD) and 95% confidence interval (CI) as effect size for assessing differences in the endogenous sex hormone levels between the treatment group and control/DNPWE.

RESULTS

Among 5888 publications retrieved, 33 studies were included. Enzyme-inducing AEDs (EIAEDs) such as phenytoin (men: SMD = 1.36; 95%CI = 1.06,1.66) and carbamazepine (men: SMD = 0.71; 95%CI = 0.39, 1.04 and women: SMD = 0.54; 95%CI = 0.25, 0.83) and weak-EIAED oxcarbazepine (men: SMD = 0.62; 95%CI = 0.26,0.99) increased the SHBG levels in PWE compared to control. The same trend was observed when comparing it to DNPWE. No significant changes in SHBG were observed for non-EIAEDs valproic acid, lamotrigine and levetiracetam in men. Lamotrigine significantly reduced SHBG in women (SMD = -0.50; 95%CI = -0.85, -0.16) compared to controls. Testosterone (T) levels were significantly reduced for both carbamazepine (SMD = -0.39; 95%CI = -0.67, -0.11) and valproic acid (SMD = -0.48; 95%CI = -0.74, -0.21) treated men compared to control.

SIGNIFICANCE

Our findings emphasize the importance of screening the endogenous sex hormonal profile in PWE on AED monotherapies to evaluate the associated endocrine-related perturbations which may impact reproductive functions.

Effects of valproic acid, levetiracetam, carbamazepine, and oxcarbazepine on thyroid function tests in children

OBJECTIVE

The aim of the study was to evaluate the effects of commonly used medications for epilepsy on thyroid function tests in children.

METHODS

Epileptic children treated with valproic acid, levetiracetam, carbamazepine, and oxcarbazepine were retrospectively examined along with a healthy control group. Levels of free thyroxine 4 and thyroid-stimulating hormone were compared.

RESULTS

In patients receiving valproic acid monotherapy, thyroid-stimulating hormone levels increased compared to both the control group and pre-treatment levels, while free thyroxine 4 levels remained unchanged. In those receiving carbamazepine or oxcarbazepine monotherapy, average free thyroxine 4 levels were found to be lower compared to the control group and pre-treatment levels, with no difference in thyroid-stimulating hormone levels. For patients receiving levetiracetam monotherapy, there was no difference in free thyroxine 4 and thyroid-stimulating hormone levels compared to the control group and pre-treatment levels.

CONCLUSION

Despite significant changes in thyroid hormone levels with valproic acid, carbamazepine, and oxcarbazepine treatment, no significant clinical findings were observed. Additionally, no effect of levetiracetam on thyroid function tests was detected.

Thyroid hormones and prognosis in adults with status epilepticus: a retrospective study

Objectives

Thyroid hormone levels have been indicated to be associated with the functional outcome in critical illness. However, the studies on thyroid hormones and status epilepticus (SE) are rare. This study aimed to evaluate the predictive value of serum thyroid hormone levels on admission for unfavorable outcome in adult patients with SE.

Methods

We investigated and validated the predictive value of serum thyroid hormone levels on admission for the prognosis of adult SE patients. We extracted the clinical information and outcomes of patients. Modified Rankin scale (mRS) scores were applied to assess the patients' functional outcome, and mortality at 30 days after SE onset was identified. Serum levels of thyroid hormones including free thyroxin (FT4), free triiodothyronine (FT3) and thyroid-stimulating hormone (TSH) were detected on admission.

Results

We first analyzed the discovery cohort of 87 patients with SE. We found that 35.6% (31/87) of the patients had a poor outcome at discharge, and 18.4% (16/87) of the patients died during hospital stay and at 30-day follow up. The serum FT3 levels in the non-survivors group were significantly lower than those in the survivors group. Low T3 syndrome occurred in 29.9% (26/87) of SE cases and patients with low T3 syndrome were more likely to have unfavorable outcomes. Furthermore, we observed similar results in the external cohort, which validated our findings.

Conclusions

Serum FT3 levels measured on admission are independently associated with 30-day mortality in SE patients. Additionally, low T3 syndrome may be a promising candidate for predicting SE prognosis.

Advances in serum thyroid hormone levels and seizures

Epilepsy, a common neurological disorder, is characterized by paroxysmal, short-term, repetitive, and stereotypical features, significantly impacting patients' quality of life. Currently, the pathogenesis of epilepsy remains incompletely understood. Changes in neuronal excitability, imbalances in glutamate and gamma-aminobutyric acid (GABA) levels, alterations in the activity of GABA receptors, and dysfunction of GABA receptors are considered closely related to its occurrence. Thyroid hormones, vital for human growth and development, also play a crucial role in the nervous system. They mediate oxidative stress, influence reactive oxygen species production, affect mitochondrial function and neuronal excitability, and modulate glutamate and GABA levels. Also, they combine with thyroid hormone receptors and exert genomic effects by regulating the expression of numerous genes. However, once there are defects in thyroid hormone signaling, these defects may lead to severe neurodevelopmental disorders that are associated with an increased frequency of seizures. The impact of antiseizure medications (ASMs) on serum thyroid hormone levels, particularly traditional ASMs, has been extensively studied. It is reported that conventional ASMs such as phenobarbital, phenytoin sodium, carbamazepine, and valproate sodium were more likely to induce subclinical hypothyroidism (elevated TSH with normal FT4) or isolated hypothyroidism (decreased FT4 with normal TSH). However, the new ASMs, such as levetiracetam, have no effect on thyroid hormone levels. Together, seizures not only affect thyroid hormone levels, but abnormal thyroid hormone levels can also influence seizures. However, the precise mechanism underlying the interaction between serum thyroid hormone levels and seizures remains unclear. This review aims to explore the relationship between thyroid hormone levels and seizures, along with the underlying mechanisms.

A Prospective Cohort Study on the Effect of Antiseizure Medications on Thyroid Function in Children Aged 6 Months to 12 Years with Epilepsy

Objectives

This study aimed to explore the effect of antiseizure medications (ASM) on thyroid function in children with epilepsy.

Methods

A prospective study involving children between 6 months and 12 years of age with new-onset seizures who took ASM within 2 months was conducted in the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India, between August 2019 to March 2022. Thyroid function tests-free T3, free T4 and thyroid stimulating hormone (TSH)-were done at baseline and after completing 3 months by competitive immunoassay using direct chemiluminescent technology. The primary outcome was the proportion of patients diagnosed with thyroid dysfunction (subclinical or overt hypothyroidism).

Results

In total, 126 patients were enrolled. Median (interquartile range [IQR]) age and follow-up months were 10 years (7-12) and 6 months (4-8), respectively. Most patients (n = 103, 81.7%) had generalised seizures, while the remaining (n = 23, 18.3%) had focal seizures. There was a significant difference noted in median (IQR) TSH (micro-IU/mL) at baseline (2.08 [1.41-3.31]) and follow-up (2.56 [1.65-4.14]; P ≤0.001). Thyroid dysfunction (subclinical hypothyroidism) was noted in 7 patients. Among the 7 children with subclinical hypothyroidism, 6 (4.8%) were on sodium valproate either as monotherapy (n = 3, 2.4%) or polytherapy (n = 3, 2.4%), while the remaining child was on phenytoin. No difference was noted between the monotherapy and polytherapy groups (4% versus 11.5%; P = 0.15).

Conclusion

The incidence of thyroid dysfunction (subclinical hypothyroidism) was 5.6% in children taking ASM with a median follow-up period of 6 months. A longer follow-up period and larger sample size study is warranted in the future.

Mass spectrometry in measurement of thyroid biomarkers

In 2022, the number of patients with thyroid disease in China exceeded 200 million (10 million with hyperthyroidism, 90 million with hypothyroidism, and 100 million with other thyroid disease such as goiter, thyroid nodules, and thyroid cancer). Well-established markers include FT3, FT4, TT3, TT4, and TSH tested by a number of immunoassay methods. This approach is based on the primary binding of antigen with antibody and a subsequent secondary chemical reaction that provides an indirect measure. The use of traceable standards for quantitation remains an important factor to ensure inter-assay reliability and precision. Recently, mass spectrometry (MS) has received considerable attention as an analytic tool due to high resolution and quantitative accuracy. In addition, MS allows for sensitive determination of low-abundance markers making it ideal for development of traceable standards. Furthermore, this technology will allow for the development of highly accurate thyroid biomarker assays to facilitate diagnosis, enable early treatment and improve outcomes. Herein, we provide a systematic review and summary of MS in enhancing the analysis of thyroid biomarkers.

Efficacy and safety of levetiracetam vs. oxcarbazepine in the treatment of children with epilepsy: a systematic review and meta-analysis

Background

Levetiracetam (LEV) and oxcarbazepine (OXC) are new antiseizure medications (ASMs). In recent years, OXC monotherapy is widely used in children with epilepsy; however, no consensus exists on applying LEV monotherapy among children with epilepsy.

Objective

The present work focused on comparing the efficacy and safety of LEV and OXC monotherapy in treating children with epilepsy.

Methods

We conducted a comprehensive search across multiple databases including PubMed, Cochrane Library, Embase, Web of Science, CNKI, Wanfang Database, VIP, and China Biology Medicine disc, covering studies from inception to August 26, 2023. We included randomized controlled trials (RCTs) and cohort studies evaluating the efficacy and safety of LEV and OXC monotherapy for treating epilepsy in children. We utilized Cochrane Risk of Bias Tool in RevMan 5.3 software for assessing included RCTs quality. In addition, included cohort studies quality was determined using Newcastle-Ottawa Scale (NOS). A random-effects model was utilized to summarize the results.

Results

This meta-analysis included altogether 14 studies, including 893 children with epilepsy. LEV and OXC monotherapy was not statistical different among children with epilepsy in seizure-free rate (relative risk [RR] = 1.010, 95% confidence interval [CI] [0.822, 1.242], P > 0.05) and seizure frequency decrease of ≥50% compared with baseline [RR = 0.938, 95% CI (0.676, 1.301), P > 0.05]. Differences in total adverse reaction rate [RR = 1.113, 95% CI (0.710, 1.744), P > 0.05] and failure rate because of serious adverse reaction [RR = 1.001, 95% CI (0.349, 2.871), P > 0.05] were not statistical different between LEV and OXC treatments among children with epilepsy. However, the effects of OXC monotherapy on thyroid among children with epilepsy was statistically correlated than that of LEV (thyroid stimulating hormone: standardized mean difference [SMD] = -0.144, 95% CI [-0.613, 0.325], P > 0.05; free thyroxine: SMD = 1.663, 95% CI [0.179, 3.147], P < 0.05).

Conclusion

The efficacy of LEV and OXC monotherapy in treating children with epilepsy is similar. However, OXC having a more significant effect on the thyroid than that of LEV. Therefore, LEV may be safer for children with epilepsy who are predisposed to thyroid disease than OXC.

Systematic Review Registration

https://www.crd.york.ac.uk/, PROSPERO (CRD42024514016).

Hormonal Changes in Women with Epilepsy

Epilepsy is a prevalent neurological disorder among women globally, often requiring long-term treatment. Hormonal fluctuations in women with epilepsy (WWE) can have reciprocal effects on epilepsy and antiseizure medications (ASMs), posing significant challenges for WWE. Notably, WWE commonly experience endocrine alterations such as thyroid dysfunctions, low bone metabolism, and reproductive hormone irregularities. On the one hand, the presence of hormones in women with epilepsy affects their susceptibility to epilepsy as well as the metabolism of antiseizure medications in various ways. On the other hand, epilepsy itself and the use of antiseizure medications impact the production, secretion, and metabolism of hormones, resulting in low fertility, increased risk of pregnancy complications, negative offspring outcomes, and so on. In order to develop more precise treatment strategies in the future, it is necessary to comprehend the explicit relationships between hormones, epilepsy, and antiseizure medications, as well as to elucidate the currently known mechanisms underlying these interactions.

The effect of plasma exchange on serum levels of lacosamide: A case report

PURPOSE

We describe the case of a 22-year-old male who developed thyroid storm necessitating therapeutic plasma exchange (TPE). The patient's past medical history was complicated by epilepsy, for which he took lacosamide. Little evidence was available to guide lacosamide dosing during TPE. Because of an exacerbation of the patient's underlying epilepsy in the context of the thyroid storm, we conducted therapeutic medication monitoring of lacosamide concentrations to guide management.

SUMMARY

We arranged for measurement of the lacosamide concentration immediately before TPE (5.1 μg/mL) and 2.5 hours after the initial measurement (3.4 μg/mL) to determine the amount of lacosamide removed by TPE. Utilizing population pharmacokinetic parameters, we calculated the expected concentration and compared this to the measured concentration. The difference between these values was used to determine the percentage removed via TPE compared to the expected post-TPE concentration. We found that one TPE session removed an additional 20% of serum lacosamide.

CONCLUSION

TPE appeared to remove an additional 20% of lacosamide when compared to the expected post-TPE concentration.

Valproate-Induced Metabolic Syndrome

Valproic acid (VPA) and its salts (sodium calcium magnesium and orotic) are psychotropic drugs that are widely used in neurology and psychiatry. The long-term use of VPA increases the risk of developing adverse drug reactions (ADRs), among which metabolic syndrome (MetS) plays a special role. MetS belongs to a cluster of metabolic conditions such as abdominal obesity, high blood pressure, high blood glucose, high serum triglycerides, and low serum high-density lipoprotein. Valproate-induced MetS (VPA-MetS) is a common ADR that needs an updated multidisciplinary approach to its prevention and diagnosis. In this review, we consider the results of studies of blood (serum and plasma) and the urinary biomarkers of VPA-MetS. These metabolic biomarkers may provide the key to the development of a new multidisciplinary personalized strategy for the prevention and diagnosis of VPA-MetS in patients with neurological diseases, psychiatric disorders, and addiction diseases.

The effects of hexabromocyclododecane on the transcriptome and hepatic enzyme activity in three human HepaRG-based models

The disruption of thyroid hormone homeostasis by hexabromocyclododecane (HBCD) in rodents is hypothesized to be due to HBCD increasing the hepatic clearance of thyroxine (T4). The extent to which these effects are relevant to humans is unclear. To evaluate HBCD effects on humans, the activation of key hepatic nuclear receptors and the consequent disruption of thyroid hormone homeostasis were studied in different human hepatic cell models. The hepatoma cell line, HepaRG, cultured as two-dimensional (2D), sandwich (SW) and spheroid (3D) cultures, and primary human hepatocytes (PHH) cultured as sandwich were exposed to 1 and 10 µM HBCD and characterized for their transcriptome changes. Pathway enrichment analysis showed that 3D models, followed by SW, had a stronger transcriptome response to HBCD, which is explained by the higher expression of hepatic nuclear receptors but also greater accumulation of HBCD measured inside cells in these models. The Pregnane X receptor pathway is one of the pathways most upregulated across the three hepatic models, followed by the constitutive androstane receptor and general hepatic nuclear receptors pathways. Lipid metabolism pathways had a downregulation tendency in all exposures and in both PHH and the three cultivation modes of HepaRG. The activity of enzymes related to PXR/CAR induction and T4 metabolism were evaluated in the three different types of HepaRG cultures exposed to HBCD for 48 h. Reference inducers, rifampicin and PCB-153 did affect 2D and SW HepaRG cultures' enzymatic activity but not 3D. HBCD did not induce the activity of any of the studied enzymes in any of the cell models and culture methods. This study illustrates that for nuclear receptor-mediated T4 disruption, transcriptome changes might not be indicative of an actual adverse effect. Clarification of the reasons for the lack of translation is essential to evaluate new chemicals' potential to be thyroid hormone disruptors by altering thyroid hormone metabolism.

Long-Term Effects of Antiseizure Medications

Most patients with epilepsy will benefit from seizure control with one of an array of chronic antiseizure medications. Knowledge of the potential long-term effects of these medications is critical to prevent adverse consequences on overall health. Antiseizure medications vary in their capacities to affect the brain and peripheral nerves, hormones, bone mineralization, cardiovascular risk, renal health, hepatic, hematological, and dermatological systems. Understanding of pathophysiology and population risk has evolved, although most of the data available are still on older generation antiseizure medications such as phenytoin, carbamazepine, and valproic acid. The enzyme-inducing properties of some antiseizure medications make their effects on cardiovascular risk and bone health detrimental. Few clear guidelines exist for monitoring long-term effects of medication therapy for epilepsy. When selecting an antiseizure medication, consideration should be given to the individual patient's risks of adverse consequences on other organ systems. During monitoring of patients on chronic therapy, screening tools such as metabolic panels and bone density measurements can help stratify risk and guide management.

Thyroid functions as a parameter in monitoring of antiepileptic drugs

INTRODUCTION

Epilepsy is a chronic neurological disorder that is treated with multiple medications that can have significant side effects. This study investigated the potential effects of antiepileptic drugs on thyroid function.

METHODS

The participants in this study were epileptic adults who had been consistently monitored in follow-up care. The effects of antiepileptic drugs on the serum levels of the thyroid stimulating hormone (TSH), free T3 (fT3), and free T4 (fT4) of these patients were investigated retrospectively by comparing laboratory recordings in three defined periods: prior to antiepileptic drug treatment, between 6 months and 1 year of treatment (early stage), and after 1 year of treatment (late stage).

RESULTS

  A total of 300 epileptic patients (F/M: 175/125) were included in the study. Significant differences in TSH and fT4 serum levels in the late stage compared to the pre-treatment stage (p = 0.006 and p = 0.0005, respectively) were found. TSH values in the late stage of treatment were abnormally high in one case and low in five cases; all six of these cases had normal pre-treatment and early-stage TSH values. Patients who received monotherapy with valproic acid, levetiracetam or carbamazepine were evaluated separately and there was no statistically significant difference in TSH and fT3 levels, while fT4 levels were significantly increased during treatment in each treatment group.

CONCLUSIONS

A significant increase in TSH levels was found in epileptic patients on polytherapy. Our results give us the opportunity to highlight the potential unique or cumulative effect of antiepileptic drugs on thyroid hormone levels.

Is the prevalence of thyroid disease higher in children receiving antiepileptic medication? A systematic review and meta-analysis

PURPOSE

Antiseizure medications (ASM) have long been examined for their potential to induce thyroid dysfunction. The aim of this systematic review and meta-analysis was to assess the prevalence of thyroid disease in children up to 16 years receiving monotherapy with valproate (VPA), carbamazepine (CBZ) and levetiracetam (LEV).

METHODS

PubMed/MEDLINE, Cochrane/CENTRAL databases and the gray literature were searched to identify observational studies providing the prevalence of thyroid dysfunction in the target population under VPA, CBZ, or LEV monotherapy schemes. The results were pooled using a random-effects model, and additional subgroup analyses were performed for the three ASM groups.

RESULTS

Fifteen and thirteen studies met inclusion criteria for the qualitative and the quantitative analysis, respectively, with a total of 945 pediatric patients with prevalence data. Only VPA and CBZ were associated with thyroid dysfunction. The overall prevalence of thyroid abnormality was higher in children receiving ASM [odds ratio (OR) 6.82, 95% confidence interval (CI) 3.96-11.75]. In the subgroup analysis, the prevalence of biochemical thyroid abnormality with increased TSH was higher in the VPA (OR 9.54, 95%CI 5.25-17.34) and the CBZ group (OR 4.08, 95%CI 1.84-9.04) compared with controls.

CONCLUSION

This study confirms the higher prevalence of biochemical thyroid abnormality in children under VPA and CBZ monotherapy, whereas no such evidence is present for LEV. In children with a predisposition for thyroid disease, LEV should be considered over VPA and CBZ, if appropriate for seizure type and epilepsy syndrome. More studies are needed to reach a consensus on monitoring and management of thyroid dysfunction in children receiving ASM therapy.

Antiseizure medications and thyroid hormone homeostasis: Literature review and practical guideline

Thyroid hormones play an essential role in central nervous system development, normal physiological brain function, and repair mechanisms. On one hand, thyroid hormone alterations influence cortical excitability, and on the other hand antiseizure medications (ASMs) are associated with alterations in thyroid hormone metabolism. Although this interaction has long been described, and epilepsy is a common and chronic neurological disease, studies describing the interplay are often small and retrospective. We performed a systematic review of the current literature on epilepsy, ASMs, and thyroid hormone metabolism. Forty-seven studies were included. Most studies were retrospective cross-sectional studies (n = 25) and investigated thyroid function alterations in patients on older ASMs such as phenobarbital, phenytoin, carbamazepine, and valproate. Overall, almost one third of patients with epilepsy had thyroid hormone alterations, especially patients on valproate (25%) and carbamazepine (10%-25%). Studies with patients receiving polytherapy are scarce, but reported a higher risk for hypothyroidism in patients with older age (p = .004), female sex (p = .014), longer duration of epilepsy (p = .001), intractable epilepsy (p = .009), and polytherapy. Studies on newer ASMs are also limited, and further studies on an interplay with thyroid hormone homeostasis are essential to improve the care for epilepsy patients. ASMs are associated with alterations in thyroid hormone metabolism. Thyroid function monitoring is indicated in patients on ASMs, especially those with refractory epilepsy and those on polytherapy. We provide a practical guideline for thyroid function monitoring for the clinician taking care of patients on ASMs.

Carbamazepine drug effect simulating biochemical central hypothyroidism in a patient with Bardet-Biedl syndrome

Carbamazepine (CBZ) is a medication used commonly in epilepsy. Decreases in free T4 levels simulating central hypothyroidism have been reported, although the clinical significance is still unclear. We present a 24-year-old man with Bardet-Biedl syndrome (BBS) who was found to have isolated biochemical central hypothyroidism. BBS is a ciliopathy occasionally associated with anterior pituitary dysfunction. While taking CBZ for epilepsy, his TSH was 1.73 mIU/L (reference range: 0.20-4.00 mIU/L) with a low free T4 of 6.6 pmol/L (reference range: 10.0-26.0 pmol/L). Pituitary MRI was normal. Although treated with levothyroxine initially, his apparent biochemical central hypothyroidism was later recognised as secondary to CBZ drug effect. This was confirmed with a normal free T4 of 12.2 pmol/L while he was off CBZ and levothyroxine. Despite the association between CBZ and biochemical central hypothyroidism, nearly all patients remain clinically euthyroid. This effect is reversible and recognition could lead to reductions in unnecessary thyroid replacement therapy if CBZ is discontinued.

Endoxifen: A new, protein kinase C inhibitor to treat acute and mixed mania associated with bipolar I disorder

OBJECTIVES

Endoxifen is a protein kinase C inhibitor. The objective of the present phase III study was to demonstrate the safety and efficacy of endoxifen in treating bipolar I disorder (BPD I) patients.

METHODS

A multicenter, double-blind, active-controlled study was conducted using a daily dose of 8 mg endoxifen compared to 1000 mg divalproex, the current standard treatment, in patients with BPD I acute manic episodes with/without mixed features. The primary endpoint of our study was the mean change in total Young Mania Rating Scale (YMRS) score at day 21.

RESULTS

Endoxifen (n = 116) significantly (p < 0.0001) reduced total YMRS score (from 33.1 to 17.8. A significant (p < 0.001) improvement in Montgomery-Åsberg Depression Rating Scale (MADRS) score was observed for endoxifen (4.8 to 2.5). Early time to remission of the disease was observed with endoxifen compared to divalproex. None of the patients required rescue medication and there was no drug-associated withdrawals. Changes in Clinical Global Impressions-Bipolar Disorder and Clinical Global Impression-Severity of Illness scores showed that treatment with endoxifen was well-tolerated.

CONCLUSIONS

Endoxifen at a low daily dose of 8 mg was as efficacious and safe in patients with BPD I acute manic episodes with/without mixed features.

Toward a science-based testing strategy to identify maternal thyroid hormone imbalance and neurodevelopmental effects in the progeny - part I: which parameters from human studies are most relevant for toxicological assessments?

The 2018 European Food Safety Authority/European Chemicals Agency Guidance on the Identification of Endocrine Disruptors lacks clarity on how the presence or absence of substance-induced maternal thyroid hormone imbalance, or the potential for subsequent deleterious consequences in child neurodevelopment, should be established by toxicological assessments. To address these uncertainties, this narrative review evaluates human evidence on how altered maternal thyroid function may be associated with child neurodevelopmental outcomes; and seeks to identify parameters in human studies that appear most relevant for toxicological assessments. Serum levels of free thyroxine (fT4) and thyroid stimulating hormone (TSH) are most frequently measured when assessing thyroid function in pregnant women, whereas a broad spectrum of neurodevelopmental parameters is used to evaluate child neurodevelopment. The human data confirms an association between altered maternal serum fT4 and/or TSH and increased risk for child neurodevelopmental impairment. Quantitative boundaries of effects indicative of increased risks need to be established. Moreover, it is unknown if altered serum levels of total T4, free or total triiodothyronine, or parameters unrelated to serum thyroid hormones might be more relevant indicators of such effects. None of the human studies established a link between substance-mediated liver enzyme induction and increased serum thyroid hormone clearance, let alone further to child neurodevelopmental impairment. This review identifies research needs to contribute to the development of toxicity testing strategies, to reliably predict whether substances have the potential to impair child neurodevelopment via maternal thyroid hormone imbalance.

The effect of levetiracetam and oxcarbazepine monotherapy on thyroid hormones and bone metabolism in children with epilepsy: A prospective study

BACKGROUND

Long-term treatment with certain antiepileptic drugs may lead to thyroid function disturbances or alterations in bone metabolism; the data on the effects of new antiepileptic drugs on this are limited and conflicting, especially in children with epilepsy. Therefore, the aim of this study was to investigate the effects of levetiracetam and oxcarbazepine on thyroid hormone levels and bone metabolism in children with epilepsy.

METHODS

A total of 51 children with new-onset partial epilepsy were selected. They were randomly treated with either levetiracetam (n = 25), or oxcarbazepine (n = 26) monotherapy. Eight of the 51 patients were excluded for failing to take the drug continuously or failing to undergo a regular review. Thus, 43 patients were finally included (levetiracetam: 23 patients, oxcarbazepine: 20 patients). A control group consisting of age- and sex-matched healthy subjects (n = 20) was included for comparison. Serum triiodothyronine, tetraiodothyronine, free triiodothyronine, free thyroxine, thyroid-stimulating hormone, calcium, phosphorus, alkaline phosphatase, osteocalcin, parathyroid hormone, and 25-hydroxyvitamin D levels and bone mineral density values were measured before and at 6 and 12 months after therapy in all groups.

RESULTS

At baseline, thyroid hormone levels, bone metabolism index, and bone mineral density values did not differ between the control group and the drug-treated groups. Levetiracetam-treated patients showed no significant changes in thyroid hormone levels, bone metabolism, and bone mineral density during the 12-month follow-up period compared with baseline values. In the oxcarbazepine group, compared to baseline values, serum free thyroxine levels decreased after 12 months of treatment (Z = -3.115, p = 0.002), and after 6 and 12 months of treatment, calcium levels decreased (Z = -3.705, p < 0.001 and Z = -3.884, p < 0.001, respectively) and parathyroid hormone levels increased (Z = -3.698, p < 0.001 and Z = -3.921, p < 0.001, respectively); however, all other parameters did not differ from baseline values.

CONCLUSION

Our data show that levetiracetam treatment has no significant effect on thyroid function and bone metabolism in children with epilepsy. Long-term use of oxcarbazepine may reduce serum free thyroxine levels, resulting in impaired thyroid function, and may reduce serum calcium and increase parathyroid hormone levels, leading to bone metabolism disorders.

Thyroid Functions in Children on Levetiracetam or Valproic Acid Therapy

The aim of this study was to investigate the thyroid functions in children receiving levetiracetam or valproate monotherapy. We retrospectively reviewed the records of children with controlled epilepsy receiving valproic acid (VPA group) or levetiracetam monotherapy (LEV group) for at least 6 months. Free thyroxine 4 levels (fT4) and thyroid stimulating hormone (TSH) levels were compared between VPA group, LEV group, and age- and gender-matched healthy children (control group). A total of 190 children were included in the study: 63 were in the VPA, 60 in the LEV, and 67 in the control group. Although there was no significant difference regarding average fT4 levels, higher TSH levels were found in the VPA group when compared with the LEV and control groups (p < 0.001 and p < 0.001, respectively). There was no significant difference in terms of fT4 and TSH values in the LEV group when compared with the control group (p = 0.56 and p = 0.61, respectively). Subclinical hypothyroidism (defined as a TSH level above 5 uIU/mL with a normal fT4 level was detected in 16% of patients in the VPA group, none in the LEV and control groups. Our study found that VPA therapy is associated with an increased risk of subclinical hypothyroidism while LEV had no effect on thyroid function tests.

Effects of modified Atkins diet on thyroid function in adult patients with pharmacoresistant epilepsy

INTRODUCTION

The use of ketogenic diet as a supplement to antiseizure medication (ASM) in refractory epilepsy has increased the past decades. This high-fat, low-carbohydrate diet mimics the metabolic state of fasting and is generally well-tolerated. However, the long-term adverse effects of the diet are unclear. The purpose of this study was to investigate whether the modified Atkins diet (MAD), a variant of the ketogenic diet, may have an impact on thyroid hormone levels.

METHODS

We assessed thyroid function by measuring thyroid stimulation hormone (TSH), fT4, T3, fT3, and rT3 before diet start (baseline) and after 12 weeks on the diet in 53 adult patients with drug-resistant epilepsy. Further, we examined the correlation between the changes in thyroid function during dietary treatment and type of (i) change in seizure frequency, (ii) drugs in use, and (iii) degree of ketosis.

RESULTS

After 12 weeks on the diet, we found a significant reduction in T3 and fT3 values (13.4% and 10.6%, respectively) and a significant increase in fT4 values (12.1%) compared with baseline. In addition, there was an insignificant increase in TSH and rT3. These changes were similar in women and men, and there was no correlation to drugs in use (enzyme-inducing vs. nonenzyme-inducing drugs), changes in seizure frequency, or level of ketosis.

CONCLUSION

This study indicates that dietary treatment for epilepsy may bring about a modest fall in thyroid hormone levels. This could be relevant for those patients with low thyroid hormones and those treated with ASMs known to lower thyroid hormone levels. A cumulative effect of ASMs, low basal thyroid hormone levels, and ketogenic diet may therefore be of clinical importance in the case of thyroid hormones when treating patients with MAD.

Evaluating Chemicals for Thyroid Disruption: Opportunities and Challenges with in Vitro Testing and Adverse Outcome Pathway Approaches

BACKGROUND

Extensive clinical and experimental research documents the potential for chemical disruption of thyroid hormone (TH) signaling through multiple molecular targets. Perturbation of TH signaling can lead to abnormal brain development, cognitive impairments, and other adverse outcomes in humans and wildlife. To increase chemical safety screening efficiency and reduce vertebrate animal testing, in vitro assays that identify chemical interactions with molecular targets of the thyroid system have been developed and implemented.

OBJECTIVES

We present an adverse outcome pathway (AOP) network to link data derived from in vitro assays that measure chemical interactions with thyroid molecular targets to downstream events and adverse outcomes traditionally derived from in vivo testing. We examine the role of new in vitro technologies, in the context of the AOP network, in facilitating consideration of several important regulatory and biological challenges in characterizing chemicals that exert effects through a thyroid mechanism.

DISCUSSION

There is a substantial body of knowledge describing chemical effects on molecular and physiological regulation of TH signaling and associated adverse outcomes. Until recently, few alternative nonanimal assays were available to interrogate chemical effects on TH signaling. With the development of these new tools, screening large libraries of chemicals for interactions with molecular targets of the thyroid is now possible. Measuring early chemical interactions with targets in the thyroid pathway provides a means of linking adverse outcomes, which may be influenced by many biological processes, to a thyroid mechanism. However, the use of in vitro assays beyond chemical screening is complicated by continuing limits in our knowledge of TH signaling in important life stages and tissues, such as during fetal brain development. Nonetheless, the thyroid AOP network provides an ideal tool for defining causal linkages of a chemical exerting thyroid-dependent effects and identifying research needs to quantify these effects in support of regulatory decision making. https://doi.org/10.1289/EHP5297.

Lipid and thyroid hormone levels in children with epilepsy treated with levetiracetam or carbamazepine: A prospective observational study

Although previous studies have investigated the influence of antiepileptic drugs (AEDs) on lipid profiles and thyroid hormone levels, there is little evidence regarding the effects of levetiracetam (LEV). Therefore, we conducted a prospective longitudinal study to evaluate the effects of LEV and carbamazepine (CBZ) treatment on lipid profile and thyroid hormone levels in patients newly diagnosed with epilepsy. Inclusion criteria were as follows: (a) age between 4 and 15 years, (b) diagnosis of epilepsy with at least two focal seizures within a year, and (c) newly treated with LEV or CBZ monotherapy. Serum lipid profile and thyroid hormone levels were measured before and after 1 and 6 months of AED initiation. Among the 21 included patients (LEV: 13 patients, CBZ: 8 patients), all but one patient in the LEV group continued AED monotherapy during the study period. Although triglyceride (TG) levels tended to be increased in the CBZ group (baseline: 58.3 ± 22.0 mg/dl, 1 month: 63.8 ± 21.6 mg/dl, 6 months: 92.3 ± 63.6 mg/dl, p = 0.22, analyses of variance (ANOVA)), there were no significant changes in total cholesterol (TC), TG levels, high-density lipoprotein cholesterol (HDL-C), or low-density lipoprotein cholesterol (LDL-C) in either group. Serum free thyroxine (fT4) levels were significantly decreased in the CBZ group (baseline: 1.15 ± 0.06 ng/dl, 1 month: 1.00 ± 0.16 ng/dl, 6 months: 0.98 ± 0.14 ng/dl, p = 0.03, ANOVA). In contrast, there were no significant changes in fT4 or thyroid-stimulating hormone (TSH) levels in the LEV group. The results of the present study suggest that LEV monotherapy does not affect lipid profile or thyroid function while CBZ monotherapy may cause thyroid dysfunction.

Levothyroxine pseudo-malabsorption: testing and treatment in the outpatient setting

Persistent elevation of thyroid stimulating hormone (TSH) is a common clinical problem in outpatient clinics treating patients with primary hypothyroidism. One challenge to practitioners involves predicaments where patients have an inadequate response to a seemingly appropriate dose of levothyroxine (L-T4). A patient's self-assessed compliance to hormone replacement therapy or verification refill history at the patient's pharmacy might not be a reliable form of confirmation of non-adherence to the drug by the patient, which has been referred to as "L-T4 pseudo-malabsorption." A fast and inexpensive tool to rule out true LT4 malabsorption and thereby properly diagnosing and ultimately successfully treat LT4 pseudo-malabsorption is available in the outpatient setting. This allows clinicians to identify which patients for individual support in adhering to their prescribed therapy and may also reduce unnecessary referrals for sub-specialty care by endocrinologists.

Changes of thyroid hormonal status in patients receiving ketogenic diet due to intractable epilepsy

BACKGROUND

Ketogenic diet (KD), which is high in fat and low in carbohydrates, mimics the metabolic state of starvation and is used therapeutically for pharmacoresistant epilepsy. It is known that generation of triiodothyronine (T3) from thyroxine (T4) decreases during fasting periods. The aim of this study was to evaluate the thyroid function of children receiving KD for at least 1 year due to drug-resistant epilepsy.

METHODS

A total of 120 patients [63 males, 52.5%; mean age 7.3±4.3 years, median interquartile range (IQR): 7.0 (4-10 years)] treated with KD for at least 1 year were enrolled. Seizure control, side effects, and compliance with the diet were recorded, and free T3, free T4, and thyroid-stimulating hormone (TSH) levels were measured at baseline and at post-treatment months 1, 3, 6, and 12. The Mann-Whitney U-test, repeated measures analysis of variance (ANOVA) with post-hoc Bonferroni correction, and logistic regression analysis were used for data analysis.

RESULTS

Hypothyroidism was diagnosed and L-thyroxine medication was initiated for eight, seven and five patients (20 patients in total, 16.7%) at 1, 3, and 6 months of KD therapy, respectively. Logistic regression analysis showed that baseline TSH elevation [odds ratio (OR): 26.91, 95% confidence interval (CI) 6.48-111.76, p<0.001] and female gender (OR: 3.69, 95% CI 1.05-12.97, p=0.042) were independent risk factors for development of hypothyroidism during KD treatment in epileptic children.

CONCLUSIONS

KD causes thyroid malfunction and L-thyroxine treatment may be required. This is the first report documenting the effect of KD treatment on thyroid function. Thyroid function should be monitored regularly in epileptic patients treated with KD.