Female issues in epilepsy: a critical review

Antiseizure medications and oral contraceptives: Impact of enzyme inducers on pregnancy outcomes and costs

PURPOSE

To show the impact of drug-drug interactions (DDIs) associated with co-administration of enzyme-inducing (EI) antiseizure medications and oral contraceptives (OCs) on the annual number of unintended pregnancies, their outcomes, and their associated costs in the United States (US).

METHODS

A Microsoft Excel pregnancy-outcomes model was developed to determine the impact of DDIs in women who take an OC as well as an EI antiseizure medication known to lower the effectiveness of the OC in preventing pregnancy. The model compared the number of unintended pregnancies, the expected pregnancy outcomes, and associated costs in women taking an OC and an EI medication with a matched cohort of women who took an OC and an enzyme-neutral (EN) antiseizure medication that is known not to interact with OCs. The model perspectives were patients and third-party payers in the US. Unintended pregnancy rates, pregnancy outcomes, and cost inputs for the model were taken from published studies.

RESULTS

The results of the analysis showed an estimated increase in the annual number of unintended pregnancies in the US of 503 (a change from 1151 to 1654), an increase of 44.7%, for the estimated 71,922 women currently taking an OC plus an EI medication in the US when compared with a matched cohort taking an OC plus an EN medication. This resulted in an estimated annual healthcare cost increase of $3 million, which is an increase of 5.5% in the annual costs for contraception and pregnancy care. A scenario analysis showed that the annual number of unintended pregnancies could be lower (575 vs 1654) for a matched cohort of women taking EI medications and using a copper intrauterine device, a highly effective and nonhormonal form of contraception, rather than an OC.

CONCLUSIONS

Physicians treating women of reproductive age for epilepsy who wish to avoid pregnancy should consider the potential for DDIs that might result in unintended pregnancies. Thus, physicians should alert women using EI medications for epilepsy control to the increased potential for unintended pregnancies if they use OCs for contraception.

Sexual dysfunction and associated factors in Chinese Han women with epilepsy

PURPOSE

Women with epilepsy (WWE) are believed to be at risk of sexual dysfunction (SD) and face many sexual challenges because of multiple factors. This study aimed to assess the factors associated with SD in Chinese Han WWE.

METHODS

This cross-sectional study examined 112 married WWE in the Affiliated Hospital of Yangzhou University with focal (FE) or generalized epilepsy (GE) on antiepileptic drugs (AEDs), and 120 healthy controls without epilepsy, all of Chinese Han nationality. Data collection tools included the Chinese version of Female Sexual Function Index (FSFI), the Chinese version of Zung Self-Rating Anxiety Scale (SAS), the Chinese version of the Zung Self-Rating Depression Scale (SDS), the Chinese version of the revised Morisky Medication Adherence Scale (MMAS-8), and the Chinese version of the National Hospital Seizure Severity Scale (NHS3). Chi-square test, t-test, one-way analysis of variance (ANOVA), and binary logistic regression were used for statistical analysis.

RESULTS

A high rate (70.5%) of SD was detected in WWE, with 24.2% in controls. Sexual dysfunction affected all dimensions: desire (85.7%), arousal (56.3%), lubrication (47.3%), orgasm (66.1%), satisfaction (58.9%), and pain (41.1%). Elevated rates of anxiety (40.2%) and depression (33%) and poor medication adherence (31.3%) were also found in WWE. Binary logistic regression found that poor economic status (odds ratio (OR) = 13.904, 95% confidence interval (CI): 2.025-95.472, P = 0.007 and OR = 6.350, 95% CI: 1.323-30.477, P = 0.021), anxiety (OR = 1.222, 95% CI: 1.055-1.415, P = 0.007), and poor medication adherence (OR = 0.297, 95% CI: 0.124-0.707, P = 0.006) were associated with SD.

CONCLUSIONS

The associated factors of SD in Chinese Han WWE are multifactorial. The WWE have higher levels of anxiety, poor family economic status, and poor medication adherence. Medical professionals should not only better control seizures but also evaluate and improve patients' sexual function so as to improve the quality of life of WWE.

Women with epilepsy in childbearing age: Pregnancy-related knowledge, information sources, and antiepileptic drugs

Pregnancy-related issues in epilepsy (PRIE) are essential for management of epilepsy in women. We conducted a study among women with epilepsy (WWE) aged 15-45years about their knowledge, sources, and needs for information regarding PRIE, which included their current antiepileptic drugs (AEDs) usage. Women with epilepsy, visitors of Croatian Association for Epilepsy webpage, were offered an online questionnaire, and 200 responses were analyzed. The mean number of correct answers about PRIE was 3.5 out of 5. Main predictors of knowledge on PRIE were a prior consultation with a neurologist and higher usage of books/brochures. A prior neurologist consultation on PRIE was stated by 45% of subjects. As the preferred future mode of being informed on PRIE, majority of women (61%) chooses their neurologist, 22% written materials distributed by a neurologist, and only 13% Internet. Levetiracetam was the most commonly used AED (34.5%). Valproate was used by 26%, and of those 59% stated no previous consultation on PRIE with their neurologist. In summary, we believe our study shows that knowledge of PRIE among WWE in their childbearing age is unsatisfactory, as are the neurologist consultation rates about PRIE. Our results demonstrate that, despite modern technologies, educational activities should be based on neurologist consultations and providing the patients with appropriate written materials. This is especially true for the relatively large proportion of women still taking valproate.

Maternal carbamazepine alters fetal neuroendocrine-cytokines axis

This study detected the impact of maternal carbamazepine (CBZ) on the fetal neuroendocrine-cytokines axis. 25 or 50mg/kg of CBZ was intraperitoneally administrated to pregnant albino rats from the gestation day (GD) 1 to 20. Both administrations of CBZ caused a hypothyroidism in dams and fetuses whereas the decreases in serum thyroxine (T4) and triiodothyronine (T3) and increases in serum thyrotropin (TSH) levels were highly significant (LSD; P <0.01) at GD 20 compared to untreated control dams. Also, both administrations had undesirable impacts on the maternofetal body weight, litter weight, survival of dams and fetuses, and their food consumption in comparison to the corresponding control. These administrations also elicited a reduction in fetal serum growth hormone (GH), interferon-γ (IFNγ), interleukins (IL-2 & 4) and prostaglandin E2 (PGE2) levels. Also, the elevation in fetal serum tumor necrosis factor-alpha (TNFα), transforming growth factor-beta (TGFβ), and interleukins (IL-1β & 17) levels was observed at embryonic day (ED) 20. Moreover, there were a cellular fragmentation, distortion, hyperemia, oedema and vacuolation in the fetal cerebellar cortex due to both maternal administrations. These developmental changes were dose-dependent. These novel results suggest that CBZ may act as a developmental immunoneuroendocrine disruptor.

Differences in quality of life of women and men with drug-resistant epilepsy in Poland

PURPOSE

The aim of the study was to assess the differences in health-related quality of life in groups of men and women suffering with drug-resistant epilepsy and to determine which factors influence quality of life.

METHODS

The examined group consisted of 64 subjects with drug-resistant epilepsy - 31 men and 33 women. The mean duration of epilepsy was 17.56±8.92 and 19±9.56years, respectively. The following diagnostic tools were used: QOLIE-31-P, Wechsler Adult Intelligence Scale - Revised (WAIS-R (PL)), and Hamilton Rating Scale for Depression (HRSD).

RESULTS

Scores in QOLIE-31-P did not differ significantly between groups of men and women with drug-resistant epilepsy; however, a more detailed analysis revealed certain disparities. Multiple regression analyses indicated that some distinct factors were associated with quality of life in each sex. In the group of women, there were no significant predictors of their quality of life. Among the group of men, depression intensity was the only statistically significant QoL predictor, explaining 16% of the variance (adjusted R(2)=0.16, F(6, 24)=19.7, p<0.01). Moreover, patients with depression had lowered scores in the Emotional Well-Being and Energy/Fatigue subscales, regardless of the sex.

CONCLUSION

The study revealed that, despite similar scores in QOLIE-31-P, specific factors may differentially affect the quality of life of men and women with drug-resistant epilepsy in Poland. Nevertheless, replication of these results with a larger number of participants is needed for a more definitive conclusion.

Cognitive Profile of Zonisamide and Valproic Acid in the Treatment of Idiopathic Generalized Epilepsy: A Comparative Observational Study

INTRODUCTION

Calls for an alternative to valproic acid (VPA) as drug of choice for idiopathic generalized epilepsies (IGEs) have intensified since the recent International League Against Epilepsy recommendation that the drug should not be administered to women of childbearing age. Zonisamide (ZNS), a third-generation antiepileptic drug, has proven effective in generalized seizures and could be considered an alternative to VPA in this population.

OBJECTIVES

The present study was designed to examine possible differences in cognitive profile between ZNS and VPA as monotherapy in patients with IGE in real-life settings.

METHODS

We conducted a comparative, descriptive, observational, retrospective cohort study in two groups of patients diagnosed with IGE treated with ZNS ≥200 mg/day or VPA ≥1000 mg/day as stable monotherapy for at least the previous 6 months. We used specific neuropsychological tests for short- and long-term mnemonic functions, working memory, visuospatial speed, attention and processing speed, verbal fluency, executive functions, visual perception, abstraction, anxiety, depression, and apathy.

RESULTS

We included 16 patients in the study: eight in the VPA and eight in the ZNS group. Significantly superior mean scores were obtained by the VPA group in working memory (Forward Digits test) and by the ZNS group in execution time for the Rey-Osterrieth complex figure test. No statistically significant differences were found between the groups in the remaining tests.

CONCLUSION

Zonisamide as monotherapy has a similar cognitive profile to that of VPA in patients with IGE. The final treatment selection setting should be individualized. ZNS may be a reasonable alternative to VPA in some cases in this population.

Seizure occurrence, pregnancy outcome among women with active convulsive epilepsy: one year prospective study

PURPOSE

To determine the prevalence of active convulsive epilepsy, seizure frequency and the outcome of pregnancy amongst a cohort of pregnant women attending antenatal clinic (ANC) at two tertiary hospitals.

METHODS

An observational cohort study conducted at the University of Maiduguri Teaching Hospital and State Specialist Hospital, Northeast Nigeria. Pregnant women attending antenatal care were screened for previous history of active convulsive epilepsy, and recruited consecutively according to a specified protocol. A standardized questionnaire was administered to record pregnancy history, nature of epilepsy and treatments received. They were followed-up during the course of the pregnancy based on the ANC schedule up to delivery. The outcome of pregnancies was recorded.

RESULTS

A total of 7063 pregnant women were screened, of whom 103 (1.46%) subjects had at least a past history of seizure. Seventy-eight (1.10%) had a past history of seizure(s) from eclampsia and 23 (0.33%) pregnant subjects recruited were identified to have active convulsive epilepsy. The unadjusted prevalence of active convulsive epilepsy in pregnant women was found to be 3.33 per 1000 (95% CI: 2.1-4.8). Subjects who had a history of head injury and encephalitis were more likely to have seizures during pregnancy. (P=0.013 and P=0.041). Those who had recurrent seizures within the last six months before recruitment were more likely to have a negative pregnancy outcome (P=0.043).

CONCLUSION

Our study found a prevalence of active epilepsy of 3.33 per 1000 among pregnant women, with about one percent having a past history of seizure from eclampsia.

Reduction in mortality and teratogenicity following simultaneous administration of folic acid and vitamin E with antiepileptic, antihypertensive and anti-allergic drugs

Aim:

The present study was designed to evaluate the teratogenic effects on breeding pattern in mice following administration of lamotrigine (LT) and levetiracetam (LV) and its combination with anti-hypertensive and anti-allergic drugs. Moreover, possibility of decrease in teratogenic effect was also evaluated upon simultaneous administration of these combinations with folic acid or vitamin E.

Materials and Methods:

The study was carried out on mature female mice housed in polycarbonate breeding cages. Drugs were administered continuously till the birth of neonates and pups were examined for any teratogenic potential of drugs.

Results:

The results of the study reveals that teratogenic effects of lamotrigine, methyldopa and loratadine (LTMLO) combination were seems to be reduced upon simultaneous administration with folic acid, while addition of vitamin E was found to be more effective in reducing the mortality rate of levetiracetam, methyldopa and loratadine combination.

Conclusion:

Teratogenic effects of LTMLO combination were better prevented by folic acid. However, further studies on large number of animals and humans are required before reaching to definite conclusion.

Effect of eslicarbazepine acetate on the pharmacokinetics of a combined ethinylestradiol/levonorgestrel oral contraceptive in healthy women

OBJECTIVE

To investigate the effect of once-daily (QD) eslicarbazepine acetate (ESL) 800 mg and 1,200 mg administration on pharmacokinetics of a combined ethinylestradiol/levonorgestrel oral contraceptive (OC) in women of childbearing potential.

METHODS

Two two-way, crossover, two-period, randomized, open-label studies were performed in 20 healthy female subjects, each. In one period (ESL+OC period), subjects received ESL 800 mg QD in one study and ESL 1200 mg QD in the other study, for 15 days; concomitantly with the Day 14 ESL dose, an oral single dose of 30 μg ethinylestradiol and 150 μg levonorgestrel was administered. In the other period (OC alone), a single dose of 30 μg ethinylestradiol and 150 μg levonorgestrel was administered. Three weeks or more separated the periods. An analysis of variance (ANOVA) was used to test for differences between pharmacokinetic parameters of 30 μg ethinylestradiol and 150 μg levonorgestrel following ESL+OC and OC alone, and 90% confidence intervals (90%CI) for the ESL+OC/OC alone geometric mean ratio (GMR) were calculated.

RESULTS

ESL significantly decreased the systemic exposure to both ethinylestradiol and levonorgestrel. GMR (90%CI) for AUC0-24 of ethinylestradiol were 68% (64%; 71%) following 1,200 mg ESL and 75% (71%; 79%) following 800 mg ESL. GMR (90%CI) for AUC0-24 of levonorgestrel were 76% (68%; 86%) following 1,200 mg ESL and 89% (82%; 97%) following 800 mg ESL.

CONCLUSIONS

A clinically relevant dose-dependent effect of ESL administration on the pharmacokinetics of ethinylestradiol and levonorgestrel was observed. Therefore, to avoid inadvertent pregnancy, women of childbearing potential should use other adequate methods of contraception during treatment with ESL, and, in case ESL treatment is discontinued, until CYP3A4 activity returns to normal.

Patient knowledge about issues related to pregnancy in epilepsy: a cross-sectional study

In 2009, new guidelines were established by the American Academy of Neurology regarding pregnancy in women with epilepsy. A questionnaire was developed to assess patient knowledge of current guidelines related to epilepsy and pregnancy. Patients were recruited from a single outpatient clinic in a large Canadian tertiary care center. Patients were eligible to participate if they were female, of reproductive age, had active epilepsy for at least 6 months and were not cognitively impaired. One hundred women completed the survey (response rate 87%) with a median score of 40%. A significant association was found between total score and years of education (p<0.001). Significant associations were not found between total score and epilepsy duration (p=0.37), previously being pregnant (p=0.22), and polytherapy (p=0.31). Patient knowledge of the impact of epilepsy on pregnancy is low. More knowledge translation efforts are required to increase knowledge of issues related to pregnancy for women with epilepsy.

[Family planning in women with epilepsy]

Epilepsy is a common neurological condition with gender-related management implications. Epilepsy and antiepileptic drug treatment affect aspects of contraception, fertility and pregnancy which are discussed in the article.

Quality of life in pregnant women with epilepsy versus women with epilepsy

It is assumed that 25% of patients with epilepsy are women of fertile age and 0.3% to 0.6% of all children are born of mothers with epilepsy. The aim of this study was to evaluate the quality of life on pregnant with epilepsy and compare with non-pregnant women with epilepsy. We evaluated two groups (Experimental Group--29 pregnant women with epilepsy and Control Group--30 women with epilepsy); they were attended at the HC/UNICAMP. The patients had three meetings to carry out and implement the anamnesis and the application of QQV-65. There were no significant differences in the measurement of quality of life when comparing both groups. However, when we analyzed individually in the pre- and post-partum periods, we observed significant differences in health aspects (p=0.0495), physical (p=0.02868) and emotional (p=0.0253) dimensions in QQV-65. This study shows that pregnancy could be interpreted as a stressor. In late pregnancy when this stressor was removed, women with epilepsy had improvement in their quality of life.